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Abstract Anaphylaxis reaction

Definition
Anaphylaxis is an acute severe, life-threatening, generalized or systemic hypersensitivity reactions
Epidemiology
- Severe anaphylaxis : 1 - 3/1! people "#oneret-$autrin et al% &ct '()
- *eneralized +ypersensitivity/Anaphylaxis : ±'/1! total patient ",etut Suryana, '()
Aetiology
-he aetiology of Anaphylactic and anaphylactoid :
1. /rugs : antibiotic : penicilin most fre0uens, aspirin, 1SA2/
'. 3oods : most commonly : fish / sea food, lobster, eggs, co4 mil5, nuts.
3. $enoms : heminoptera insects
!. 6adiographic contrast media
(. 2diopathic
7. &thers : blood products, physical factors " cold 8 exercise 9 induced )
Pathophysiology
- -ype 2 reaction "2g: mediated)
- Anaphylactoid reaction "Non IgE mediated) : complement activation, physical factors,
substance for +istamine release, idiopathic, arachidonic acid modulation
Clinical Features
Grading system for generalised hypersensitivity / anaphylaxis
(Brown SGA . Clinical features and severity grading of anaphylais !. Allergy Clin Immunol "##$% &&$("' ( )*&+, '
1. #ild "involvement of the s5in-mucosal tissues) : generalised erythema , urtica, periorbital
edema or angioedema
'. #oderate "involvment of 6espiratory, ;ardiovascular, *2 syst) : S&<, Stridor, 4heezing,
nausea, vomiting, dizziness presyncope),diaphoresis, chest / throat tightness, abd. pain / abd.
;ramp
3. Severe "hypoxia, hypotention, neurological compromise) : cyanosis"Sp&' ≤ ='>),
hypotention"adults % S<? @ = mm+g), confusion, collapse, A&; / Aoss of ;onsciousness,
incontinence.
"1 B acute hypersensitivity reaction) "' 83 B anaphylaxis)

Clinical Criteria for Diagnosing Anaphylaxis
(Sampson -A% et al. !ACI "##,'
&. Acute onset of an illness " minutes to several hours) 4ith involvement of the s5in, mucosal
tissues, or both "eg, generalized hives, pruritus or flushing, s4ollen lips-tongue-uvula)
A1/ A- A:AS- &1: &3 -+: 3&AA&C21*
a. 6espiratory compromise "eg, dyspnea, 4heeze-bronchospasm, stridor, reduced ?:3,
hypoxemia)
b. 6educed <? or associated symptoms of end-organ dysfunction "eg, hypotonia /collapse,
syncope, incontinence)
'. -4o or more of the follo4ing that occur rapidly after exposure to a li5ely allergen for that
patient "minutes to several hours) :
a. 2nvolvement of the s5in-mucosal tissue "eg, generalized hives, itch-flush, s4ollen lips-
tongue-uvula)
b. 6espiratory compromise "eg, dyspnea, 4heeze-bronchospasm, stridor, reduced ?:3,
hypoxemia)
c. 6educed <? or associated symptoms "eg, hypotonia collapse, syncope, incontinence)
d. ?ersistent gastrointestinal symptoms "eg, crampy abdominal pain, vomiting)
3. 6educed <? after exposure to 5no4n allergen for that patient " minutes to several hours ) :
a. 2nfants and children: lo4 systolic <? "age specific) or greater than 3> decrease in systolic
<?
b. Adults: systolic <? of less than = mm +g or greater than 3> decrease from that personDs
baseline
Laboratory Findings
Aaboratory test are seldom necessary or helpful initially, although certain test may be used later to
assess and monitor treatment and to detect complications.
E <lood cell counts " haemoconcentration F )
E :osinophil counts, stool examination
E 2g: total
E :;*
E ;hest G 9 ray
E &thers : dou to progress note " eg % :lectrolyte, <lood *as Analyse, <lood Suger )
Differential diagnosis
E Shoc5 : septic shoc5 , hypovolemic shoc5, cardiogenic shoc5, vasovagal reaction
E 6espiratory distress 4ith 4heezing or stridor : corpus alienum in resp. tract, Asthma
bronchiale, ;&?/, vocal cord disfunction
Factors Associated ith !everity "eactions #Prognostic Factors$
E Age
E Allergen
E Atopy
E ;$/ ";ardiovascular /isease)
E ;&?/ ";hronic &bstructive ?ulmonary /isease)
E Asthma <ronchiale
E Acid base and electrolyte inbalance
E /rugs " eg, beta-bloc5er, A;:-inhibitor)
E 2nterval of epinephrine inHection after exposure
%anagement acute hypersensitivity / anaphylaxis
Acute hypersensitivity reaction
"involvement of the s5in, mucosal tissues, or
both only)
Anaphylaxis reaction
"involvement of ' or more system / organ)
/ipenhydramine inH "1-' mg) 2# #anagement of anaphylaxis
&bservation for !-7 hours
*ood 6esponse
"no clinical
manifestation)
4orsening
1o 6esponse
"be 4orsen)
:xplore the prognostic
factors
Another treatment
"due to the problem)
*ood 6esponse
1o 6esponse
"be 4orsen)
&bservation
Ambulatory

&ral
antihistamie
for 3 days
1o
response
2n patient
2$3/
A+1 inH i.m
A+' inH i.v
Steroid inH
%A&AGE%E&' (F A&AP)*LA+,!
&bservation for ' - 3 x '! horus, for mild case Hust need 7 hours
*ive ;orticosteroid and antihistamine orally for 3 x '! horus
:lderly " ≥7 y.o), ;$/ è adrenalin dose ,1-,'cc 2# 4ith interval (-1 mnt
Dosage and route of in-ection
- /ose epinephrine and route of inHection :
- ,3-,( ml inH S;/2# lateral thigh / deltoid "North American Guidelines% 2ndonesia'
- ,(-1 ml inH S;/2# lateral thigh / deltoid "European .iterature)
- ?harmaco5inetic and pharmacodynamic epinephrine
P"E.E&',(&
a. :xplore the maHor ris5 factors for anaphylaxis include a prior history of such reactions, β-
adregenric bloc5er or possibly A;: inhibitor therapy, and the multiple antibiotic sensitivity
syndrome, atopic bac5ground.
b. Application the rationale therapy
c. 2nformed consent
d. ?atients 8 their families education maybe the most important preventive strategy% be carefully
instructed about hidden allergens, cross-reactions to various allergens, unforeseen ris5 during
medical procedures, 4hen and ho4 to use self-administration epinephrine "if available).
e. 2n a future% inHection anti 2g: antibody 4ith regular interval could be prevent the ris5 or the
severity of anaphylaxis reactions
History of severe allergic reaction with respiratory difficulty or hypotension, especially
if skin changes present
Oxygen high flow
Adrenalin / epinephrine (1 : 1000 0,! " 0,# $l %& (0,01 $g/kg '(
)epeat in #*1# $inutes if no clinical i$prove$ent
Antihista$ine 10*+0 $g %& or slowly %ntravenously
%n addition
,ive 1*+ l of fluid intravenously if clinical $anifestation of shock do not respond to drug treat$ent
-orticosteroid for all severe or recurrent reactions . patients with asth$a/
&ethyl prednisolone 1+#*+#0 $g %0
1exa$ethasone +0 $g %0
Hydrocortisone 100*#00 $g %0 slowly
continue 2y $aintenance dose
%nhaled short acting β*+ agonist $ay used if 2ronchospas$ severe
0asopressor (dopa$ine, do2uta$ine with titration dose
3top ad$inistration of precipitant
A&AP)*LA+,!
3emale 3 years old, came to the :mergency Init 4ith cheap complain % edema on
palpebra, itching 9 redness on the 4hole body s5in, ' minutes after ta5e the metampiron
( mg tab.as a treatment for headache. She also complains% shortness of breath, fatigue,
4arm on lo4er extremity.
Learning tas/
- Chat should you do for the firstF
- ;ould you complate your anamnesisJ
- Chat do you find on physical examinationF
- -he laboratory planF or other diagnostic prosedureF
!elf assessment
- Chat are the differential diagnosesF
- ;ould you describe the pathophysiology of anaphylaxisF
- ;ould you describe the clinical manifestationsF
- -he management in this caseJ
- /escribe the preventionJ
- ;omprehend any prognostic factorsJ

Abstract !/in test and Clinical application
Focus in !/in Pric/ 'est #!P'$
,ntroduction
- -he diagnosis of allergic diseases :
- A comprehensive history
- ?hysical examination
- Aaboratory and other diagnostic testing : laboratory "eos. count, feces ex, 2g:), roentgen,
!/in test
!/in test 0 the direct introduction of an antigen into the s5in of a patient. A simple, rapid and
efficient techni0ue for determining 2g: antibodies to specific antigens
%ethods of s/in testing 0 ?atch test, Scratch test, ?ric5 test, 2ntradermal test
!/in Pric/ test #Epicutaneous tests$
- /iagnostic approach for the immediate hypersensitivity reaction.
- /etermining 2g: antibodies to specific antigens
- S?- are done before any intradermal testing
- /ood allergy : 0ositive predictiv1e value 2 3#45 Negative predictive value 6 734
- 2nterpretation base on Cheal and 3lare / C3 reaction.
- ,ndications for !P'
- An allergic patient / suspected allergy
- When SPT should be done :
- S08 should 1e underta9en during periods of free symptoms
- 8o prevent worsening of the clinical status
- Preparations of SPT :
- :ashout of any medication include 5
- antihistamines A-+& (a )+days washout'% A-+" (one day washout'
- antidepressants% codeine% long+term oral steroid (a &+wee9 washout'
- A &+ wee9 course of daily glucocorticosteroids was reported to have no effect on immediate
s9in tests.
- -igh dose allergy immunotherapy results in a reduction in s9in test reaction.
- Emergency ;it
- Procedure of !P'
- S?- 4as performed on volar region of antebrachium
- ;leanse the s5in 4ith K > ethyl alcohol and allo4 it to dry by evaporation
- Aseptically place a drop of a standardized allergen "' cm apart, to prevent coalescence of
positive results)
- -he vaccinostyl / a sterile needle no. '7 should not be inserted so deep "1mm) at about a
!(° angle into the superficial s5in
- About ' minutes, observe the tes sites for erythema and 4heal formation "C3 reaction)
S5in pric5 test "L)
Anamnesis
?hysical
examination
/iagnostic testing
Are used to assess 0
-he diseases pathomechanisms
Specific allergic triggers
Sensitivity grading
- Grading and interpretation 0 è based on the diameter C3
- Although many grading systems, consistency and familiarity 4ith the system are most
important.
- 1egative B no C3 formation / diameter @ 3 mm
- L1 B C3 formation 4ith diemeter ≥ 3 mm
- L' B C3 formation 4ith diemeter !-7 mm
- L3 B C3 formation 4ith diemeter M 7 mm
A negative control : a test using diluent solution "coca solution)
A positive control : a test using .1> histamine solution
Control test could be evaluate 0 technic, non spesific, allergen, false negative / false positive
- False negative : technic test, lo4 allergen, preparation not optimal "discontinue of the drugs)
- False positivie : technic test, deviation from physiologic p+ / osmolaritas of the allergen,
presence of A#C, irritans
Clinical application
Asthma
*astro-intestinal
Sign 8
symptoms
:xem /
itching
6hinitis
?ositive +istory oft
allergy
1egativ
e
S5in test /
6AS-
S5in test /
6AS-
?ositive 1egative ?ositive
1egative
6evie4 the anamnesis
;linical history
Anamnesis / clinical history
4as not confirm
;ontinue s5in test / 6AS-
?rovocative tes
3or target organ
/iagnostic approach by
allergen avoidances
;onsider to
6eferal
/iagnosis
allergy
4as confirmed
6epeat the prior
procedure
/iagnosis
allergy
4as excluded
;onsider
Allergen avoidance
2mmunotherapyi
1o spcific theraphy for
allergy
!1,& 'E!'
3amale 1K years old, suffer from shortness of breath recurrently especially in the
midnaight. +er mother has a history of asthma bronchial. &n the S5in ?ric5 -est 4e found:
L ! for allergen house dust, L ' for allergen nut, L ' for allergen eggs.
Learning tas/
. ;ould describe completly the S5in ?ric5 -est resultJ
. ;omprehend the clinical applicationJ
. +o4 to manage and give some educationJ
!elf assessment
. /escribe the s5in test typeJ
. 2ndication and preparation of the s5in test "S?-)
. ;omprehend the immunopathophysiology of the S5in test
. +o4 to interpret the S5in test result
. ;omprehend the clinical application of the s5in test.