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    EMERGENCY TREATMENT

    OFANAPHYLACTIC REACTIONS

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    DEFINITION

    The European Academy of Allergology and

    Clinical Immunology Nomenclature Committee :ANAPHYLAXIS IS A SEVERE, LIFE-THREATENING, GENERALISED OR SYSTEMIC

    HYPERSENSITIVITY REACTION.

    LIFE-THREATENING AIRWAY AND/OR

    BREATHING AND/OR CIRCULATIONPROBLEMS

    ASSOCIATED WITH SKIN AND MUCOSAL CHANGE

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    TRIGGER

    TRIGGER CASE

    Stings 47 29 wasp, 4 bee, 14 unknown

    Nuts 32 10 peanut, 6 walnut, 2 almond, 2 brazil, 1 hazel, 11 mixed or unknown

    Food 13 5 milk, 2 fish, 2 chickpea, 2 crustacean, 1 banana, 1 snail

    Food possible cause 17 5 during meal, 3 milk, 3 nut, 1 each - fish, yeast, sherbet, nectarine,grape, strawberry

    Antibiotics 27 11 penicillin, 12 cephalosporin, 2 amphotericin, 1 ciprofloxacin, 1vancomycin

    Anaesthetic drugs 39 19 suxamethonium, 7 vecuronium, 6 atracurium, 7 at induction

    Other drugs 24 6 NSAID, 3 ACEI, 5 gelatins, 2 protamine,2 vitamin K, 1 each - etoposide, acetazolamide, pethidine, localanaesthetic, diamorphine, streptokinase

    Contrast media 11 9 iodinated, 1 technetium, 1 fluorescein

    Other 3 1 latex, 1 hair dye, 1 hydatid

    Suspected triggers for fatal anaphylactic reactions in the UK between 1992-2001

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    TIME COURSE FOR FATAL

    ANAPHYLACTIC REACTIONS When anaphylaxis is fatal, death usually occurs

    very soon after contact with the trigger.

    From a case-series, fatal food reactions causerespiratory arrest typically after 3035 minutes;

    insect stings cause collapse from shock after 10

    15 minutes; and deaths caused by intravenous

    medication occur most commonly within fiveminutes.

    Death never occurred more than six hours after

    contact with the trigger.

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    RECOGNITION OF AN ANAPHYLACTIC

    REACTION A diagnosis of anaphylactic reaction is likely if a

    patient who is exposed to a trigger

    (allergen) develops a sudden illness (usually

    within minutes of exposure) with rapidlyprogressing skin changes and life- threatening Aand/or B and/or C problems. The reaction isusually unexpected.

    The lack of any consistent clinical manifestation

    and a range of possible presentations causediagnostic difficulty. Many patients with agenuine anaphylactic reaction are not given thecorrect.

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    When recognising and treating any acutely illpatient, a rational ABCDE approach must be

    followed and life-threatening problems treatedas they are recognised

    Anaphylaxis is likely when all of the following 3

    criteria are met :1. Sudden onset and rapid progression of

    symptoms

    2. Life-threatening Airway and/or Breathingand/or Circulation problems

    3. Skin and/or mucosal changes (flushing,urticaria, angioedema)

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    Remember :

    Skin or mucosal changes alone are not a sign of an

    anaphylactic reaction Skin and mucosal changes can be subtle or absent

    in up to 20% of reactions (some patients can have

    only a decrease in blood pressure, i.e., aCirculation problem)

    There can also be gastrointestinal symptoms (e.g.vomiting, abdominal pain, incontinence)

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    Use the ABCDE approach to

    recognise

    AIRWAY PROBLEMS

    BREATHING PROBLEMS CIRCULATION PROBLEMS

    DISABILITY PROBLEMS

    EXPOSURE PROBLEMS

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    TREATMENT OF

    AN ANAPHYLACTIC REACTIONThe specific treatment depends on :1. Location : Out of hospital, an ambulance must be called

    earlypatient transported to an ED.

    2. Training and skills of rescuers : Clinical staff who giveparenteral medications should have initial training andregular updates in dealing with anaphylactic reactions.

    3. Number of responders : The single responder must alwaysensure that help is coming.

    4. Equipment and drugs available : Resuscitation equipment& drugs for rapid resuscitation must be immediatelyavailable in all clinical settings. Clinical staff should befamiliar with the equipment and drugs they have availableand should check them regularly.

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    Patients having an anaphylactic reaction in any

    setting should expect the following as a minimum:

    1. Recognition that they are seriously unwell.

    2. An early call for help.3. Initial assessment and treatments based on

    an ABCDE approach.

    4. Adrenaline therapy if indicated.5. Investigation and follow-up by an allergy

    specialist.

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    Patient positioning

    The following factors should be considered :

    1. Patients with Airway and Breathing problems mayprefer to sit up as this will make breathing easier.

    2. Lying flat with or without leg elevation is helpful forpatients with a low blood pressure (Circulation

    problem). If the patient feels faint, do not sit or standthem up - this can cause cardiac arrest.

    3. Patients who are breathing and unconscious should beplaced on their side (recovery position).

    4. Pregnant patients should lie on their left side toprevent caval compression.

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    Remove the trigger if possible

    Removing the trigger for an anaphylactic reaction is

    not always possible.1. Stop any drug suspected of causing an

    anaphylactic reaction (e.g., stop intravenousinfusion of a gelatin solution or antibiotic).

    2. Remove the stinger after a bee sting. Earlyremoval is more important than the method ofremoval.

    3. After food-induced anaphylaxis, attempts to

    make the patient vomit are not recommended.4. Do not delay definitive treatment if removing

    the trigger is not feasible.

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    Cardiorespiratory arrest following ananaphylactic reaction

    1. Start cardiopulmonary resuscitation (CPR)immediately and follow current guidelines.

    2. Rescuers should ensure that help is on its

    way as early advanced life support (ALS) isessential.

    3. Use doses of adrenaline recommended in

    the ALS guidelines.4. The intramuscular route for adrenaline is

    not recommended after cardiac arrest hasoccurred.

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    ANAPHYLAXIS ALGORITHM

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    DRUGS AND THEIR DELIVERY

    1. ADRENALINE

    2. OXYGEN

    3. FLUIDS

    4. ANTIHISTAMINE

    5. CORTICOSTEROID

    6. OTHER DRUGS

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    ADRENALINE

    The most important drug for the treatment of an

    anaphylactic reactionlogical treatment.

    Alpha-receptor agonistreverses peripheralvasodilation and reduces oedema

    Beta-receptor activity dilates the bronchialairways, increases the force of myocardialcontraction, and suppresses histamine and

    leukotriene release. Beta-2 adrenergic receptors on mast cells

    inhibit activation

    Adrenaline attenuates the severity of IgE-

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    THE RISK OF ADRENALIN

    Adrenaline is not without risk, particularlywhen given intravenously.

    Adverse effects are extremely rare withcorrect doses injected intramuscularly (IM).Sometimes there has been uncertainty aboutwhether complications (e.g., myocardial

    ischaemia) have been caused by the allergenitself or by the adrenaline given to treat it.

    ?

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    WHY IS GIVEN INTRAMUSCULAR ? The IM route has several benefits :

    1. There is a greater margin of safety.

    2. It does not require intravenous access.3. The IM route is easier to learn.

    The best siteanterolateral of the middle third of the thigh.The needle needs to be sufficiently long to ensure that the

    adrenaline is injected into muscle. The subcutaneous / inhaled routes are not recommended.

    Repeat the IM adrenaline dose if there is no improvement inthe patients condition.Further doses can be given at about 5-

    minute intervals according to the patientsresponse. Monitor the patient as soon as possible (pulse, BP, ECG, pulse

    oximetry). This will help monitor the response to adrenaline.

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    ANTIHISTAMINES

    Antihistamines are a second line treatment.

    Antihistamines (H1) may help counter histamine-mediated vasodilation and bronchoconstriction.

    Inject chlorphenamine or diphenhydramine slowlyintravenously or intramuscularly. The dose dependson age : (Diphenhydramine)

    Adult : 50 mg iv or imChildren : 5 mg/kgBB

    There is little evidence to support the routine use of

    an H2-antihistamine for the initial treatment.

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    STEROIDS

    Corticosteroids may help prevent or shortenprotracted reactions. In asthma, earlycorticosteroid treatment is beneficial in

    adults and children. There is little evidence on which to base the

    optimum dose of hydrocortisone inanaphylaxis.

    Inject hydrocortisone slowly intravenously orintramuscularly, taking care to avoid inducingfurther hypotension.

    Ind : dexamethasone and methyl

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    OTHER DRUGS

    Bronchodilators : salbutamol (inhaled or IV),ipratropium (inhaled), Aminophylline (IV) ormagnesium (IV).

    Cardiac drugs : vasopressors and inotropes(noradrenaline, vasopressin, dopamin) wheninitial resuscitation with adrenaline and fluids

    has not been successful. IV atropine for bradycardia.

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    STEPS TO RECOGNISE AND TREAT

    ANAPHYLAXIS

    ( )

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    AIRWAY (A)

    Airway obstruction is an emergency. Get expert

    help immediately.1. Look for the signs of airway obstruction :

    Complete or severe airway obstruction

    paradoxical chest & abdominal movements. The use of the accessory muscles of

    respiration.

    Central cyanosis is a late sign of airwayobstruction.

    Complete airway obstructionthere areno breath sounds at the mouth or nose.

    In partial obstruction, air entry is diminished

    AIRWAY (A)

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    AIRWAY (A)

    2. Treat airway obstruction as an emergency :

    In most cases where airway obstruction iscaused by the tongue falling to the back of thethroat, e.g., loss of consciousness because of

    hypotension, only simple methods of airwayclearance are needed (e.g., airway openingmanoeuvres, suction, insertion of anOPA/NPA).

    Anaphylaxis can cause airway swelling

    (pharyngeal or laryngeal oedema)obstruction may be very difficult and early

    tracheal intubation is often required. This

    AIRWAY (A)

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    AIRWAY (A)

    3. Give oxygen at high concentration :

    Give high concentration oxygen using a mask

    with an oxygen reservoirhigh flow oxygen(greater than 10 lt/min). If the patients trachea

    is intubatedself-inflating bag. In acute respiratory failure, try to maintain the

    PaO2as close to normal as possible (100

    mmHg). In the absence of AGB, use pulseoximetry to guide oxygen therapy. Aim for anoxygen saturation of 94-98%. If is not alwayspossible, you may have to accept lower values

    (60 mmHg) ~ 90-92% oxygen saturation on a

    BREATHING (B)

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    BREATHING (B)1. Immediate assessment of breathingdiagnose

    and treat immediately life-threatening (acute

    severe bronchospasm).Look, listen and feel for the general signs ofrespiratory distress : sweating, central cyanosis,use of the accessory muscles of respiration,subcostal and sternal recession in children, andabdominal breathing.

    2. Count the RR. The normal adult rate is 12

    20x/min. A high, or increasing, respiratory rate isa marker of illness and a warning that the patient

    may deteriorate suddenly.the depth of eachbreath, the pattern (rhythm) of respiration andwhether chest ex ansion is e ual and normal on

    BREATHING (B)

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    BREATHING (B)

    3. Record the inspired oxygen concentration (%)given to the patient and the SpO2reading of thepulse oximeter. The patient may be breathing

    inadequately and have a high PaCO2.4. Listen to the patients breath sounds a short

    distance from his face. Stridor or wheezesuggests partial, but important, airway

    obstruction. Bronchospasm causing wheeze iscommon in anaphylaxis. All critically ill patientsshould be given oxygen.

    BREATHING (B)

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    BREATHING (B)

    5. Initially give the highest possible concentrationof inspired oxygen. As soon as a pulse oximeter isavailable, titrate the oxygen to maintain anoxygen saturation of 94-98%.

    6. If the patients depth or rate of breathing is

    inadequate /stopped breathing (apnea)use apocket mask. Upper airway obstruction or

    bronchospasm may make bag mask ventilationdifficult or impossible. Early tracheal intubationshould be considered.

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    Perkiraan Tekanan Parsial Oksigen

    (PaO2)

    dibandingkanTingkat Saturasi Oksigen (SaO2)

    Tingkat PaO2 Tingkat SaO2

    90 mmHg 100%

    60 mmHg 90%

    30 mmHg 60%

    27 50%

    CIRCULATION (C)

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    CIRCULATION (C)

    In anaphylaxis the shock is usually caused byvasodilation and fluid leaking from capillaryblood vessels (hypovolaemia). Unless there

    are obvious signs of a cardiac cause (e.g.,chest pain, heart failure), give intravenousfluid to any patient with low blood pressureand a high heart rate.

    Remember that breathing problems, whichshould have been treated earlier on in thebreathing assessment, can also compromisea patients circulatory state.

    CIRCULATION (C)

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    CIRCULATION (C)

    1. Look at the colour of the hands and digits : arethey blue, pink, pale or mottled?

    2. Assess the limb temperature by feeling the

    patients hands : are they cool or warm?3. Measure the capillary refill time. The normal refill

    time is less than two seconds. A prolonged time

    suggests poor peripheral perfusion.4. Count the patients pulse rate.

    CIRCULATION (C)

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    CIRCULATION (C)6. Palpate peripheral & central pulses

    presence, rate, quality, regularity and equality.Barely palpable central pulses suggest a poorcardiac output.

    7. Measure the patients blood pressure. Even in

    shock, the blood pressure may be normal,because compensatory mechanisms increaseperipheral resistance in response to reduced

    cardiac output.A low diastolic BParterial vasodilation (as inanaphylaxis or sepsis). A narrowed pulsepressure (difference between systolic and

    diastolic pressures)arterial vasoconstriction

    CIRCULATION (C)

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    CIRCULATION (C)

    8. Listen to the heart sounds.

    9. Lie the person flat /raise the legsit may worsenany breathing problems.

    10. Pregnantleft lateral tilt of at least 15 degrees to

    avoid caval compression. After 20 weeks gestationuterus can press down on the inferior vena cavaand impede venous return to the heart.

    CIRCULATION (C)

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    CIRCULATION (C)

    11. Insert large-bore iv cannulaeuse short, wide-

    bore cannulaehighest flow. Intra osseousaccess in children when iv access is difficult.

    12. Give a rapid fluid challenge : Adults - 500 mL of

    warmed crystalloid solution (Hartmanns or 0.9%saline) if the patient is normotensive or 1000 mL ifthe patient is hypotensive. Patients with cardiac

    failuresmaller volumes (250 mL and use closer

    monitoring (listen to the chest for crepitationsafter each bolus). For children give 20 mL/kg ofwarmed crystalloid.

    13. Reassess the pulse rate and BP regularly (every 5

    DISABILITY (D)

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    DISABILITY (D)

    Common causes of unconsciousness include profound

    hypoxia, hypercapnia, cerebral hypoperfusion due tohypotension.

    1. Review and treat the ABC : exclude hypoxia andhypotension.

    2. Examine the pupils (size, equality, and reaction tolight).

    3. Assess the patients conscious level rapidly usingthe AVPU orGCS.

    4. Measure the blood glucose to excludehypoglycaemia.

    5. Nurse unconscious patients in the lateral position if

    EXPOSURE (E)

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    EXPOSURE (E)

    To examine properly, full exposure of the body is

    necessary. Respect the patients dignity. Skin and mucosal changes after anaphylaxis can

    be subtle.

    Skin and/or mucosal changes are often the firstfeature and present in over 80% of anaphylacticreactions.

    There may be just skin, just mucosal, or both skinand mucosal changes.

    There may be erythema or there may be urticaria.

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    REFERENCES

    Anestesiologi. Soenarjo, Marwoto,Witjaksono, dkk. Cetakan I. Semarang :IDSAI; 2010.

    Emergency medical treatment ofanaphylactic reactions. Project Team of TheResuscitation Council (UK). Resuscitation

    1999;41(2):93-9.

    Journal Allergy Clinical ImmunologyAnaphylaxis : A review of causes and

    h