Understanding Anaphylactic Shock
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ScribdTranslationsUnderstanding Anaphylactic Shock
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ScribdTranslationsAnaphylactic Shock
Pr. AIT SLIMANE
Emergency Services
Bab El Oued Hospital
Plan
• Definitions
• Elements of pathophysiology
• Clinical presentation
• Emergency treatment
• Diagnostic investigations
• Long-term support
Definitions
Atopy:
Tendanceconstitutionnelled’unsujetàprésenter
immediate hypersensitivity reactions to some
allergens
Allergy:
Abnormal reactivity of a subject towards a
antigen
Anaphylaxis:
Severe allergic reaction, with difficulties
respiratory and/or hypotension
Anaphylactic shock:
State of shock due to an allergic reaction
Definition of shock
anaphylactic
Severetroubleofcirculatoryhomeostasis
induced by introduction into the organism
of a responsible foreign substance
of
immune reactions, shock
anaphylaxis
tique represents the most significant manifestation
severe immediate hypersensitivity.
Elements of pathophysiology
Anaphylaxis is the most severe manifestation.
immediate hypersensitivity reactions (type I)
from the classification of Gell and Coombs
It involves IgE antibodies, an allergen and
cells of the immune system (mast cells,
PN basophils
It takes place in 2 successive phases:
"Preparing contact": first meeting with
the allergen and synthesis of IgE, which will bind to the
mast cells and basophils (Fc receptor)
Triggering contact: fixation of the allergen on IgE
then cellular degranulation
Pathophysiology:
Cellular activation
14 days
Ag Ag
1st contact 2nd contact
Pathophysiology:
Anaphylactoid reactions
Activation des mastocytes et basophiles
by direct non-IgE dependent mechanism
Possible reaction from the first contact with
the antigen
Indiscernible clinical expression of the
IgE dependent reaction
So: Anaphylactic Clinical Syndrome
With several mechanisms
physiopathological
Pathophysiology:
The responsible agents
Foods
Egg, fish, shellfish, strawberries, peanut...
Venoms of Hymenoptera
Bees, wasps, hornets...
Medications
IgE dep: penicillins, cephalosporins, Aspirin,
AINS
Non IgE dependent: Aspirin, NSAIDs, morphine, products
of radio contrast, curatives…
Latex
Others: Vaccines, serums, enzymes, cold,
exercise...
We distinguish: haptenes, proteins,
polysaccharides…
Pathophysiology:
The mediators
"Pre-trained" mediators
Histamine +++
Chemotactic factors (ECF-A, NCA...)
Tryptase, Kallikreins, hydrolases...
Néo-trained mediators
Metabolites of arachidonic acid
Cyclooxygenase Pathway: Prostaglandins,
prostacyclines, thromboxanes
Lipoxygenase Pathway: leukotrienes
Platelet activating factor (PAF)
Pathophysiology:
Actions of the mediators
Vasodilation and increased permeability
hair
Hypotension, shock
Hives, Flush
Angioedema
Laryngeal edema
Interstitial edema
Laryngeal edema, Angioedema
Rhinitis
Asthmatic dyspnea
Smooth muscle contraction
asthmatic dyspnea
Abdominal pain
Pulmonary or coronary arterial vasoconstriction
Clinical presentation
Approximately 1000 deaths per year (USA)
Population at risk of anaphylaxis (US data)
Penicillin: 2 to 20 million
Venoms: 1 to 10 million
Contrast agents: 20,000 to 100,000
Food: 1000
Latex: 200
Delay of appearance of signs after stimulation
Variable by way of introduction: sting < mucosa
A few minutes to a few hours
Non-specific signs
Malaise, anxiety
Palmar-plantar itching, tingling
Cardiovascular signs: the
choc
Mechanism: Vasoplegia, capillary leakage
The shock is a shock due to relative hypovolemia
Hypotension: < 90 mmHg
Tachycardia
Fast pulse, barely perceived
Choc says 'Hot': peripheral vasodilation
Hemodynamic table of shock
Initially (2-3 min): PA , DC , RVS , PVC ,
FATHER
Then: PA , DC , RVS , PVC DAD
Risk: CARDIAC ARREST (disarming, trouble)
rhythm
Respiratory signs
Upper airways and
lower
By increasing permeability
capillary, interstitial edema and
smooth contraction fibers mm
Bronchospasm: RESPIRATORY ARREST
Quincke's edema: Asphyxia, Stop
respiratory
Other signs:
Rhinorrhea, nasal obstruction
Toux sèche, raucité de la voie
Cutaneous-mucosal signs
Start: regions rich in mast cells and
basophiles
Face, neck, face Ant thorax
Association of:
Itching
Urticaria
Lobster red erythema
horripilation
Angioedema
Reaches the face, the neck, the tongue
May extend to the larynx with dysphonia,
dyspnea
Major risk: Asphyxia, Respiratory arrest
Images...
Images...
Images...
Other signs
Gastrointestinal signs
Hypersalivation
Vomiting
Abdominal pain
Diarrhea, sometimes hemorrhagic
Neurological signs (anoxia)
Headaches, confusion, dizziness,
tinnitus
Visual disturbances, Seizures
Some clinical forms
Severity
Variable depending on the signs present
Maximum in case of respiratory distress
Thermodynamics
Aggravating factors +++
-blockers: bradycardia, hypotension
severe adrenaline resistant
IEC: aggravation of collapse
Asthma, heart failure: background
aggravating
Severity grades of the reaction
anaphylactic
Skin and digestif respiration cardiovascular
mucosa re
s
Erythema grade,
1 itching
hives
angioedema
Grade erythema nausea rhinorrhea tachycardia
2 urticaria Cramps cough hypotension
conjunctivitis abs dyspnea
angioedema hoarse voice
Erythema grade, vomiting Edema choc
3 urticaria defecation laryngeal
Conjunctivitis diarrhea bronchospasm
angioedema ,
cyanosis
Erythema grade, vomiting stop Inefficiency
4 urticaria defecation cardio-respiratory
conjunctivitis diarrhea circulatory
angioedema
Differential diagnostics
Other shocks
Septic
Cardiogenic
Hemorrhagic
Tamponade
The clinical context allows for the most
often to make a difference
Sometimes, more difficult, especially during
of general anesthesia
Care in
URGENT
Stop contact with the allergen
2. Cardiopulmonary resuscitation
Raise the legs
Airway freedom, ventilation, O2
MCE and cardiac arrest
2bis: Alert emergency services
3. ADRENALINE( +, 1+ 2+)
1 mg subcutaneously (10 g/kg for children)
In IV, bolus of 0.1 to 0.2 mg
Possible inhaled route (Aerosol in case of edema of
Quincke, or directly in intubation probe)
4. Hospitalization in intensive care for continuation
of treatment and monitoring
Adjuvanttreatments
Vascular filling (crystalloids,
colloids
Corticosteroids
ARE NOT the emergency treatment of shock
anaphylactic
Because their action is delayed
Prescription possible for anti-edema role
and prevention of early relapses (especially in cases
of food allergen
Hydrocortisone Hemisuccinate IV: 100 mg, then
100 mg X 6
Then Cortancyl, 1 mg/kg orally, for 7 to 10
days
Aucun intérêt aux antihistaminiques après
Diagnostic investigations
Immediate assessment
2 tubes of blood (dry and EDTA)
Histamine and tryptase in blood
Specific IgE search (venoms, latex,
medications
Allows differentiation of reactions
anaphylactic/anaphylactoid
Sometimes of medico-legal interest
Secondary allergological assessment
4 to 6 weeks later
Skin tests: Prick test, Patch test
But: responsible allergen identifier
Long-term support
Inform the patient, explain the illness, avoid contact
with allergen
Card holder, bracelet
List of products containing the allergen
Explain the steps to take in case of a relapse
To the patient, to the relatives: adrenaline, call for help
Usefulness of the mobile phone...
Prescription for an emergency kit containing
the adrenaline
Ready-to-use kit: AnaHelp, AnaKit
Always keep the kit on you (and not in the refrigerator), or even
several kits
Fears light and heat (turns brown-pink, but does not become
non-toxic
The emergency kit of every doctor must include
adrenaline...
Consider desensitization (especially venoms)
Antiallergic protocol for Rx examination (Anti H1,
corticoïdes)