Anaphylactic shock T78.2

Authors: Prof. Dr. med. Peter Altmeyer, Lydia König

Co-Autor: Hadrian Tran

All authors of this article

Last updated on: 25.12.2020

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Synonym(s)

Allergy Shock; Anaphylactic reaction; Anaphylactic shock; Anaphylaxis; Emergency treatment; Shock anaphylactic

History
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Porter and Richet, 1902

Definition
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Maximum form of an immunological type I reaction (see also tryptase) or a pseudoallergic, acute general reaction with release of vasoactive substances (vasodilative) and inflammatory mediators, increase of vascular permeability (fluid extravasation) and generalized vasodilatation with consecutive shock. Optional bronchoconstriction, exanthema, angioedema (see anaphylaxis below).

Etiopathogenesis
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The most common triggers of anaphylactic shock are:

Summative anaphylaxis: It is not uncommon for anaphylactic reactions to become symptomatic only after the simultaneous presence of one or more co-factors (see also food allergy). These combinations are particularly difficult to diagnose, as only their interaction triggers the anaphylaxis.

Clinical features
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Classification from stage 0 - IV, see Table 1 In addition to the
symptoms listedinTab
.1, reflex bradycardia (Bezold-Jarisch reflex) or hypertension may occur, although less frequently. First signs are:

  • Itching on the palms of the hands/foot soles or genitals
  • metallic taste
  • Tingling in the mouth and throat
  • hot flash
  • Unrest
  • Reddening of larger areas of skin.

A biphasic shock reaction (can be expected in about 2% of patients). Biphasic reactions are observed 1 to max. 36 hours after the initial event.

Diagnosis
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The determination of serumtryptase is a helpful marker to distinguish an allergic reaction from a non-allergic one. Elevated levels of tryptase after an anaphylactic event can usually be detected 3 to 6 hours after the reaction. Levels normalize within 12 to 14 hours.

Differential diagnosis
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Differential diagnosis of anaphylactic shock (var. n. Ludolph-Hauser et al.):

  • Cardiovascular diseases:
    • vagovagal syncope
    • Non-anaphylactic shock (e.g. cardiogenic)
    • Hypertonic crisis
    • Capillary Leak Syndrome
    • Neuropsychiatric diseases
    • Hyperventilation tetany
    • Panic Attack
    • Globe hystericus
    • Epilepsy
    • Apoplexy
  • respiratory diseases:
    • Asthma unrelated to anaphylaxis
    • Tracheal/bronchial obstruction
  • Intoxications
  • Pathological mediator release:
  • Urticaria diseases
  • Angioedema (hereditary/acquired).

Therapy
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From stage II at the latest, intensive medical care.

General therapy
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Venous, access as large-lumen as possible; oxygen supply, keep the airways clear, blood pressure control. If the shock is triggered by local injections or stitches in the extremities, the temporary ligature of the respective limb can soften the reaction.

Procedure:

  • IMMEDIATELY: Stop allergen supply!
  • Sedation of patient (and parents)
  • Storage symptom-oriented: Flat storage is preferred.
  • In unconsciousness: stable lateral position
  • For hemodynamic instability: Trendelenburg position (legs up)
  • For respiratory distress: sitting or semi-seated position
  • Severity assessment: Identifying and treating the most threatening symptom
  • Creating secure access
  • In case of respiratory or circulatory problems, adrenalin i.m. and oxygen inh. should be given beforehand!
  • In case of cardiovascular reaction or cardiac arrest, possibly intraosseous access

Internal therapy
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Adrenalin: As soon as symptoms like stridor, hypotension, dyspnoea are present 0.01mg/kgKG should be injected i.m. (see below).

From stage III or in acute respiratory distress inject adrenalin e.g. Suprarenin 1:1000 (1 ml contains 1 mg adrenalin = epinephrine) 0.3-0.5 ml slowly i.v., in case of laryngeal or glottic oedema and acute respiratory distress inject a total dose of up to 1 ml.

In highly acute cases, after diluting 1 ml of commercial epinephrine solution (1:1000) to 10 ml or using a ready-to-use epinephrine syringe (e.g. Anapen 300 µg, Anapen 150 µg, Fastjekt), 0.5-1.0 ml (= 0.05-0.1 mg epinephrine) is injected slowly i.v. (0.1 mg/min.) under pulse and blood pressure control; a maximum dose of 1 mg epinephrine should not normally be exceeded.

Autoinjector for intramuscular injection, weight-adjusted.

  • >7,5-15kg: 150µg adrenalin
  • >25-30kg: 300µg adrenalin
  • >50kg: 300µg 0r 500µg adrenalin

Notice. In case of insufficient hemodynamic stabilization by volume administration and adrenalin, if necessary, administration of vasopressors such as noradrenalin or dopamine 35 µg/kg/min (= 2.5 mg/min/70 kg bw).

Volume substitution: I.v. administration of electrolyte solutions in stage I to II, from stage III plasma substitutes such as Ringer's solution, in exceptional cases gelatine preparations, low molecular weight dextran and hydroxyethyl starch solutions.

Caution. Dextrans may be given only after pretreatment with low-molecular-weight dextran hapten because of the risk of the existence of preformed antibodies against dextrans.

Antihistamines: From stage I to II Clemastine (e.g. Tavegil) or Dimetinden (e.g. Fenistil) 1-2 Amp. i.v.

Theophylline (e.g. Euphyllin): For bronchial dilation from stage III 0.12-0.24 g i.v.

Glucocorticoids: From stage II, concomitant high-dose glucocorticoids such as methylprednisolone (e.g. Urbason) 500-1000 mg i.v.; dose may be repeated as required.

β 2 -Sympathomimetics: For obstructive respiratory symptoms, supplemental injection of a β-sympathomimetic such as terbutaline sulfate (e.g., Bricanyl) 0.5-1 amp. of 0.5 mg s.c., up to a maximum of 2 mg/day.

Dosage recommendations in children:

  • Adrenaline 0.005-0.01 mg/kg bw as bolus; 0.05-0.5 µg/kg/min as continuous infusion (endotracheal 2-3 times higher).
  • Dopamine 1.5-2.5 µg/kg/min as continuous infusion.
  • Norepinephrine 0.05-1.0 µg/kg/min as continuous infusion.
  • H1 antagonists, e.g. Fenistil 0.1-0.5 mg/kg bw i.v. or Tavegil 0.025-0.05 mg/kg bw i.v.
  • H2 antagonists, e.g. Tagamet 2.5-5.0 mg/kg bw i.v.
  • Crystalloid solutions, e.g. Ringer's lactate 20-30 ml/kg bw (repeat every 20-30 minutes if necessary).
  • Colloids, e.g. HES 10-20 ml/kg bw.
  • Prednisolone 2-5 mg/kg bw i.v. (max 20 mg/kg bw).
  • Theophylline 5 mg/kg bw as a slow bolus; 0.5-1.0 mg/kg bw/hour as a continuous infusion.

Prophylaxis
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Formulation and practical instruction for the handling of an emergency set, in particular the adrenaline auto-injectors (Jext®, Fastjekt®, Emerade® 150ug from 15 kg, 300ug from 30kg, 500ug from 60kg).

Tables
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Staging and symptoms of anaphylactic immediate reactions

Stadium

Spread

Symptomatology

0

local

localised cutaneous reaction

I

mild general reaction

disseminated cutaneous reactions (e.g. flush phenomenon, urticaria, pruritus), mucous membrane reactions (e.g. nose, conjunctiva), general reactions (e.g. restlessness, headache)

II

distinct general reaction

Circulatory dysregulation (changes in blood pressure and pulse), shortness of breath (slight dyspnoea, incipient bronchospasm), stool or urine leakage

III

threatening general reaction

Shock (severe hypotension, paleness), bronchospasm with threatening dyspnoea, loss or clouding of consciousness; possibly with defecation and urine

IV

vital organ failure

Manifest failure of vital functions (respiratory and circulatory arrest)


Stage 0

Monitoring

local cooling, if necessary local antihistamines (e.g. Fenistil Gel)

Stage I

venous access with the largest possible lumen

if necessary, antihistamines i.v. (e.g. Fenistil)

stage II

as above, furthermore

  • Keep airways clear, oxygen supply

  • Volume substitution i.v. (electrolyte solutions or plasma expander)

  • internal medication:

  • glucocorticoids i.v. (e.g. Urbason) 500-1000 mg

  • Antihistamines i.v. (e.g. Fenistil) 1-2 amp. i.v.

  • β Sympathomimetics (e.g. Bricanyl) 0.5 mg s.c. (up to max. 2 mg/day)

Stage III + IV

as above, furthermore

  • Volume substitution with plasma expanders

  • Theophylline 0.12-0.24 g i.v.

  • Adrenalin 0.3-0.5 ml (up to 1 ml) i.v.

  • in case of circulatory arrest intubation and cardio-pulmonary resuscitation

Aftercare
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Those affected are provided with an anaphylaxis pass (source of supply: e.g. www.pina-infoline.de).

Case report(s)
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  • Case 1) A 17-year-old male patient, who underwent intubation anaesthesia for an uncomplicated, planned knee surgery, suffered anaphylactic shock during the induction phase. He was administered the following medications during anesthesia: thiopental, propofol, remifentanil, suxamethonium; he also received amoxicillin and Clexane. The planned surgery was subsequently postponed.
  • Laboratory: Total IgE (20,5 kU/l); Tryptase (4,57µg/l); Remark: Normal values. Basophil degranulation test with 5 different concentrations of thiopental gave a positive reaction at 250 µg/ml.
  • Allergological diagnosis: Prick test: positive reaction to thiopental. All further skin tests (prick and intracutaneous tests) for the above mentioned drugs as well as different latex extracts and soy. Latex extracts and soy did not show positive reactions.
  • Diagnosis: Anaphylactic shock to the anaesthetic Thiopental.

  • Case 2) During a cystoscopy a 62-year-old patient suddenly developed flushing symptoms, a generalized urticarial exanthema and sudden unconsciousness with a drop in blood pressure (shock stage III).
  • During the cystoscopic procedure, a lubricant was used which contained lidocaine and chlorhexidine, among others. Furthermore, the patient received 200 mg ciprofloxacin p.o. immediately before the procedure.
  • Laboratory: Total IgE (25,5 kU/l); Tryptase (4,20µg/l); Remark: Normal values.
  • Allergological diagnostics: Prick-, intracutaneous- and epicutaneous tests with local anaesthetics and antibiotics, chlorhexidine digluconate, chlorhexidine acetate and different latex extracts (latex was also provoked conjunctivally). Oral provocation test with ciprofloxacin. Subcutaneous provocation test with lidocaine.
  • Results: In the prick test, the patient showed a positive reaction to ciprofloxacin and chlorhexidine digluconate. In epicutaneous testing, chlorhexidine showed an immediate reaction.
  • Diagnosis: Anaphylactic shock to the disinfectant chlorhexidine.

Literature
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  1. Dybendal T et al (2003) Screening for mast cell tryptase and serum IgE antibodies in 18 patients with anaphylactic shock during general anaesthesia. Acta Anaesthesiol Scand 47: 1211-1218
  2. Guideline of the German Society for Allergology and Clinical Immunology (DGAI) and Medical Association of German Allergologists (ÄDA). Recommendations for the practical implementation of specific immunotherapy with allergens (hyposensitization). AWMF Guidelines Register No. 061/013
  3. Leibl M et al (2011) Anaphylaxis after hidden chlorhexidine exposure. Abstract CD 46th DDG meeting: P02/25
  4. Pepper I et al (2011) Acetylsalicylic acid - dependent anaphylaxis on carrot in mastocytosis. JDDG 9: 230-231
  5. Porter P, Richet C (1902) De l'action anaphylactique de certains venins. C R Soc Biol (Paris) 54: 170-172
  6. Rohacek M et al(2014) Biphasic anaphylactic reactions: occurrence and mortality.
    Allergy 69:791-797
  7. Simon J (2014) The allergy emergency. SDDG 12: 379-388
  8. Stratmann E (2011) Anaphylactic shock to thiopental. Abstract CD 46th DDG meeting: P02/24.

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

Authors

Last updated on: 25.12.2020