Anaphylactic shock

Definition, pathophysiology, etiology, clinical manifestations, management

1. Prof. DR.Dr.Ariyanto Harsono SpA(K) 1 Prof Ariyanto Harsono MD, PhD SpA(K) Ana phi la ctic Shock

2. Prof. DR.Dr.Ariyanto Harsono SpA (K) 2 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

3. Prof. DR.Dr.Ariyanto Harsono SpA(K) 3 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 PLASMA SEL MEMORI IL-6 IL-10 CTL MHC-I L MEMORY CELLS Aktifasi Komplemen Blocking Antibody Precipitatigng Aglutinating AB Anafilaksis

4. Prof. DR.Dr.Ariyanto Harsono SpA (K) 4 Pathophysiology There are 5 stages: 1. Mast cells / basophils walls change therefore stimuli:        * Allergens- IgE        * Aggregation of immune complex        * Activation of complement

5. Prof. DR.Dr.Ariyanto Harsono SpA(K) 5 Mast Cells and basophiles involve in allergic reaction in the context of antigen-IgE Basophil Mast Cell

6. Prof. DR.Dr.Ariyanto Harsono SpA(K) 6 Granule contents: Histamine,TNF- a Proteases, Heparin Lipid mediators: Prostaglandins Leukotrienes Cytokine production: Specifically IL-4, IL-13 Rapid onset Reaction Late onset Reaction Very Late Onset Reaction

7. Prof. DR.Dr.Ariyanto Harsono SpA (K) 7 2. Cell wall enzyme activation: * Arachidonic acid breakdown        * Decrease in the ratio of cAMP / cGMP

8. Prof. DR.Dr.Ariyanto Harsono SpA(K) 8 Arachidonic Acid Phospholiphase A Cyccloxygenase Lipoxygenase Prostaglandine TXA Prostacyclin Leukotriene A Leukotriene B Leukotriene C HETE,5-HETE, PAF

9. Prof. DR.Dr.Ariyanto Harsono SpA(K) 9 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

10. 10 Prof. DR.Dr.Ariyanto Harsono SpA(K)

11. 11 Prof. DR.Dr.Ariyanto Harsono SpA(K)

12. Prof. DR.Dr.Ariyanto Harsono SpA(K) 12 4. Functional Pathology response: *Increased vascular permeability: swollen, hypotension * Smooth muscle contraction * Secretion of mucus * Changes in excitability and cardiac muscle contractability

13. Prof. DR.Dr.Ariyanto Harsono SpA(K) 13 Nature Rev Immunol 2004: 3:234-237

14. Prof. DR.Dr.Ariyanto Harsono SpA(K) 14 5. Inflammation and involvement of secondary mediators: *Leukocyte infiltration by chemotactic * Platelet Aggregation * Complement Activation * Proteolytic break-down

15. Prof. DR.Dr.Ariyanto Harsono SpA(K) 15 Complement Activation

16. Prof. DR.Dr.Ariyanto Harsono SpA(K) 16 Complement Activation …

17. Prof. DR.Dr.Ariyanto Harsono SpA(K) 17 Effector mechanisms against extracellular pathogens COMPLEMENT Activation Bacteria in plasma Ab & COMPLEMENT + Phagocytosis binding Complement & Fc receptor Lysis Opsonisation

18. Prof. DR.Dr.Ariyanto Harsono SpA (K) 18 Etiology 1. 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

19. 19 Etiologi 1. 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

20. Prof. DR.Dr.Ariyanto Harsono SpA (K) 20 Food: milk, eggs, marine fish Polysaccharides: Dextran Drugs: penicillin, cephalosporins , tetracyclines , Aminoglikosid , Cyclophosphamide , Metrotrexate Other: Heparin, Tubokurarin , ethylenediamine , 2. Causes of non- IgE Blood products: IgA , albumin, Imonoglobulin , Complement C4, Cryoprecipitate dialysis membrane protamine L- Asperginase Murine monoclonal antibody penicillin

21. Prof. DR.Dr.Ariyanto Harsono SpA(K) 21 3. cause of anaphylactoid Jodium diagnostic materials, Decheolin , BSP, Fluoresin , Indosianin green Analgesics: Salicylates , NSAIDS, Aminopirin Antibiotics: Aminoglikosid Xylocain Alkaloids: Morphine, Codeine Drug: Histamine, Amphetamines, diuretics, anticonvulsants Food additives: Sulfites, Tartrasin , Sodium bensoat

22. Prof. DR.Dr.Ariyanto Harsono SpA (K ) 22 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

23. Prof. DR.Dr.Ariyanto Harsono SpA(K) 23

24. Prof. DR.Dr.Ariyanto Harsono SpA(K) 24 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

25. Prof. DR.Dr.Ariyanto Harsono SpA(K) 25 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

26. Prof. DR.Dr.Ariyanto Harsono SpA(K) 26 Differential Diagnosis Sinkope Subsides when placed in the recumbent position T, N: Normal Other symptoms of anaphylactic negative

27. Prof. DR.Dr.Ariyanto Harsono SpA(K) 27 Prevention 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

28. Prof. DR.Dr.Ariyanto Harsono SpA(K) 28 Management 1. Primary treatment Adrenaline 1:1000 with a dose of 0.001 ml / kg maximum: 0.3 ml subcutaneously Tourniquet on the proximal shock / injection Adrenaline 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

29. 29 Place the patient at shock position Pulmonal Ressuscitation Oropharyngeal airway Tube endotrakeal Tracheostomy Cardiac compression

30. Prof. DR.Dr.Ariyanto Harsono SpA (K) 30 Adrenaline HCL Dose 1:1000 according age Age Dose 2-6 Bulan 0.07 ml Bulan 0.1 ml 18-48 Bulan 0.15 ml 5 Tahun 0.2 ml 6-9 Tahun 0.3 ml 10-13 Tahun 0.4 ml >14 Tahun 0.5 ml

31. Prof. DR.Dr.Ariyanto Harsono SpA(K) 31 2. C omplementary 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

32. Prof. DR.Dr.Ariyanto Harsono SpA(K) 32 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 : C imetidine Corticosteroid : Solukortef 4-7 mg/kg i.v . continued with 4-7 mg/kg/24 hour oral ( devided 3 doses ) H1 H2 H3 H4 Down Regulation H1-antagonist H2-antagonist Histamin

33. Prof. DR.Dr.Ariyanto Harsono SpA(K) 33 Granule contents: Histamine,TNF- a Proteases, Heparin Lipid mediators: Prostaglandins Leukotrienes Cytokine production: Specifically IL-4, IL-13 Rapid onset Reaction Late onset Reaction Very Late Onset Reaction

34. Prof. DR.Dr.Ariyanto Harsono SpA(K) 34 Increase c apil a r y permeabilit y Fluid shift shock Urtikaria Wheezing

35. Prof. DR.Dr.Ariyanto Harsono SpA (K) 35 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 m g/kg/menit

36. Prof. DR.Dr.Ariyanto Harsono SpA(K) 36 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!

37. 37 Selesai