Rapid Diagnosis and

Treatment for
Anaphylactic Shock
A.Guntur H.
Subbagian Alergi-Imunologi Tropik Infeksi Bagian Ilmu
Penyakit Dalam
Fak. Kedokteran UNS. / RSUD.Dr. Moewardi Surakarta

Hypersensitivity Reactions
Reaction Type I (Anaphylaxis with AB Ig E)
Reaction type II (Cytolitic or cytotoxic with AB
Ig M / Ig G)
Reaction type III (immune complex reaction
with AB Ig M / Ig G)
Reaction type IV (cell-mediated immunity or
type reactions slow)

Type I Reaction
Anaphylactic reaction is a reaction of the host
change (Von Pirquet, 1906)
Anaphylactic reactions are type I allergic
reaction
Reactions may be local and systemic

Type I Allergy Reaction

Urticaria

allergic rhinitis

asthma bronchiole

anaphylactic shock

Type Allergen

Protein (Serum, Vaccines)

Powder plant (Pollens)
Drugs (penicillin, local anesthetics, Sulfa,
Contrast Ro)
Food (Peanuts, Food. Seafood, Eggs, Milk)
Products insects (mites / dust mite)
Spore
Hair & Fur animals
(Kuby, 2000)

Type I Reaction Stage

Stage I: Sensitization
Stage II: Activation
Stage III: Effectors

Guntur, 1999

Ca2+
Lyso PC

Mast Cells Wall

PMT I

PE

FUSOGEN

PHOSPO
LIPHASE

PC
PMT II

DEGRANULATION

PS

Ca2+

Microtubulus
and microfilaments
Swollen
granule

Granule

Arachidonic acid
Leukotriene A4

Prostaglandin D2

Mediators
(e.g., histamine)

(PGD2)

LTB4
LTC4
LTD4
LTE4

SRS-A

Secretion

antihistamin

Secretion

(Kuby, 2000)

Allergic Inflamation Respons

Antigen

IgE
Fc-

Acute phase

- Bronchus contraction asthma

- Perifer vasodilatation
- Capillary permeability increase
Mucous secretion increase
relative Hipovolemik

Infiltration eosinofil and netrofil

Eritema, fluid transudation

Urtikaria, Pruritus

Shock

Late phase

Cell Infiltration mononucleosis

(macrophage, fibroblast)
Tissue damage

TYPE I REACTION MEDIATOR

HISTAMIN
SEROTONIN
HEPARIN
ECF-A dan NCF - A

SRS - A (LTC4, LTD4, LTE4), & LTB4

PROSTAGLANDIN
BRADIKININ
SITOKIN (IL 1, TNF , IL-6, IL-8)
(Kuby, 2000)

CHARACTERISTICS OF TYPE I REACTION

1. IMMEDIATE REACTION
PEAK 30 MINUTES
LOST 2-3 HOURS
VASO ACTIVE
2. LATE REACTION
PEAK 4-6 HOURS
LOST 12-24 HOURS
inflammatory cells

Signs and Symptoms of anaphylaxis

Dermatologic

Angioedema, urticaria, pruritus, general

erythema

Respiratory

Dyspnea, chest tighness, wheeze, cough

Otorhinolaryngologi
c

Stridor, hoarseness, sneeze, nasa

congestion/itching, dysphagia

Gastrointestinal

Vomiting, nausea, abdominal pain, fecal

incontinence

Cardiovascular

Tachycardia, hypotension, syncope

Neurologic

Headace, mental status change

General

Anxiety, sense of impending doom, pallor

Shock Anaphylactic

Emergencies are characterized by

(hypotension) circulatory collapse
decrease in systolic blood pressure <90
mmHg accompanied by shortness of
breath due to type I hypersensitivity
response (the reaction of antigen with IgE
antibody)

Diagnosis

Careful anamnesis with alo / auto

diagnose.

There Anamnesa contact with allergens

Insect stings.

Symptoms of
anaphylactic shock

Severe systemic reaction: occurs suddenly,

such reactions were mild and moderate
system gain weight. laryngeal edema,
bronchospasm, hoarseness, stridor,
shortness of breath, cyanosis.
Edema and gastrointestinal hypermotility so
sick swallowing, stomach cramps, diarrhea,
vomiting and generalized seizures.
Cardiovascular disorders, cardiac
arrhythmias, collapse (shock).

Differential Diagnosis of Anaphylaxis

Pulmonary
Asthma, foreign body, aspiration, pulmonary embolus,
epiglottitis
Cardiac
Myocardial Infarction, cardiac arrest, arrhythmias
Shock
Cardiogenic, septic, hemorrhagic
Neurologic
Autonomic epilepsy, cerebrovascular accident
Psychogenic
Panic Attack, hyperventilation

Therapy

Shock
1.

In Private Clinic

Adrenalin solution of 1: 1000, amounting

to 0.3 to 0.5 ml subcutaneously /
intramuscularly in the upper arm or thigh.
Intramuscular more effective than
subcutaneous. This dose may be repeated
after 5-10 minutes if it does not show a
response.
Preparation was sent to the hospital.

2.

In the polyclinic Hospital

Adrenalin solution of 1: 1000, amounting to

0.3 to 0.5 ml subcutaneously /
intramuscularly in the upper arm or thigh.

Intramuscular more effective than

subcutaneous.

This dose may be repeated after 5-10

minutes if it does not show a response.

If the seizure was caused by an insect sting

anaphylaxis give second shot of adrenaline
surge from 0.1 to 0.3 ml in place unless the
sting in the head, neck, hands and feet.

O2 when tightness, wheezing, cyanosis 35 L / min with a lid or nasal kanuf.

IVFD Dextrose 5% in 0.45% NaCl 2-3
L/m2 body surface.
Antihistamines intravenous,
intramuscular or oral.
Corticosteroid hydrocortisone 7-10 mg /
kg followed 5mg/kgBB intreavena every
6 hours, which was stopped after 72
hours.

Pharmacology of
epinephrine
Epinephrine

1-receptor

vasoconstriction
peripheral vascular resistance
mucosal edema

2-receptor

insulin release
neropinephrine release

1-adrenergic
receptor

inotropy
chronotropy

Estelle FER. J Allergy Clin Immunol 2004;113:837-44

2-adrenergic
receptor

bronchodilation
vasodilation
glycogenolysis
mucosal edema

Absorption of epinephrine is faster

after intramuscular injection than
after subcutaneous injection

Intramuscular
epinephrine
(Epipen)

8 2 minutes

Subcutaneous
epinephrine

34 14 (5-120) minutes
p < 0.05

10

15

20

25

30

Time to Cmax after infection (minutes)

Estelle FER. J Allergy Clin Immunol 2004;113:837-44

35

When accompanied by spasm of the

bronchi that can be given:
Inhaled beta-2 agonists.
If bronchospasm settled aminophylline
4-6 mg / kg dissolved in 10 ml 0.9%
NaCl given slowly in 20 minutes, if
necessary followed by aminophylline
infusion of 0.2 to 1.2 mg / kg / hour.

Monitoring at least 24 hours

Complication

Severe laryngeal edema.

Irreversible shock, multi organ failure.

If the above measures do not improve,

followed

by treatment in the ICU patient.

Prognosis
Fatality from anaphylactic shock,
although rare,
can occur most commonly from the
number of organs involved and the
severity of symptoms.
cardiovascular collapse and airway
obstruction if treated late.

Summary

Anaphylactic shock is a type I allergic

reactions and systemic nature occur very
quickly which could endanger the lives of
patients.
Whatever drugs that enter the body can
cause even the slightest reaction type I.
What is important is early recognition of the
risk of septic shock.
Giving adrenalin early is highly
recommended.