Anaphylaxis

Larisa Rezneac, MD, PhD

Emergency Medicine

ANAPHYLAXIS
Anaphylaxis is a systemic allergic
reaction, severe, potentially fatal,
acute occurs after contact with the
allergen. (Second symposium on the definition and management of anaphylaxis:
Summary reportSecond National Institute of Allergy and Infectious Disease/Food Allergy and
Anaphylaxis Network symposium)

ANAFILAXIA OCUL ANAFILACTIC

ANAFILAXIA OCUL ANAFILACTIC

ANAPHYLAXIS
Incidence
21 to 100.000 person-year adult

10.5
per
100,000
person-year
Yocum et al. J Allergy Clin Immunol 1999

Bohlke et al. J Allergy Clin Immunol 2004

children

ANAFILAXIA OCUL ANAFILACTIC

Lethality by
anaphylaxis
Lethality is related to ~ 4%
Increased risk in the presence:
1. Severe hypotension,
2. Bradycardia,
3. Bronchospasm claimed
inadequate response to
epinephrine administration,
4. Adrenal insufficiency
5. Asthma
ANAFILAXIA OCUL ANAFILACTIC

6. Heart disease

Lethality by anaphylaxis
following age groups

ANAFILAXIA OCUL ANAFILACTIC

Underlying mechanisms of
anaphylaxis is immune:
The development of anaphylactic reactions
are different phases:
Sensitization phase (48-72 hours)
Pathochimical phase
Pathophysiological phase

ANAFILAXIA OCUL ANAFILACTIC

Sensitization phase (48-72

hours)
The primary contact
with the allergen
occurs synthesis of
IgE , which is
attached to the
tissue mast cells and
basophil (sensitized
cells).

ANAFILAXIA OCUL ANAFILACTIC

PATHOCHIMICAL PHASE
Repeated contact with the
allergen forms AntigenAntibody reaction with
tissue basophils and mast
cells degranulation and
release of biologically active
substances (histamine,
bradykinin, leukotrienes,
cytokines, slow reactive
substance of anaphylaxis)
ANAFILAXIA OCUL ANAFILACTIC

PATHOPHYSIOLOGICAL PHASE
INCREASE vascular permeability - angioedema,
urticaria, pulmonary edema
Peripheral vasodilation - hypotension, shock
Muscle spasms - bronchospasm, larigospasm,
intestinal colic, renal colic.

ANAFILAXIA OCUL ANAFILACTIC

Anaphylactoid reaction
Missing the sensitization phase and
the phases pathochimical and
pathophysiological runs without IgE
involvement

Mechanisms are involved:

Histamine release
Activating compliment system
Disorders in the synthesis of
arachidonic acid
ANAFILAXIA OCUL ANAFILACTIC

Classification of generalized
hypersensitivity reactions
Mild (affecting the skin and
subcutaneous tissue) - erythema,
urticaria, periorbital edema,
angioedema.
MODERATE (involving the respiratory,
gastrointestinal, cardiovascular)
nausea, vomiting, wheezing, chest
discomfort, abdominal pain
SEVERE- hypotension <90 mm HG,
hypoxia Sp O <92%, confusion,
ANAFILAXIA OCUL ANAFILACTIC
unconsciousness.

CLASSIFICATION
Anaphylactic reaction (allergic or IgE
itself dependent)
Anaphylactoid reaction (pseudo or nonIgE dependent)

ANAFILAXIA OCUL ANAFILACTIC

Common Causes of Allergic Reactions

Insect Stings
Plants

Foods

Medications

Four Routes of Anaphylaxis

INHALATION

INGESTION

INJECTION

ABSORPTION

IgE antigens
Proteins:
latex
Insect venom (bees, ants)
Sperm
Protamine
Chymopapain

ANAFILAXIA OCUL ANAFILACTIC

IgE antigens
MEDICINES
Antibiotics and antimicrobial
Sulfanilamide
allergenic extracts

ANAFILAXIA OCUL ANAFILACTIC

IgE antigens
FOOD
Milk
Eggs
Nuts
Fruits and vegetables
Fish

ANAFILAXIA OCUL ANAFILACTIC

Antigens mediators of
anaphylactoid reactions
Ag activators of compliment:
Blood and its derivatives
Immunoglobulins
Products containing iodine

ANAFILAXIA OCUL ANAFILACTIC

Antigens mediators of
anaphylactic reactions
ELIBERATE of HISTAMINE:
Beer, chocolate, cheese
narcotic
local anesthetics

Inhibition of the enzyme cyclooxygenase :

NSAIDs
Tartrazine (E 102)

ANAFILAXIA OCUL ANAFILACTIC

Clinical Manifestations
1. Hemodynamic form:
Tachycardia (27%)
Pallor, diaphoresis,
Hypotension (11%)
Chest pain (3%)
Bradycardia (2%)
Cardiac arrest.
Seminar Respirator Critical Care 2004
ANAFILAXIA OCUL ANAFILACTIC

2. Asphyxic form:
Respiratory symptoms:
rhinorrhea
Laryngeal / pharyngeal
hoarse voice
Cough, shortness of breath
Respiratory stridor, wheezing,
Chest discomfort

ANAFILAXIA OCUL ANAFILACTIC

3. Mucocutaneous form:
Skin manifestations:

Erythema (55%), rash (85%), pruritis,

angioedema (90%)

Ocular manifestations:

Itching, tearing, "red eye" (23%)

Genitourinary symptoms:

Pain, dysuria, meno / metrorrhagia, imminent

miscarriage or premature birth

ANAFILAXIA OCUL ANAFILACTIC

4. Abdominal form:
Nausea
Vomiting
Abdominal cramps
Swelling of the tongue
Diarrhoea

ANAFILAXIA OCUL ANAFILACTIC

5. Brain shape
Headache
Vertigo
Seizures
Vomiting

ANAFILAXIA OCUL ANAFILACTIC

The evolution of anaphylaxis

Unistage
Unique Clinical
Second-Phase (4% - 20%)
Early allergic reaction
Recurrence of clinical signs over 1 -8 hours

ANAFILAXIA OCUL ANAFILACTIC

DIAGNOSTICUL
Based on:
history
clinical signs
Laboratory:
Serum tryptase
Histamine and metylhistamine (24 hours) in urine

ANAFILAXIA OCUL ANAFILACTIC

Algorithm of Emergency care

Patient position = > supine with / or
without lifting legs
- Beneficial hypotensive patients
- Contraindicated in the presence of
respiratory difficulties
Safety lateral position if patient is
unconscious with present breathing
The left lateral position in pregnant
women, that is to prevent vena cava
compression.
ANAFILAXIA OCUL ANAFILACTIC

Algorithm of Emergency care

Stopping exhibition of antigen (application a turnstile
proximal to the allergen inoculation) max 25 min
Extracting needle punctured
Sol. Epinephrine (adrenaline): 0.3 ml 0,5ml (1: 1000,)
5-6 infiltration around the inoculation site of
allergen.
ABC - algorithm

ANAFILAXIA OCUL ANAFILACTIC

Medicine of choice
Epinephrine (1: 1000) dose
0.01mg / kg, (proposed in
1925), max 0.5 mg I. M.
(maximum plasma concentration
over 8 minutes vs. 34 minutes
subcutaneous)
is repeated every 5 minutes to
stabilize the BP, max. 2mg.
is given in different places in the
side of the thigh
ANAFILAXIA OCUL ANAFILACTIC

ANAFILAXIA OCUL ANAFILACTIC

Rebalancing of volume
Orders !!!!!!!
Because in 10 minutes
extravasation of CBV is 50%
Sol. Refortan 6% to 10% 1020ml / kg
Crystalloids 10-20 ml / kg up to
hemodynamic stabilization.
bolus within 5 min
Children 20 ml / kg

ANAFILAXIA OCUL ANAFILACTIC

Antihistamines
Diphenhydramine 0,5-1 mg / kg PO / IM / IV
(max 75 mg)
Chlophenamina 10-20 mg
Ranitidine 1-2 mg / kg IM / IV
Adults - max 300 mg,
Children - max 50 mg

ANAFILAXIA OCUL ANAFILACTIC

CORTICOSTEROIDS
Hydrocortison 5-10 mg / kg IV
2-1 mg / kg IV Prednisolone
2 mg / kg IV Methylpredisolone (approx 250 mg)
That is effectiv of the iodine-induced anaphylaxis
Ineffective in the protracted reactions

ANAFILAXIA OCUL ANAFILACTIC

Bronchodilators
Salbutamol (Albuterol) aerosol 1 spray
(0.2 mg), the necessity readministration
1-2 min
Fenoterol (Berotec) aerosol 1 spray
(0.1 mg) as needed readministration 1-2
min
Sol Aminophylline 5-6 mg / kg i / v
slowly 20-30 min, followed by 0.5 mg /
kg / hr
Sol. Magnesium sulfate
40 / mg / kg
ANAFILAXIA OCUL ANAFILACTIC
ANAFILAXIA OCUL ANAFILACTIC
for 20 minutes

 Bradycardia
Atropine 0.5 to 1 mg IV

In patients receiving blocker

medication:
Glucagon1-2 mg IM, IV every 5 minutes
Magnesium sulfate 250 mg

ANAFILAXIA OCUL ANAFILACTIC

CONCLUSIONS: Anaphylaxis
Multisystemic syndrome resulting from systemic release of
mediators from mast cells and basophils ;
Acute start acute;
The variety of symptoms range from mild until to fatal;
IgE or non-IgE mediating;
Adrenaline and oxygen therapy are the most important
therapeutic agents in the management of anaphylaxis;
Replete of volume and hospitalization is essential in case of
hemodynamic unstable or anaphylaxis refractory to standard
treatment.
ANAFILAXIA OCUL ANAFILACTIC

ANAFILAXIA OCUL ANAFILACTIC