Definition, pathophysiology, etiology, clinical manifestations, management

1. Prof. DR.Dr.Ariyanto Harsono
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Anaphilactic Shock

2. Prof. DR.Dr.Ariyanto Harsono
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Definition
Anaphylaxis: Reactions sudden life-
threatening because the process
immonologic of allergen-antibody
reaction
Anaphylactoid Reaction causing physical
the same symptoms but caused no
immunological reaction

3. Prof. DR.Dr.Ariyanto Harsono
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Alergen
APC MHC-II
Th0
IL-12/ IL-1
Th-2
Th.1
IL-1
TNF-β, IFN-γ
IL-2, IFN-γ
B-Cell
IL-4
IL-5
SEL PLASMASEL MEMORI
IL-6
IL-10
CTL
MHC-I
L
MEMORY CELLS
Aktifasi
Komplemen
Blocking Antibody
Precipitatigng
Aglutinating AB
Anafilaksis

4. Prof. DR.Dr.Ariyanto Harsono
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Pathophysiology
There are 5 stages:
1. Mast cells / basophils walls change therefore stimuli:
* Allergens-IgE
* Aggregation of immune complex
* Activation of complement

5. Prof. DR.Dr.Ariyanto Harsono
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Mast Cells and basophiles involve in allergic
reaction in the context of antigen-IgE

6. Prof. DR.Dr.Ariyanto Harsono
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Granule contents:
Histamine,TNF-a
Proteases, Heparin
Lipid mediators:
Prostaglandins
Leukotrienes
Cytokine production:
Specifically IL-4, IL-13

7. Prof. DR.Dr.Ariyanto Harsono
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2. Cell wall enzyme activation:
*Arachidonic acid breakdown
* Decrease in the ratio of cAMP /
cGMP

8. Prof. DR.Dr.Ariyanto Harsono
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Arachidonic Acid
Phospholiphase A
Cyccloxygenase Lipoxygenase
Prostaglandine
TXA
Prostacyclin
Leukotriene A
Leukotriene B
Leukotriene C
HETE,5-HETE, PAF

9. Prof. DR.Dr.Ariyanto Harsono
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3. MEDIATORs RELEASE:
*Preformed mediators: histamine, serotonin,
Neutrophil chemotactic factor, Eosinophile chemotactic
Factor
 * Newly generated mediators: leukotrienes B4, LTC4,
LTD4, Thromboxan, Prostaglandine D2, Kinin, Platelet
Actifating Factor

10. 10Prof. DR.Dr.Ariyanto Harsono
SpA(K)

11. 11Prof. DR.Dr.Ariyanto Harsono
SpA(K)

12. Prof. DR.Dr.Ariyanto Harsono
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4. Functional Pathology response:
*Increased vascular permeability:
swollen, hypotension
* Smooth muscle contraction
* Secretion of mucus
* Changes in excitability and cardiac
muscle contractability

13. Prof. DR.Dr.Ariyanto Harsono
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Nature Rev Immunol 2004: 3:234-237

14. Prof. DR.Dr.Ariyanto Harsono
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5. Inflammation and involvement
of secondary mediators:
*Leukocyte infiltration by chemotactic
* Platelet Aggregation
* Complement Activation
* Proteolytic break-down

15. Prof. DR.Dr.Ariyanto Harsono
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Complement Activation

16. Prof. DR.Dr.Ariyanto Harsono
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Complement Activation …

17. Prof. DR.Dr.Ariyanto Harsono
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Effector mechanisms against
extracellular pathogens
COMPLEMENT Activation
Bacteria in plasma
Ab &
COMPLEMENT
+
Phagocytosis
binding
Complement &
Fc receptor
Lysis
Opsonisation

18. Prof. DR.Dr.Ariyanto Harsono
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Etiology
1. Associated with IgE
Serum Protein: antisera, antitoxin, the monoclonal Ab,
IgA
Venom and sting: bee, hornet, fire ants, snakes,
spiders, mosquitoes, jellyfish
Enzymes: trypsin, penicillinase
Vaccines / Extract: DPT, pollen extract, food
Hormones: Isulin, ACTH, Progesterone

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Etiologi
1. Associated with IgE
Serum Protein: antisera, antitoxin, the monoclonal Ab,
IgA
Venom and sting: bee, hornet, fire ants, snakes,
spiders, mosquitoes, jellyfish
Enzymes: trypsin, penicillinase
Vaccines / Extract: DPT, pollen extract, food
Hormones: Isulin, ACTH, Progesterone

20. Prof. DR.Dr.Ariyanto Harsono
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oFood: milk, eggs, marine fish
oPolysaccharides: Dextran
oDrugs: penicillin, cephalosporins, tetracyclines,
Aminoglikosid, Cyclophosphamide, Metrotrexate
oOther: Heparin, Tubokurarin, ethylenediamine,
2. Causes of non-IgE
oBlood products: IgA, albumin, Imonoglobulin,
Complement C4, Cryoprecipitate
odialysis membrane
oprotamine
oL-Asperginase
oMurine monoclonal antibody
openicillin

21. Prof. DR.Dr.Ariyanto Harsono
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3. cause of anaphylactoid
Jodium diagnostic materials, Decheolin, BSP,
Fluoresin, Indosianin green
Analgesics: Salicylates, NSAIDS, Aminopirin
Antibiotics: Aminoglikosid
Xylocain
Alkaloids: Morphine, Codeine
Drug: Histamine, Amphetamines, diuretics,
anticonvulsants
Food additives: Sulfites, Tartrasin, Sodium
bensoat

22. Prof. DR.Dr.Ariyanto Harsono
SpA(K)
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Clinical Manifestations
• Skin: Itching, erythema, Urtica, Angioudem
• Respiratory: sneezing; runny nose; clogged;
coughing; wheezing; swollen larynx; tightness;
hoarseness; stridor; cyanosis
• Digestive: nausea, vomiting, diarrhea, abdominal
pain
• Eyes: itching, tears
• Cardiovascular: collapse, fainting, hypotension, pale,
cold, tachycardia, arrhythmias, cardiac arrest

23. Prof. DR.Dr.Ariyanto Harsono
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24. Prof. DR.Dr.Ariyanto Harsono
SpA(K)
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Clinical Manifestations
• Skin: Itching, erythema, Urtica, Angioudem
• Respiratory: sneezing, runny nose, clogged,
coughing, wheezing; swollen larynx: tightness,
hoarseness, stridor, cyanosis
• Digestive: nausea, Mutah, diarrhea, abdominal
pain
• Eyes: itching, tears
• Cardiovascular: collapse, fainting, hypotension,
pale, cold, tachycardia, arrhythmias, cardiac arrest

25. Prof. DR.Dr.Ariyanto Harsono
SpA(K)
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Clinical Manifestations
• Skin: Itching, erythema, Urtica, Angioudem
• Respiratory: sneezing, runny nose, clogged,
coughing, wheezing; swollen larynx: tightness,
hoarseness, stridor, cyanosis
• Digestive: nausea, Mutah, diarrhea, abdominal
pain
• Eyes: itching, tears
• Cardiovascular: collapse, fainting, hypotension,
pale, cold, tachycardia, arrhythmias, cardiac arrest

26. Prof. DR.Dr.Ariyanto Harsono
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Differential Diagnosis
Sinkope
o Subsides when placed in the recumbent
position
o T, N: Normal
o Other symptoms of anaphylactic negative

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Prevention
1. Pre vaccination screening:
(1)history of allergy to component of vaccines:
-egg,
-gelatin,
-antibiotics.
(2) healthy.
2. Anticipation
• Patient should be kept under supervision for
at least 15’.
• Ready Anaphylactic equipment

28. Prof. DR.Dr.Ariyanto Harsono
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Management
1. Primary treatment
Adrenaline 1:1000 with a dose of 0.001 ml / kg
maximum: 0.3 ml subcutaneously
Tourniquet on the proximal shock / injection
Adrenaline can be repeated 3X every 15-20 '
Sprong oxygen nose / hoad box 2-3 L / min
Free the airway, neck hyper-extension position,
head tilted, suction mucus, monitor vital
signs

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•Place the patient at shock position
•Pulmonal Ressuscitation
•Oropharyngeal airway
•Tube endotrakeal
•Tracheostomy
•Cardiac compression

30. Prof. DR.Dr.Ariyanto Harsono
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Adrenaline HCL Dose 1:1000
according age
Age Dose
2-6 Bulan 0.07 ml
12 Bulan 0.1 ml
18-48 Bulan 0.15 ml
5 Tahun 0.2 ml
6-9 Tahun 0.3 ml
10-13 Tahun 0.4 ml
>14 Tahun 0.5 ml

31. Prof. DR.Dr.Ariyanto Harsono
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2. Complementary treatment
Intended for complications:
Seizures: diazepam, phenobarbital
Bronchial Spasm : Aminophylline 7 mg
dissolved in 10-20 ml of 0.9% NaCl
followed 9 mg/kg/24 hours (divided into 3
doses)
b-2 agonist: Ventolin nebulizer

32. Prof. DR.Dr.Ariyanto Harsono
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3. Additional treatment
•Antihistamine (H1 Receptor antagonist): Benadril 2 mg/kg
i.m. continued with 3 mg/kg/24 jam oral (dibagi 3 dosis)
•H-2 receptor antagonist : Cimetidine
•Corticosteroid: Solukortef 4-7 mg/kg i.v. continued with 4-7
mg/kg/24 hour oral (devided 3 doses)
H1
H2
H3
H4
H1-antagonist
H2-antagonist
Histamin

33. Prof. DR.Dr.Ariyanto Harsono
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Granule contents:
Histamine,TNF-a
Proteases, Heparin
Lipid mediators:
Prostaglandins
Leukotrienes
Cytokine production:
Specifically IL-4, IL-13

34. Prof. DR.Dr.Ariyanto Harsono
SpA(K)
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Increase
capilary
permeability
Fluid shift shock
Urtikaria
Wheezing

35. Prof. DR.Dr.Ariyanto Harsono
SpA(K)
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Fluid therapy
• Kristaloid
• Koloid
“The most important is not the composition, but
rather the rate of administration”
In children: 30ml/kg hour I
Cardiac output
Dopamine 2-20 mg/kg/menit

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NB
• Tourniquet is released every 3 minutes
until symptoms resolved shock
• If the vaccine subcutaneously, may be
added adrenaline 0.005 ml / kg (max: 0.3
ml) at the injection site, one time only!

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