anaphylactic shock
DESCRIPTION
Definition, pathophysiology, etiology, clinical manifestations, managementTRANSCRIPT
1Prof. DR.Dr.Ariyanto Harsono SpA(K)
Anaphilactic Shock
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Definition
Anaphylaxis: Reactions sudden life-threatening because the process immonologic of allergen-antibody reaction
Anaphylactoid Reaction causing physical the same symptoms but caused no immunological reaction
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Alergen
APC MHC-II
Th0
IL-12/ IL-1
Th-2
Th.1
IL-1
TNF-β, IFN-γ
IL-2, IFN-γ
B-Cell
IL-4
IL-5
SEL PLASMASEL MEMORI
IL-6
IL-10
CTL MHC-I
L
MEMORY CELLS
AktifasiKomplemen
Blocking Antibody
Precipitatigng
Aglutinating AB
Anafilaksis
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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PathophysiologyThere are 5 stages:1. Mast cells / basophils walls change therefore stimuli: * Allergens-IgE * Aggregation of immune complex * Activation of complement
Prof. DR.Dr.Ariyanto Harsono SpA(K)
5Mast Cells and basophiles involve in allergic reaction in the context of antigen-IgE
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Granule contents:Histamine,TNF-aProteases, Heparin Lipid mediators:
ProstaglandinsLeukotrienes
Cytokine production:Specifically IL-4, IL-13
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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2. Cell wall enzyme activation:
*Arachidonic acid breakdown
* Decrease in the ratio of cAMP / cGMP
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Arachidonic Acid
Phospholiphase A
Cyccloxygenase Lipoxygenase
Prostaglandine
TXA
Prostacyclin
Leukotriene A
Leukotriene B
Leukotriene C
HETE,5-HETE, PAF
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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3. MEDIATORs RELEASE: *Preformed mediators: histamine, serotonin,
Neutrophil chemotactic factor, Eosinophile chemotactic Factor
* Newly generated mediators: leukotrienes B4, LTC4,
LTD4, Thromboxan, Prostaglandine D2, Kinin, Platelet Actifating Factor
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11Prof. DR.Dr.Ariyanto Harsono SpA(K)
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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4. Functional Pathology response:
*Increased vascular permeability: swollen, hypotension
* Smooth muscle contraction* Secretion of mucus* Changes in excitability and cardiac
muscle contractability
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Nature Rev Immunol 2004: 3:234-237
14Prof. DR.Dr.Ariyanto Harsono SpA(K)
5. Inflammation and involvement of secondary mediators:
*Leukocyte infiltration by chemotactic* Platelet Aggregation* Complement Activation* Proteolytic break-down
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Complement Activation
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Complement Activation …
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Effector mechanisms against extracellular pathogens
COMPLEMENT ActivationBacteria in plasma
Ab & COMPLEMENT
+
Phagocytosis
binding
Complement &Fc receptor
Lysis
Opsonisation
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Etiology1. Associated with IgE
Serum Protein: antisera, antitoxin, the monoclonal Ab, IgA
Venom and sting: bee, hornet, fire ants, snakes, spiders, mosquitoes, jellyfish
Enzymes: trypsin, penicillinase
Vaccines / Extract: DPT, pollen extract, food
Hormones: Isulin, ACTH, Progesterone
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Etiologi1. Associated with IgE
Serum Protein: antisera, antitoxin, the monoclonal Ab, IgA
Venom and sting: bee, hornet, fire ants, snakes, spiders, mosquitoes, jellyfish
Enzymes: trypsin, penicillinase
Vaccines / Extract: DPT, pollen extract, food
Hormones: Isulin, ACTH, Progesterone
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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oFood: milk, eggs, marine fishoPolysaccharides: DextranoDrugs: penicillin, cephalosporins, tetracyclines,
Aminoglikosid, Cyclophosphamide, MetrotrexateoOther: Heparin, Tubokurarin, ethylenediamine,
2. Causes of non-IgEoBlood products: IgA, albumin, Imonoglobulin,
Complement C4, Cryoprecipitateodialysis membraneoprotamineoL-AsperginaseoMurine monoclonal antibodyopenicillin
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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3. cause of anaphylactoidJodium diagnostic materials, Decheolin, BSP,
Fluoresin, Indosianin greenAnalgesics: Salicylates, NSAIDS, AminopirinAntibiotics: AminoglikosidXylocainAlkaloids: Morphine, CodeineDrug: Histamine, Amphetamines, diuretics,
anticonvulsantsFood additives: Sulfites, Tartrasin, Sodium
bensoat
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Clinical Manifestations
• Skin: Itching, erythema, Urtica, Angioudem• Respiratory: sneezing; runny nose; clogged;
coughing; wheezing; swollen larynx; tightness; hoarseness; stridor; cyanosis
• Digestive: nausea, vomiting, diarrhea, abdominal pain
• Eyes: itching, tears• Cardiovascular: collapse, fainting, hypotension, pale,
cold, tachycardia, arrhythmias, cardiac arrest
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Clinical Manifestations• Skin: Itching, erythema, Urtica, Angioudem
• Respiratory: sneezing, runny nose, clogged, coughing, wheezing; swollen larynx: tightness, hoarseness, stridor, cyanosis
• Digestive: nausea, Mutah, diarrhea, abdominal pain
• Eyes: itching, tears• Cardiovascular: collapse, fainting, hypotension,
pale, cold, tachycardia, arrhythmias, cardiac arrest
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Clinical Manifestations
• Skin: Itching, erythema, Urtica, Angioudem• Respiratory: sneezing, runny nose, clogged,
coughing, wheezing; swollen larynx: tightness, hoarseness, stridor, cyanosis
• Digestive: nausea, Mutah, diarrhea, abdominal pain
• Eyes: itching, tears• Cardiovascular: collapse, fainting, hypotension,
pale, cold, tachycardia, arrhythmias, cardiac arrest
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Differential Diagnosis
Sinkopeo Subsides when placed in the recumbent
positiono T, N: Normalo Other symptoms of anaphylactic negative
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Prevention1. Pre vaccination screening: (1)history of allergy to component of vaccines: -egg, -gelatin, -antibiotics. (2) healthy.2. Anticipation• Patient should be kept under supervision for
at least 15’.• Ready Anaphylactic equipment
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Management1. Primary treatment
Adrenaline 1:1000 with a dose of 0.001 ml / kg maximum: 0.3 ml subcutaneously
Tourniquet on the proximal shock / injectionAdrenaline can be repeated 3X every 15-20 'Sprong oxygen nose / hoad box 2-3 L / min
Free the airway, neck hyper-extension position, head tilted, suction mucus, monitor vital
signs
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•Place the patient at shock position•Pulmonal Ressuscitation•Oropharyngeal airway
•Tube endotrakeal•Tracheostomy
•Cardiac compression
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Adrenaline HCL Dose 1:1000 according age
Age Dose
2-6 Bulan 0.07 ml12 Bulan 0.1 ml18-48 Bulan 0.15 ml5 Tahun 0.2 ml6-9 Tahun 0.3 ml10-13 Tahun 0.4 ml>14 Tahun 0.5 ml
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2. Complementary treatment
Intended for complications:
Seizures: diazepam, phenobarbital
Bronchial Spasm : Aminophylline 7 mg dissolved in 10-20 ml of 0.9% NaCl followed 9 mg/kg/24 hours (divided into 3 doses)
b-2 agonist: Ventolin nebulizer
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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3. Additional treatment• Antihistamine (H1 Receptor antagonist): Benadril 2 mg/kg
i.m. continued with 3 mg/kg/24 jam oral (dibagi 3 dosis)
• H-2 receptor antagonist : Cimetidine
• Corticosteroid: Solukortef 4-7 mg/kg i.v. continued with 4-7 mg/kg/24 hour oral (devided 3 doses)
H1
H2
H3
H4
H1-antagonist
H2-antagonist
Histamin
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Granule contents:Histamine,TNF-aProteases, Heparin Lipid mediators:
ProstaglandinsLeukotrienes
Cytokine production:Specifically IL-4, IL-13
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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Increase capilary permeability
Fluid shift shockUrtikariaWheezing
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Fluid therapy
• Kristaloid• Koloid
“The most important is not the composition, but rather the rate of administration”
In children: 30ml/kg hour I
Cardiac output
Dopamine 2-20 mg/kg/menit
Prof. DR.Dr.Ariyanto Harsono SpA(K)
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NB
• Tourniquet is released every 3 minutes until symptoms resolved shock
• If the vaccine subcutaneously, may be added adrenaline 0.005 ml / kg (max: 0.3 ml) at the injection site, one time only!
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