HistoryThis section has been translated automatically.
DefinitionThis section has been translated automatically.
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EtiopathogenesisThis section has been translated automatically.
The most common triggers of anaphylactic shock are:
- Food (see below food allergy: peanuts, various types of nuts, milk, eggs, fish, shellfish, various food additives).
- Insecticides (see below insecticide allergy: bee, wasp, hornet)
- Drugs (see below drug reaction, undesirable: antibiotics, anti-inflammatory drugs, non-steroidal drugs, narcotics, antiepileptic drugs, muscle relaxants, X-ray contrast media [see below contrast media intolerance])
- Physical triggers (cold, UV rays) or physical exertion (= exercise induced anaphylaxis) are rare as the maximum variant of cholinergic urticaria (see below urticaria, cholinergic).
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 featuresThis section has been translated automatically.
Classification from stage 0 - IV, see Table 1 In addition to the
.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
- 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.
DiagnosisThis section has been translated automatically.
Differential diagnosisThis section has been translated automatically.
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
- respiratory diseases:
- Asthma unrelated to anaphylaxis
- Tracheal/bronchial obstruction
- Pathological mediator release:
- Urticaria diseases
- Angioedema (hereditary/acquired).
TherapyThis section has been translated automatically.
General therapyThis section has been translated automatically.
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.
- 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 therapyThis section has been translated automatically.
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.
Theophylline (e.g. Euphyllin): For bronchial dilation from stage III 0.12-0.24 g i.v.
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.
ProphylaxisThis section has been translated automatically.
TablesThis section has been translated automatically.
Staging and symptoms of anaphylactic immediate reactions
localised cutaneous reaction
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)
distinct general reaction
Circulatory dysregulation (changes in blood pressure and pulse), shortness of breath (slight dyspnoea, incipient bronchospasm), stool or urine leakage
threatening general reaction
Shock (severe hypotension, paleness), bronchospasm with threatening dyspnoea, loss or clouding of consciousness; possibly with defecation and urine
vital organ failure
Manifest failure of vital functions (respiratory and circulatory arrest)
local cooling, if necessary local antihistamines (e.g. Fenistil Gel)
venous access with the largest possible lumen
if necessary, antihistamines i.v. (e.g. Fenistil)
as above, furthermore
Stage III + IV
as above, furthermore
AftercareThis section has been translated automatically.
Case report(s)This section has been translated automatically.
- 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.
LiteratureThis section has been translated automatically.
- 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
- 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
- Leibl M et al (2011) Anaphylaxis after hidden chlorhexidine exposure. Abstract CD 46th DDG meeting: P02/25
- Pepper I et al (2011) Acetylsalicylic acid - dependent anaphylaxis on carrot in mastocytosis. JDDG 9: 230-231
- Porter P, Richet C (1902) De l'action anaphylactique de certains venins. C R Soc Biol (Paris) 54: 170-172
- Rohacek M et al(2014) Biphasic anaphylactic reactions: occurrence and mortality.
- Simon J (2014) The allergy emergency. SDDG 12: 379-388
- Stratmann E (2011) Anaphylactic shock to thiopental. Abstract CD 46th DDG meeting: P02/24.
Incoming links (40)Ace inhibitor-induced angioedema; Adrenalin; Ammonium persulfate; Androgens; Bee sting; Benzocaine; Beta2 sympathomimetics; Botulinum toxin a; Cold urticaria; Contact urticaria; ... Show all
Outgoing links (30)Adrenalin; Adverse drug reactions of the skin; Anaphylaxis; Angioedema (overview); Antihistamines, systemic; Basophil granulation test; Beta2 sympathomimetics; Capillary leak syndrome; Carcinoid syndrome; Chlorhexidine; ... Show all
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