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ANAPHYLACTIC

SHOCK
PAZ, CHENNEY MYRA P.
P O S T G R A D UAT E I N T E R N
P E R P E T UA L S U C C O U R H O S P I TA L
Anaphylaxis
A life-threatening anaphylactic
response of sensitized humans
which occurs after minutes after
exposure of specific antigen

SOURCE: KASPER, D., HAUSER, S., ET.AL. (2015). HARRISON’S PRINCIPLES OF INTERNAL MEDICINE. 19TH EDITION. MCGRAW-HILL COMPANIES, INC.
Anaphylactic Shock
Fatal consequence of anaphylaxis when there is vascular
collapse, resulting in blood pressure drop, and later on
multiorgan failure.

SOURCE: KASPER, D., HAUSER, S., ET.AL. (2015). HARRISON’S PRINCIPLES OF INTERNAL MEDICINE. 19TH EDITION. MCGRAW-HILL COMPANIES, INC.
EPIDEMIOLOGY/PREVALENCE
•The median age was 31 years.
•The overall age- and sex-adjusted incidence rate was 42 per 100,000
person-years.
•Lifetime prevalence is estimated at 0.05 to 2 percent.
•In the Philippines, a record of 29 in-patients in Philippine General
Hospital has been recorded from 2012 to 2013. However, no deaths
have been recorded so far.

SOURCE: KASPER, D., HAUSER, S., ET.AL. (2015). HARRISON’S PRINCIPLES OF INTERNAL MEDICINE. 19TH EDITION. MCGRAW-HILL COMPANIES, INC.
THE PHILIPPINE SOCIETY OF ALLERGY, ASTHMA, AND IMMUNOLOGY, 2013
PREDISPOSING FACTORS
MATERIAL EXAMPLE
Hormones insulin, vasopressin, parathormone
Enzymes trypsin, chymotrypsin, penicillinase, streptopkinase
Pollen extracts ragweed, grass, tress
Non-pollen allergen dust mites, dander of cats, horse, dogs, and laboratory
extracts animals
Food peanut, milk, eggs, seafood, nuts, grains, beans, gelatin
Occupation-related latex rubber
products

SOURCE: KASPER, D., HAUSER, S., ET.AL. (2015). HARRISON’S PRINCIPLES OF INTERNAL MEDICINE. 19TH EDITION. MCGRAW-HILL COMPANIES, INC.
MATERIAL EXAMPLE
Hymenoptera venom yellow jacket, yellow and white-faced hornets, paper
wasp, honey bee, fire ants
Polysaccharides Dextran, thiomersal (vaccine reservative)
Drugs Protamine; Antibiotics (penicillins, cephalosporins,
amphotericin B, nitrofurantoin, quinolones);
chemotherapy agents (carboplatin, paclitaxel,
doxorubicin); local anesthetic (procaine, lidocaine);
muscle relaxants ( suxamethonium, gallamine,
pancuronium); vitamins (thiamine, folic acid);
diagnostic agents (sodium dehydrocholate,
sulfobromophthalein); biologics (omalizumab,
rituximab, etanercept)
Occupation-related Ethylene oxide
chemicals

SOURCE: KASPER, D., HAUSER, S., ET.AL. (2015). HARRISON’S PRINCIPLES OF INTERNAL MEDICINE. 19TH EDITION. MCGRAW-HILL COMPANIES, INC.
PATHOGENESIS
◦ Hypersensitivity is an injurious immune reaction causing a
disease.
◦ Classifications:
1. Immediate hypersensitivity
2. Antibody-mediated disorders
3. Immune complex–mediated disorders
4. Cell-mediated immune disorders
◦ Anaphylaxis is a prototypical disorder of Type 1
(Immediate) Hypersensitivity

SOURCE: KASPER, D., HAUSER, S., ET.AL. (2015). HARRISON’S PRINCIPLES OF INTERNAL MEDICINE. 19TH EDITION. MCGRAW-HILL COMPANIES, INC.
Type Immune Mechanisms Histopathologic Prototypical
Lesions Disorders

Production of IgE antibody Vascular dilation,


Immediate → immediate release of edema, smooth Anaphylaxis;
(type I) vasoactive amines and muscle contraction, allergies; bronchial
hypersensitiv other mediators from mast mucus production, asthma (atopic
ity cells; later recruitment of tissue injury, forms)
inflammatory cells inflammation
Production of IgG, IgM → binds to Phagocytosis and lysis of
Antibody-mediated antigen on target cell or tissue → cells; inflammation; in some Autoimmune hemolytic
(type II) phagocytosis or lysis of target cell by diseases, functional anemia; Goodpasture
hypersensitivity activated complement or Fc receptors; derangements without cell or syndrome
recruitment of leukocytes tissue injury
Deposition of antigen-antibody
complexes → complement activation → Systemic lupus
Immune complex–
recruitment of leukocytes by Inflammation, necrotizing erythematosus; some forms
mediated (type III)
complement products and Fc receptors vasculitis (fibrinoid necrosis) of glomerulonephritis; serum
hypersensitivity
→ release of enzymes and other toxic sickness; Arthus reaction
molecules

Activated T lymphocytes → (1) release


Perivascular cellular Contact dermatitis; multiple
Cell-mediated (type of cytokines, inflammation and
infiltrates; edema; granuloma sclerosis; type 1 diabetes;
IV) hypersensitivity macrophage activation; (2) T cell–
formation; cell destruction tuberculosis
mediated cytotoxicity

KUMAR, V., ABBAS, A., ET. AL. (2015). ROBBIN’S AND COTRAN PATHOLOGIC BASIS OF
DISEASE, 9TH EDITION
KUMAR, V., ABBAS, A., ET. AL. (2015). ROBBIN’S AND COTRAN PATHOLOGIC BASIS OF DISEASE, 9TH EDITION
KUMAR, V., ABBAS, A., ET. AL. (2015). ROBBIN’S AND COTRAN PATHOLOGIC BASIS OF DISEASE, 9TH EDITION
KUMAR, V., ABBAS, A., ET. AL. (2015). ROBBIN’S AND COTRAN PATHOLOGIC BASIS OF DISEASE, 9TH EDITION
KUMAR, V., ABBAS, A., ET. AL. (2015). ROBBIN’S AND COTRAN PATHOLOGIC BASIS OF DISEASE, 9TH EDITION
Clinical Manifestations
◦ Hallmark is the onset of some manifestation within seconds to
minutes after introduction of the antigen
◦ Cutaneous
Pruritus, urticaria, and with or without angioedema
Flushing with diffuse erythema and a feeling of warmth
Characteristic feature: eruption of a well-circumscribed, discrete cutaneous
wheals with erythematous, raised, serpiginous borders and blanched centers

Kasper, D., Hauser, S., et.al. (2015). Harrison’s Principles of Internal Medicine. 19th edition. McGraw-Hill Companies, Inc.
Clinical Manifestations
◦ Respiratory
Laryngeal edema
Bronchial obstruction
Lungs: marked hyperinflation.
◦ Gastrointestinal
Nausea, vomiting, crampy abdominal pain, and diarrhea
Angioedema of the bowel wall

Kasper, D., Hauser, S., et.al. (2015). Harrison’s Principles of Internal Medicine. 19th edition. McGraw-Hill Companies, Inc.
Clinical Manifestations
• Electrocardiographic abnormalities: primary cardiac event
mediated by mast cells or may be secondary to a critical
reduction in blood volume
• Systemic vasodilation with a fall in blood pressure, which
may progress to circulatory collapse and death within
minutes (Anaphylactic Shock).

Kasper, D., Hauser, S., et.al. (2015). Harrison’s Principles of Internal Medicine. 19th edition. McGraw-Hill Companies, Inc.
Diagnostics/Laboratory Procedure
Immunoassays using purified or recombinant antigens
 Prausnitz-Küstner reaction

Serum tryptase level


Elevated level: mast cell activation in a systemic reaction
 Within 4 hours of a systemic reaction

Kasper, D., Hauser, S., et.al. (2015). Harrison’s Principles of Internal Medicine. 19th edition. McGraw-Hill Companies, Inc.
Treatment
Immediate Intervention:
◦ Assess circulation, airway and breathing
◦ IM Epinephrine
◦ IV access, oxygen, and monitoring
◦ Proper positioning

L. CAMPBELL ET AL./ANN ALLERGY ASTHMA IMMUNOL 113 (2014) 599E608 EMERGENCY DEPARTMENT DIAGNOSIS AND TREATMENT
Treatment
Epinephrine 1:1000 (1mg/ml), 0.3-0.5 mL, subcutaneously
or intramuscularly, with repeated dose as needed at 5 to 20-
minute interval for severe reactions
A1 Increase vasoconstriction and vascular
adrenergic resistance; Increased BP; decreases
receptor mucosal edema in the airways

B1
Increase cardiac contraction force and
adrenergic heart rate
receptor
B2
decrease mediator release and increases
adrenergic bronchodilation
receptor
JOSEPH P WOOD, STEPHEN J TRAUB, AND CHRISTOPHER LIPINSKI SAFETY OF EPINEPHRINE FOR ANAPHYLAXIS IN THE EMERGENCY SETTING WORLD J EMERG
MED. 2013 th
Kasper, D., Hauser, S., et.al. (2015). Harrison’s Principles of Internal Medicine. 19 edition. McGraw-Hill Companies, Inc.
Treatment
◦ Oxygen via nasal catheter or with nebulized albuterol
◦ Progressive hypoxia
- Endotracheal intubation or a tracheostomy

Kasper, D., Hauser, S., et.al. (2015). Harrison’s Principles of Internal Medicine. 19th edition. McGraw-Hill Companies, Inc.
Treatment
Second Line Management
Rapid IV infusion (IV, IO)
Repeat IM epinephrine/ IV epinephrine
Bronchodilators
Steroids, antihistamines

L. CAMPBELL ET AL./ANN ALLERGY ASTHMA IMMUNOL 113 (2014) 599E608 EMERGENCY DEPARTMENT DIAGNOSIS AND TREATMENT
Treatment
An IV infusion of 2.5 mL epinephrine, diluted 1:10,000, at 5-
to 10-min intervals
If hypotension occurs, volume expanders, and vasopressor
agents are given as well.
For bronchospasm, aminophylline, 0.25–0.5 g IV

Kasper, D., Hauser, S., et.al. (2015). Harrison’s Principles of Internal Medicine. 19th edition. McGraw-Hill Companies, Inc.
Treatment
For urticaria-angioedema, antihistamine diphenhydramine,
50–100 mg IM or IV
Intravenous glucocorticoids 0.5–1 mg/kg may alleviate later
recurrence of bronchospasm, hypotension, or urticaria.

Kasper, D., Hauser, S., et.al. (2015). Harrison’s Principles of Internal Medicine. 19th edition. McGraw-Hill Companies, Inc.
Prevention
•Sensitivity of the individual
•Dose and character of the diagnostic and therapeutic agent
•Effect of the route of administration on the rate of
absorption.

Kasper, D., Hauser, S., et.al. (2015). Harrison’s Principles of Internal Medicine. 19th edition. McGraw-Hill Companies, Inc.
Fin.