Ari Baskoro

Division of Allergy and Clinical Immunology

Department of Internal Medicine
School of Medicine Airlangga University /
Dr. Soetomo Teaching Hospital - Surabaya
Objectives-to understand
• What is anaphylaxis ?
• Who gets anaphylaxis ?
• What causes anaphylaxis ?
• How to recognise anaphylaxis
• How to treat anaphylaxis
• Follow up of the patient with anaphylaxis
Characteristic of anaphylaxis
• Potentially fatal systemic reaction
• Acute/rapid onset
• Vary widely clinical manifestations
• Affecting multiple organ
• Serious allergic/immediate type reaction
• Multi mediators/mechanisms involvement
Anaphylaxis is :
- A severe, life-threatening, generalized or
systemic hypersensitivity reaction
Characterised by :
- Rapidly developing, life threatening,
airway and/or breathing and/or circulation
problems
- Usually with skin and/or mucosal changes
• Mainly children and young adults
• Commoner in females
• Incidence seems to be increasing
• ABCDE approach
• Treat life threatening problems
• Asses effects of treatment
• Call for help early
• Diagnosis not always obvious
• Sudden onset and rapid progression of
symptoms
• Life-threatening Airway and/or Breathing
and/or Circulation problems
• Skin and/or mucosal changes ( flushing,
urticaria, angioedema)
• Exposure to a known allergen / trigger for
the patient helps support the diagnosis
Common:
• Foods: most commonly peanuts, tree nuts, egg, seafood and
fish, cow’s milk, wheat
• Medications: most commonly antibiotics
• Insect stings (bees and wasps)
• Natural rubber latex
• Unidentified (no cause found; idiopathic anaphylaxis)
Less common:
• Exercise
• Semen
• Food additives: monosodium glutamate, metabisulfite
• Hormonal changes: menstrual factors
• Topical medications
• Transfusions

Kim and Fischer Allergy, Asthma & Clinical Immunology 2011 7(Suppl 1):S6 doi:10.1186/1710-1492-7-S1-S6
• Skin or mucosal changes alone are not a
sign of an anaphylactic reaction
• Skin or mucosal changes can be subtle or
absent in up to 20 % of reactions ( some
patients can have only a decrease in blood
pressure i.e., a Circulation problem )
• There can also be gastrointestinal
symptoms ( e.g. vomiting, abdominal pain,
incontinence )
 Penicillin 4-6 hours after consuming
Anti serum drug…
protein
Insulin Rhinitis
Peptide
hormone Laryngeal
Chymopapain Bronchial edema
spasme
Allergen
Hypotensi
extract Pruritus tachycardia
Vaccine
Streptokinase Urticaria Nausea
vomiting
Abdominal
colic Uterine spasm
Radiocontrast
media Diarrhea
Narcotic drugs
Pseudoallergy =
• Airway swelling e.g. throat and tongue
swelling
• Difficulty in breathing and swallowing
• Sensation that throat is “closing up”
• Hoarse voice
• Stridor
• Shortness of breath
• Increased respiratory rate
• Wheeze
• Patient becoming tired
• Confusion caused by hypoxia
• Cyanosis ( appears blue ) – a late sign
• Respiratory arrest
• Signs of shock – pale, clammy
• Increased pulse rate ( tachycardia )
• Low blood pressure ( hypotension )
• Decreased conscious level
• Myocardial ischaemia / angina
• Cardiac arrest
DO NOT STAND PATIENT UP
• Sense of “impending doom”
• Anxiety , panic
• Decreased conscious level caused by
airway, breathing or circulation problem
Look for skin changes

• Skin changes often the first feature

• Present in over 80% of anaphylactic
reactions
• Skin , mucosal , or both skin and mucosal
changes
Look for skin changes

• Erythema – a patchy , or generalised ,

red rash
• Urticaria ( also called hives, nettle rash ,
weals or welts ) anywhere on the body
• Angioedema – similar to urticaria but
involves swelling of deeper tissues e.g.
eyelids and lips , sometimes in the mouth
and throat
Anaphylaxis Angioedema
Life- threatening conditions :

• Asthma : can present with similar

symptoms and signs to anaphylaxis ,
particularly in children

• Septic shock : hypotension with

petechial / purpuric rash
Non- life- threatening conditions :

• Vasovagal episode
• Panic attack
• Breath- holding episode in a child
• Idiopathic ( non-allergic ) urticaria or
angioedema
Seek help early if there are any doubts
about the diagnosis
 0 1 6 8 24 48 (h)
Early phase Late phase Very late phase
APC
TNF- Epithelium
Ag IL-
MBP, ECP,
FcεRI EDN, CLC etc
IL-3 RANTES
IL-4 MCP-4 MBP, ECP,
Mast cells IL-5 Eotaxin
IL-8 EDN, CLC etc
Th2 B cells
GM-CSF
Eos
IL-4
Histamin, PGD2, IL-3
TNF-
LTs etc IL-4 IL-4
IL-5 IL-5
Th0 IL-8 IL-6
Th2
GM-CSF IL-13
MIP-1 RANTES
MCP-3
IL-4
RANTES IL-13 RANTES
Eotaxin Baso MIP-1 Eotaxin
IL-8 IL-8
GM-CSF Histamin, LTC4 GM-CSF
Endothelium PAF
VCAM-1 PAF
ICAM-1 Endothelium
VCAM-1
E-selectin
Eos Th2 Baso Eos
 SKIN TEST
ALLERGEN
10 min.
NON-IgE TRIGGERS
TH1
–
IgE TH2 IFN ACH noradrenalin C3a
SYNTHESIS C5a
IL-4
 
B OEDEMA
IgE + + + MUCUS
Fc
+ cGMP SECRETION

ATTACHMENT
cAMP BRONCHIAL
TO MAST
CONSTRICTION
CELL + MEDIATORS

– PG, LT CHEMOTAXIS
DSCG
CROSS-LINKING adrenalin steroids
BY ALLERGEN Ca2+ antihistamines
INHIBITORS
VASCULAR
CALCIUM
PERMEABILITY
INFLUX DEGRANULATION &
MEDIATOR RELEASE
 Anaphylactic reaction?

Assess: Airway, Breathing, Circulation, Disability, Exposure

Diagnosis - look for:

• Acute onset of illness • Life-threatening features 1
• And usually skin changes
+/- Exposure to known allergen
+/- Gastrointestinal symptoms

Call for help

Lie patient flat and

raise legs (if breathing not impaired)

Adrenaline

When skills and equipment available:

A. Establish airway
B.High flow oxygen Monitor:
C.IV fluid challenge 3 • Pulse oximetry
Chlorphenamine 4 • ECG
Hydrocortisone 5 • Blood pressure
Remove
allergen
Adrenaline

IM doses of 1 : 1000 adrenaline ( repeat after 5 min if no better )

• Adult of child more than 12 years : 500 micrograms IM (0,5 mL)
• Child 6 – 12 years : 300 micrograms IM (0,3 mL)
• Child 6 months – 6 years : 150 micrograms IM(0,15mL)
• Child less than 6 months : 150 micrograms IM(0,15mL)
For use by experts only
Monitored patient
• International guidelines concur that AH &
glucocorticoids are second line or even third line
medications in anaphylaxis
• Administered adjunctive to relieve itching &
hives
• NOT relieve the other symptyoms of
anaphylaxis  not life saving & should not be
use in initial or sole treatment.
• Once IV access established
• 500 – 1000 mL IV bolus in adults
• 20 mL/Kg IV bolus in child
• Monitor response – give further bolus
as necessary
• Colloid or crystalloid
( 0,9% sodium chloride or Hartmann’s )
• Avoid colloid , if colloid throught to have
caused reaction
• Second line drugs
• Use after initial resuscitation started
• Do not delay initial ABC treatments
• Can wait until transfer to hospital
• Follow Basic and Advanced Life Support
guidelines
• Consider reversible causes
• Give intravenous fluids
• Need for prolonged resuscitation
• Good quality CPR important
Ideal sample timing :

• After initial resuscitation started and

feasible to do so
• 1-2 hours after onset of symptoms
• 24 hours or in convalescence
or at follow up
 Serum sample has to be
taken as soon as possible ( 1-
2 hours of drug allergy onset
Result : (+)  type I reaction
or anaphylactoid reaction
Result (-) :  not rule out the
possibility of these reaction

Patient with anaphylaxis

• For self- use by patients or carers
• Should be prescribed by allergy specialist
• For those with severe reactions and
difficult to avoid trigger
• Train the patient and carers in using
the device
• Practice regularly with a trainer device
• Rescuers should use these if only
adrenaline available
Ewan (2000).BMJ 316 ,1442
Anaphylaxis :
• Recognition and early treatment
• ABCDE approach
• Adrenaline
• Investigate
• Specialist follow up
• Education – avoid trigger
• Consider auto-injector