Documente Academic
Documente Profesional
Documente Cultură
An unpleasant surprise
Medical history
You checked the medical history before administering the
amoxicillin and so you know that the patient is a wellcontrolled asthmatic taking salbutamol on occasions. She
also suffers from eczema, as do her mother and her two
children, and uses a topical steroid cream as required. The
patient has had antibiotic cover before and refuses treatment without. See Case 44 for further discussion.
Dental history
The patient has been a regular attender for a number of
years. She has had previous courses of penicillin from her
general medical practitioner for chest infections.
SUMMARY
A 30-year-old lady develops acute shortness of
breath following administration of amoxicillin.
What would you do?
Examination
The patients face is shown in Figure 3.1. What do you see?
There is patchy erythema. In the most inflamed areas there
are well-defined raised oedematous weals, for instance at the
corner of the mouth and on the side of the chin. This is a
typical urticarial rash and indicates a type 1 hypersensitivity
reaction.
History
Complaint
The patient complains that she feels unwell, hot and
breathless.
History of complaint
The patient has an appointment for routine dental treatment
involving scaling and a restoration under local anaesthesia
and antibiotic prophylaxis. She took a 3g oral dose of amoxicillin 45 minutes ago.
CASE
14
An unpleasant surprise
What is the pathogenesis of anaphylaxis?
Anaphylaxis is an acute type 1 hypersensitivity reaction
triggered in a sensitized individual by an allergen. The
allergen enters the tissues and binds to immunoglobulin E
(IgE) that is already bound to the surface of mast cells,
present in almost all tissues. Binding of allergen to IgE induces
degranulation and the release of large amounts of
inflammatory mediators, particularly histamine. This causes
the vasodilatation, increased capillary permeability and
bronchospasm.
Treatment
What treatment would you perform?
Before the breathing problems were noted you correctly laid
the patient flat. However, their lungs must now be raised
above the rest of their body to prevent oedema fluid
collecting in the lungs.
An unpleasant surprise
CASE
15
CASE
16
An unpleasant surprise
drop in blood pressure or worsening oedema indicates a
need for further adrenaline (epinephrine). This is likely to be
needed about 5 minutes after the previous administration
and it can be repeated again as often as necessary. However,
the chlorphenamine (chlorpheniramine) will start to become
effective and no more than two doses of adrenaline
(epinephrine) should be necessary.
Late relapse, hours later, is also possible. Mast cells also
release other potent inflammatory mediators and some have
long half-lives. The hydrocortisone prevents this late relapse.
Dose
400 micrograms/dose
100 micrograms/puff
Adrenaline injection
1:1000 1mg/ml
Aspirin dispersible
300mg
Glucagon injection
1mg
Midazolam
5mg/ml or 10mg/ml
Oxygen
adrenaline (epinephrine)?
If the only features are a rash and mild swelling not involving
the airway it may be appropriate to give chlorphenamine
(chlorpheniramine) and hydrocortisone in the first instance
and observe the response. However, if bronchospasm,
hypotension or oedema around the airway develops,
adrenaline (epinephrine) will be needed. Adrenaline
(epinephrine) should be administered as early as possible to
be effective and it is better not to delay unless the signs and
symptoms are very mild.
Further points
Why is adrenaline (epinephrine) effective?
Adrenaline (epinephrine) is the prototypical adrenergic
agonist and has both alpha and beta receptor activity. Alpha
receptor-mediated action on arterioles causes
vasoconstriction and thus reverses oedema. Beta receptormediated actions include increasing the cardiac output by
increasing the force of contraction and heart rate (beta 1) and
bronchodilatation (beta 2). Mast cell degranulation is also
suppressed.
An unpleasant surprise
Other possibilities
If you discovered that you had just administered a penicillin
orally to a patient known to be allergic to penicillins, what
would you do?
Absorption of only a very small amount of the penicillin is
needed to trigger an allergic response so there is no point in
thinking that inducing vomiting would be helpful. The best
thing to do would be to administer the chlorphenamine
(chlorpheniramine) and steroid immediately, prepare the
adrenaline (epinephrine) and oxygen and administer the
adrenaline (epinephrine) immediately any signs begin to
develop. The patient would still have to seek medical care as
soon as possible because the late phases of the reaction
might still develop even if the immediate phases were
prevented.
CASE
17