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

Anaphilactic Shock

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

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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

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

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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 PLASMASEL MEMORI

IL-6

IL-10

CTL MHC-I

L

MEMORY CELLS

AktifasiKomplemen

Blocking Antibody

Precipitatigng

Aglutinating AB

Anafilaksis

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

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PathophysiologyThere are 5 stages:1. Mast cells / basophils walls change therefore stimuli:       * Allergens-IgE       * Aggregation of immune complex       * Activation of complement

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

5Mast Cells and basophiles involve in allergic reaction in the context of antigen-IgE

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

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Granule contents:Histamine,TNF-aProteases, Heparin Lipid mediators:

ProstaglandinsLeukotrienes

Cytokine production:Specifically IL-4, IL-13

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

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2. Cell wall enzyme activation:

*Arachidonic acid breakdown

       * Decrease in the ratio of cAMP / cGMP

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

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Arachidonic Acid

Phospholiphase A

Cyccloxygenase Lipoxygenase

Prostaglandine

TXA

Prostacyclin

Leukotriene A

Leukotriene B

Leukotriene C

HETE,5-HETE, PAF

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

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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

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

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

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4. Functional Pathology response:

*Increased vascular permeability: swollen, hypotension

* Smooth muscle contraction* Secretion of mucus* Changes in excitability and cardiac

muscle contractability

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

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Nature Rev Immunol 2004: 3:234-237

14Prof. DR.Dr.Ariyanto Harsono SpA(K)

5. Inflammation and involvement of secondary mediators:

*Leukocyte infiltration by chemotactic* Platelet Aggregation* Complement Activation* Proteolytic break-down

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

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Complement Activation

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

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Complement Activation …

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

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Effector mechanisms against extracellular pathogens

COMPLEMENT ActivationBacteria in plasma

Ab & COMPLEMENT

+

Phagocytosis

binding

Complement &Fc receptor

Lysis

Opsonisation

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

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Etiology1. 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

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Etiologi1. 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

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

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oFood: milk, eggs, marine fishoPolysaccharides: DextranoDrugs: penicillin, cephalosporins, tetracyclines,

Aminoglikosid, Cyclophosphamide, MetrotrexateoOther: Heparin, Tubokurarin, ethylenediamine,

2. Causes of non-IgEoBlood products: IgA, albumin, Imonoglobulin,

Complement C4, Cryoprecipitateodialysis membraneoprotamineoL-AsperginaseoMurine monoclonal antibodyopenicillin

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

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3. cause of anaphylactoidJodium diagnostic materials, Decheolin, BSP,

Fluoresin, Indosianin greenAnalgesics: Salicylates, NSAIDS, AminopirinAntibiotics: AminoglikosidXylocainAlkaloids: Morphine, CodeineDrug: Histamine, Amphetamines, diuretics,

anticonvulsantsFood additives: Sulfites, Tartrasin, Sodium

bensoat

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

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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

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

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

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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

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

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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

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

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Differential Diagnosis

Sinkopeo Subsides when placed in the recumbent

positiono T, N: Normalo Other symptoms of anaphylactic negative

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

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Prevention1. 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

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

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Management1. Primary treatment

Adrenaline 1:1000 with a dose of 0.001 ml / kg maximum: 0.3 ml subcutaneously

Tourniquet on the proximal shock / injectionAdrenaline 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

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•Place the patient at shock position•Pulmonal Ressuscitation•Oropharyngeal airway

•Tube endotrakeal•Tracheostomy

•Cardiac compression

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

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Adrenaline HCL Dose 1:1000 according age

Age Dose

2-6 Bulan 0.07 ml12 Bulan 0.1 ml18-48 Bulan 0.15 ml5 Tahun 0.2 ml6-9 Tahun 0.3 ml10-13 Tahun 0.4 ml>14 Tahun 0.5 ml

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

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2. Complementary 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

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

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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 : Cimetidine

• Corticosteroid: Solukortef 4-7 mg/kg i.v. continued with 4-7 mg/kg/24 hour oral (devided 3 doses)

H1

H2

H3

H4

H1-antagonist

H2-antagonist

Histamin

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

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Granule contents:Histamine,TNF-aProteases, Heparin Lipid mediators:

ProstaglandinsLeukotrienes

Cytokine production:Specifically IL-4, IL-13

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

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Increase capilary permeability

Fluid shift shockUrtikariaWheezing

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

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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 mg/kg/menit

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

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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!

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