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CZ.1.07/2.4.00/17.0059
Allergic Reactions
Anaesthesiology, emergency medicine and intensive care
EMERGENCY MEDICINE
AAR - History
2 640 BC
pharaoh Menes
First described death of „allergic“ reaction?
hieroglyph
? ?
pharaoh Menes
AAR - History
• 1902
– Charles Robert Richet
– Paul Portiér
– Sailing the Meditteranean
– Effect of sea anemone toxins on dogs
– anaphylaxis(Greek)=antiprotection
• 1913
– Nobel Prize in medicine and physiology
(Charles Robert Richet)
Paul Portiér
AAR – Epidemiology and Terminology
Current lifestyle, chemicalization and unfavourable ecological situation may mean that, in the future, reactions will be more severe in intensity.
In the today's population there are ≥30% atopy sufferers and 22% allergy sufferers with clinical symptoms.
Precise incidence of anaphylactic reactions in the population is not known; in Europe it is estimated as 9.8/100,000 residents and the incidence is the same in allergy sufferers as well as the healthy population.
In the Czech Republic, 5 anaphylactic deaths are reported per year (according to the Institute of Health Information and Statistics).
Hypersensitivity = abnormal response of the body to irritation without the knowledge of pathological mechanism
Allergen = antigenic material
Atopy= genetically based ability to sensitize and take an allergic disease (100 genes).
Allergy = hypersensitivity based on immunological sensibillization (type 1 immunopathological reaction according to Coombs and Gell).
Pseudoallergy = non-immunological hypersensitivity with clinical symptoms consistent with allergy – allergic disease.
AAR – The Most Severe Forms
Anaphylactic reaction (anaphylaxis)
Acute allergic reaction occurring based on type 1 immunopathological reaction, mediated by IgE antibodies. Anaphylactic shock is the most severe form of anaphylactic reaction (doc. MUDr. Vít Petrů)
Top-most variant of immunologically conditioned immediate acute allergic reaction of the system with simultaneous affliction of multiple organs.
Anaphylactoid reactions
If the core problem is not an immunological reaction, mediated by IgE antibodies, but another type of antibodies (e.g. IgG), immunocomplexes or anaphylatoxis, or it is not a case of immune mechanism at all (doc.MUDr.Vít Petrů)
Top-most variant of pseudoallergy with clinical symptoms almost indistinguishable from anaphylaxis.
AAR - Pathophysiology
AAR - Pathophysiology
Aktivace žírných buněk Mast Cell Activation
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Mast Cell Degranulation
There are a number of patterns
Biological Effect of Mediators There
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AAR Mechanism Pattern
Immunological path “Chemical path“
Mast cells
(mastocytes, basophil leukocytes)
Chemotactically
active/proinflammatory
vasoactive
spasmogenic
Primary mediators
Secondary mediators
(eosinophilic proteins)
Early phase (10-30 min.) Late phase (2-6 hours)
Biphasic course up to 72 hours (on average 24 hours)
AAR – Clinical Info
modified classification according to Muellen
Stage 0 - local skin reaction
Stage 1 – light general reaction
Stage 2 – strong general reaction
Stage 3 – life-threatening general reaction
Stage 4 – vital functions failure
STAGE 0
Local skin reactions without any clinical significance.
STAGE 1
Light general reaction with clinical symptoms:
– CNS – restlessness, headaches and general discomfort,
– Skin and mucous membranes – disseminated skin reaction (flushing, generalized urticaria, perioral, perianal and palmoplantar pruritus, Quincke‘s oedema) and reactions on mucous membranes (nose, conjunctival sac).
AAR – Clinical Info
STAGE 2
Strong general reaction with symptoms
• Cardiovascular- changes in pressure and pulse (circulation dysregulation),
• Respiratory – slight dyspnoea as incipient spastic finding,
• GIT and urological – urge to pass stool and urine
STAGE 3
Life-threatening general reaction with leading clinical symptoms:
• Cardiovascular - severe hypotension and pallor to shock
• Respiratory – severe dyspnoea with bronchospasm
• CNS – impaired consciousness to coma
• GIT and urological – faecal and urinary incontinence
STAGE 4
Vital functions failure – respiratory and circulatory arrest.
AAR – Differential Diagnostics
• Vasovagal response
• Hyperventilation syndrome
• Globus hystericus
• Acute vocal cords dysfunction, sometimes to the point of laryngospasm or bronchospasm
• Primary heart disease
• Hereditary angioedema
• Serum sickness
• Cold urticaria
• Pheochromocytoma
• Drug intoxication
AAR – Essential Therapeutic Measures
Manner (immunological x chemical), reaction (anaphylactic x anaphylactoid), mediators...?
Symptomatic therapy is rational - Fast + Aggresive + Generous
General measures
The first measure is to immediately cease intake of assumed trigger.
In appropriate situations (insect bite)
Local cooling
Strangulating the extremity over the area of penetration
Adrenaline shot dosed at 0.1-0.2 mg s.c.
From stage 1
Venous cannulation using large lumen aids,
Lying down in Trendellenburg‘s position (pulmonary oedema)
Support oxygenation, O2 via nasal catheter, oxygen mask
In refractory hypotension or dyspnoea, controlled ventilation with 100% O2 (OTI)
In larynx oedema, do not force intubation, instead try to ensure controlled breathing through minitracheotomy - coniotomy.
Monitoring vital functions
AAR – Essential Therapeutic Measures
Medicamentous therapy = practically proven as effective
sympathomimetics (adrenaline, ephedrine, noradrenaline, salbutamol, fenoterol, terbutaline), replacement solutions, corticosteroids, antihistamines, other bronchodilators, oxygen
Sympathomimetics - catecholamines
ADRENALINE = the first choice medicament
Prevents further release of histamine, improves myocardial contractility, increases peripheral vascular resistance and relieves bronchospasm
To be administered even if shock reaction symptoms initially do no appear as life threatening
If injected, administer in the area of allergen penetration
Initial dose for an adult is 200–500 ug (0.2ml to 0.5 ml - 1 ml contains 1000 ug) i.m.
May be repeated every 5-10-15 minutes to maximum individual dose of 1000 ug (1 ml)
In children, 100 ug (i.e. 0.1 ml) for every 10 kg of body weight, up to maximum 500u ug (0.5 ml)
Given its faster absorption, intramuscular administration is more effective (thigh, the deltoid)
If no response to several s.c. or i.m. administration – infusion is administered – linear dosing device no. 2 of advantage –10 ug/min (5mg/50mlFR at a speed of 1–6 ml/hour)
AAR – Essential Therapeutic Measures
NORADRENALINE
When hypotension persists following adequate volumotherapy and administration of corticosteroides
Using linear dosing device 5mg/50 ml FR at 2…??ml/hour.
VENTOLIN ® (salbutamol), BEROTEC® (fenoterol), BRICANYL®(terbutaline)
In the event of bronchospasm – spacer, aerochamber, nebulization
Up to 4 doses (40% on the wall) administered via adapters, up to 3 times per 10–20 minutes
Volume replacement (crystalloids and colloids )
PLASMALYTE ®, VOLUVEN®
Volume loss to the interstitium is greater then we think (up to 50% i.v. volume in 10 minutes!!!)
Through overpressure 1,000 ml of crystalloids
Common is 1,000 – 2,000 ml fast
In children 30 ml/kg in the first hour
Colloids (HAES 6%) up to dose of 20 ml/kg ?
AAR – Essential Therapeutic Measures
Histamine antagonists
DITHIADEN ®(bisulepin)
Adults = 1 mg (2 ml) i.m., preferably via i.v.,max. 8 mg per day
Children up to 6 years of age = 0.5 mg (1ml), max. 3 mg per day
Options - clemastine (Tavegyl ®) 4mg + cimetidine (Primamet ®) 400 mg in FR 250ml
Corticosteroids No distinct effect during initial phase, but blocking the late phase
Development of condition is never known; therefore, to be administered immediately and best i.v.
SOLUMEDROL® 40 mg, in shock up to 2,000 mg/24 hours
HYDROCORTISON®200 mg, in shock up to 150 mg/kg/24 hours
DEXONA® 8 mg, in shock up to 300 mg/24 hours
Other bronchodilators
SYNTOPHYLLIN® (theophylline)
5mg/kg bolus i.v. + infusion or dosing device at 40 mg/hour
bronchodilatation-positive inotropic-diuretic effect
OXYGEN
Inhalation of humidified oxygen for dyspnoea or clinical symptoms of asphyxia
Through a mask >6l/minute with benefit of nebulization
0
10
20
30
40
50
60
70
80
35 33
72
39
66
2005
2006
2007
2008
2009
Number of Patients Treated for Allergic Reaction at the Emergency Department FNOL
n=245 patients
Number of Patients According to the Stage of Allergic Reaction at the Emergency Department FNOL
n=245 patients
86
131
51
10 3
0.stupeň
1.stupeň
2.stupeň
3.stupeň
4.stupeň
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
60 051
245
počet pacientů ER+INT
počet alergických reakcí
Number of patients ER + INT (number of non-allergic reactions) Number of allergic reactions
Number of Patients According to the Stage of Allergic Reaction at the Emergency Department FNOL
n= 60,296 patients (ER+INT) (n=177,138 patients (ER)
AAR – Emergency Department Statistics 2005-2009
Etiological agents of allergic reactions BITING INSECTS (wasp – hornet – bee – bumblebee – flies in the grass)
FOOD (mandarins – almonds – yoghurt – onions – apricot – cucumber salad – strawberies – milk thistle – sunflower oil – aubergine – mushrooms – radishes – cheries – cellery - manadin – vegetable and cheese salad („Šopák“) – pasta and ham dish („šunkofleky“) – canapés („chlebíčky“) – pasta – cashew nuts – seed mix – mulled wine – lemon juice – tomatoes – chicken salad – chocolate with peanuts – tuna – honey – goulash – apple – sunflower seeds – cheese – beans – radishes – sunflowers – tomatoes – cucumber – potatoe salad – peach – honey – kidneys – tuna – mandarin – melon – tomato – kidney – hazel-nut – peanuts – mandarin – mustard – honey – potato soup – tomato – cherries – strawberries – mandarin – pistachio – cheese – flour – litchi – tuna – lentils – pistachios)
MEDICAMENTS (Fabrazyme (substitutional therapy for Fabry disease) – Algifen – PNC – Cefzin – Hotemin(piroxicam) – Paralen – Hot drink – Saridon – Holicin – Iodine – Augmentin – Ospen – ASA – Dolmina – Muscoril – tincture of birch – Novalgin – Cotrimoxazol – Seropram – Klabax – Myolastan – Gynopevaryl – Depo-Provera – Ataralgin – Rovamycin – Ospamox – Valetol – Asentra – Ospen – ULTRAVIST – Agen – Modafen – Diclofenac – Nimesulid – Brufen – Bromhexin )
INHALATION (nut dust – washing powders – dust – shrubs)
CONTACT (grasses)
Recommended Procedures and Equipment
STAGE 0
Characteristics = local skin reaction without any clinical significance
Therapy
Urgent therapy not initiated
STAGE 1
Characteristics = light general reaction with clinical symptoms
CNS (restlessness, cephalea, discomfort)
Skin and mucous membranes (disseminated skin reaction + mucous membranes)
Therapy:
Obligatory –lying down position , i.v. access + crystalloids, ogygen
CNS – midazolam (Dormicum®) titrated by 1 mg
Dermal/mucosal - bisulepin (Dithiaden®)1mg i.m./i.v. + methylprednisolon (Solu Medrol®) 40-125 mg i.v.
Recommended Procedures and Equipment
STAGE 2
Characteristics = strong general reaction
Cardiovascular ( circulation dysregulation = changes in BP + HR)
Respiratory (slight dyspnoea, mild spastic finding)
GIT and urological (urge to pass stool and urine )
Therapy
Obligatory – lying down in Trendellenburg‘s position , i.v. access, oxygen therapy
Cardiovascular- crystalloids (Plasmalyte®) - 30 ml/kg/hour
Ephedrine (Ephedrin®) – 10-20 mg i.v.
Adrenaline - 0,2-0,5 mg i.m. repeatedly after 10 - 15 minutes (max. 1 mg), via LD-2-10 ug/min. (5mg/50mlFR at the speed of 1–6 ml/hour)
Noradrenaline - from 0.2 mg/hour (5mg/50 ml FR at the speed of…2ml/hour)
Respiratory
Salbutamol (Ventolin®), terbutanil (Bricanyl®)
Methylprednisolon (Solu Medrol®) 125-500 mg i.v.
If therapy insufficient histamin antagonists to be added
Bisulepin (Dithiaden®) 1mg i.m./i.v. (max. 8 mg)
Clemastine (Tavegyl®) 4 mg + cimetidine (Primamet®) 400 mg via infusion every 5 minutes
Recommended Procedures and Equipment
STAGE 3
Characretistics = life-threatening general reaction
Cardiovascular (severe hypotension to shock)
Respiratory (severe dyspnoea with bronchospasm and clinical symptoms of respiratory distress)
CNS (impaired consciousness to coma)
GIT and urological (faecal and urinary incontinence)
Therapy
Obligatory – Trendellenburg‘s position + PVC, 2x if possible
OTI, mechanical ventilation s FiO2 1,0, VT 6-8 ml/kg, DF 12/min. – to normocapnia
Cardiovascular
HAES 6% (Voluven®)-20 ml/kg/hour, Plasmalyte®-30 ml/kg/hour – through overpressure
Adrenaline – 0.2-0.5 mg i.m repeatedly after 5-10-15 minutes (max. 1 mg)
Adrenaline via LD - 2-10 ug/min (5mg/50mlFR at the speed of 1–6 ml/hour)
Noradrenaline - from 0.2 mg/hour (5mg/50 ml FR at the speed of 2…..ml/hour)
respiratory
Salbutamol (Ventolin®), terbutanil (Bricanyl®) - adapter / nebulization
Terbutanil – 0.5 mg/ 6 hours i.v. (an alternative to adrenaline)
Theophylline ( Syntophyllin®) - 5 mg/kg i.v. + inf. 40mg/hour
Recommended Procedures and Equipment
STAGE 3 - continued
If therapy insuffiecient - H blockers and corticosteroids
Bisulepin (Dithiaden®) 1mg i.m. / i.v. (max. 8 mg)
Clemastine (Tavegyl®) 4 mg + cimetidine (Primamet®) 400 mg via infusion every 5 min.
Methylprednisolon (Solu Medrol®) -1000 mg via infusion every 10-15 min.
STAGE 4
Characteristics = sudden respiratory and circulatory arrest
Therapy
Proceed according to the principles of BLS and ALS ( GL 2010)
Recommended Procedures and Equipment
Recommended Procedures and Equipment
Thank you for your patience.
