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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