FIRST-SOLUTION

A woman suddenly unconscious after an injection of antibiotics by doctors clinic, unfortunately she did not tell the doctor that she was allergic to penicillin and have a history of asthma since childhood. What happened? If this happened to the people we love, what should we do? Well, this article will explain it to you. Congratulations to follow ...

This article will discuss all about anaphylactic shock, which include: synonyms, understanding, etiology (cause),
pathophysiology, clinical manifestations, an important sign, pearl diagnosis, investigation, treatment, diagnosis, complications, prognosis (prediction of disease development), prevention, and references.

Synonym
Shock anafilaktik, renjatan anafilaktik, anaphylactic shock.

Definition
In short, anaphylactic shock can be interpreted as an allergic reaction to an emergent against allergens (such as injection) which can be fatal (fatal).

Anaphylactic shock is a response to life-threatening anaphylaxis in people who are exposed to specific antigen, occurred within minutes, and manifests as failure of breath (respiratory distress), swelling of the throat (laryngeal edema), and / or respiratory muscle to tighten that causes narrowing of the airway (intense bronchospasm), often followed by failure of function of blood vessels (vascular collapse) or by the shock without preceded by difficulty in breathing.

Characteristic (hallmark) of anaphylactic reaction (anaphylactic reaction) is the onset of some clinical manifestations that occur within a few seconds to several minutes after exposure to the antigen, usually by injection (injection) or can be entered through the digestive process (ingestion).

Anaphylaxis classic terminology refers to a hypersensitivity reaction mediated by a subclass of the antibody IgE and IgG immunoglobulins. Has occurred prior exposure (prior sensitization) against allergens, which produce antigen-specific immunoglobulins. Repeated exposure to the next (subsequent reexposure) against allergens cause anaphylactic reactions (anaphylactic reactions). However, many of anaphylactic reactions that occur without a preceded by a history of exposure to allergens (documented prior expoure).

The reaction anafilaktoid or pseudoanafilaksis (pseudoanaphylactic or anaphylactoid reactions) shows a collection of similar clinical symptoms / similar, but not through the immune system (not immune-mediated).

Anafilaktoid reaction (anaphylactoid reaction) occurs when an attacker agent (the offending agent) causes direct release of certain substances without a mediated (mediated) by IgE.

Etiology (cause)
The cause of anaphylactic shock is the antigen-antibody reaction. Antigen which is the role of immunoglobulin E (IgE). As for some of the factors responsible for the occurrence of anaphylactic shock include:
1. Hapten, such as: antibiotics, beta-laktam, penicillin, sefalosporin, amphotericin B, nitrofurantoin, kuinolon, sulfonamides, streptomycin, vancomycin, other medicines (especially given intravenously), aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), contrast media, demeclocycline, protamine, a local anesthetic (procaine, lidocaine), polysaccharides (dextran and thiomersal as a vaccine preservative), agent chemotherapy (carboplatin, paclitaxel, doxorubicin), pelemas muscle or muscle relaxants (suxamethonium, gallamine, pancuronium), vitamin (thiamine, folic acid), diagnostic agents (sodium dehydrocholate, sulfobromophthalein), chemicals associated with the job (ethylene oxide).
2. Serum products, such as: immunoglobulins, Immunotherapy for allergic diseases, heterologous serum.
3. Food, such as: seafood, nuts, seeds, shells, buckwheat (Fagopyrum esculentum), egg whites, milk, cotton seed, corn, potatoes, rice, legumes, citrus, chocolate, etc..
4. Poison (venom), for example: insect sting especially the Hymenoptera (bees, wasps, ants, fire ants [fire ants], ichneumons [mongoose / mongoose North Africa]).
5. Certain hormones, such as insulin, ACTH (adrenocorticotrophic hormone), TSH (thyroid-stimulating hormone), ADH (= antidiuretic hormone, vasopressin), parathyroid hormone (parathormone).
6. Certain enzymes, such as chymopapain, L-Asparaginase, trypsin, chymotrypsin, penicillinase, streptokinase.
7. Others, such as: the seminal fluid (semen), a variety of products made from rubber latex.

As some agents cause anafilaktoid reaction is:
1. Various reactions mediated by complement (complement-mediated reactions), for example: blood, serum, plasma, plasmanate (not albumin), immunoglobulins.
2. Mast cell Nonimunologic Activators, such as opioids, radiokontras media, dextran, neuromuscular blocking agents, etc..
3. Arachidonic acid modulators, for example: anti-inflammatory drugs, tartrazine (maybe).
4. Unknown cause (idiopathic), most of the conclusions made after a thorough evaluation.

Pathophysiology
Anaphylactic shock after exposure to the antigen of the immune system that produces degranulasi mast cells and release of mediators. Mast cell activation may occur either by the mediated pathway (mediated) by immunoglobulin E or IgE (anafilaktik) or that are not mediated by IgE (anafilaktoid).

Inflammatory mediators include histamine, leukotrien, triptase, and prostaglandins. When released, these mediators cause increased mucous secretion, increased bronchial smooth muscle tone, respiratory tract edema, decreased vascular tone and capillary leak. Constellation of these mechanisms cause respiratory and cardiovascular collapse.

Clinical Manifestation
Reaction can occur or disturbances in several organ systems in a matter of seconds, minutes after antigen exposure:
A. Cardiovascular system (heart and blood vessels), which is characterized by: palpitation (rapid heart rhythms and irregular), tachycardia (rapid heartbeat, more than 100x/menit), hypotension (low blood pressure), shock, fainting, and the examination ECG (electrocardiogram) found: aritmi, T flat / inverted, nodal rhythm, ventricular fibrillation until asistol.
B. System respiration (breathing), which is marked with: rhinitis (inflammation of the mucous membranes of the nose), sneezing, itching of the nose, coughing, shortness of breath, wheezing, Stridor (snore), hoarse voice, severe breathing, tachypnoea (rapid breathing) until apnoea (stopping breathing).
C. Gastrointestinal system (digestive), which is marked with: nausea, vomiting, pain / abdominal pain, diarrhea, abdominal cramps.
D. Integumentary system / cutaneous (skin), which is characterized by: pruritus (itching), urticaria (biduran, chilblain, itching), angioedema (biduran severe, severe, ongoing, not tickling itch, characterized by swelling of the lips, eyes, hands, tongue, uvula [pharynx]).
E. Vision system, characterized by: Itchy, red swollen, lacrimation (watery eyes).
F. Central nervous system, characterized by: disorientation (feeling confused or not aware of the place, space, time), hallucinations, convulsions, coma.

Clinical manifestations of the above are not all there or come together in patients, can be only one, two, or several experienced patients.

Signs Important
1. Rapid pulse or small, to not palpable.
2. Tension fell to unmeasured.
3. Limbs, especially legs, feels cold.
4. Cold sweat.

Mutiara Diagnosis
According to FS Bongard and DY Sue (2003), there are six essentials of the diagnosis:
1. Cutaneous flushing, pruritus (itching).
2. Abdominal distention, nausea (nausea), vomiting (vomiting), diarrhea.
3. Airway obstruction (airway obstruction) due to edema of the larynx.
4. Bronkospasme, bronchorrhea, lung edema.
5. Tachycardia, syncope (fainting while the reduction of blood flow to the brain), hypotension.
6. Cardiovascular collapse.

Examination Support
- It takes an EKG and blood gas analysis for diagnosis.
- Increased public hematocrit hemokonsentration found as a result of the permeability of blood vessels.
- Serum mast cell tryptase are increased.

Management
There are several steps / handling according to the experts that will be described below.

According to Prof. DR. Dr. A. Halim Mubin, SpPD., MSc, KPTI. (2008):
a. Rest
- Patients on the basis ditelentangkan rather hard.
- Legs elevated about 30-40 degrees.
- If the patient is not conscious, do triad movement:
1. Head diekstensi.
2. The mandible (lower jaw) was pushed forward.
3. Mouth open.
- If the patient apneu, done immediately and assisted artificial ventilation pure oxygen 100%.
- If the airway is blocked due to edema of the larynx, trachea intubation attach.
- In the event of cardiac arrest (cardiac arrest), do 15x cardiac compression with 80-100x speed per minute followed by 2x ventilation.
- Given the fluid or colloid like albumin fluid.
- Observation must be done within 2-4 hours.

b. Diet
c. Medical
c.1. First drug:
- Adrenaline: 3-5 mL dose of 1:10, 000 solution IV.
- Adrenaline: 0, 3-0, 5 mL dose im / sk 1:1000 solution when light conditions, repeated every 5-10 minutes, enough 1-4x injection. Adrenaline intrakardiak if there is a vein of the dam.
- If hypotension does not improve with adrenaline, give IV adrenaline 1:10, 000 solution of 1-5 mL in copy + 1 liter in the first 15-30 minutes and so on until 6 liter/12 hours.
- Anti-H2 receptor is sometimes useful to hypotension.
- If not resolved renjatan too, can be given vasopresor, such as: dopamine 2-20 mg / kg / min.
- Corticosteroids such as hydrocortisone 5 mg / kgBB every 4-6 hours on renjatan prolonged and bronchial spasms.
c.2. Alternative medicine
- Aminofilin, if there bronkospasme. Dose: 5-6 mg / kg per infusion for 20 minutes followed 0, 4-0, 9 mg.kg BW / hour plus 4-6 liters of oxygen per minute.
- Corticosteroids / hydrocortisone, 100-200 mg, intravenous (IV).
- Antihistamines: 50-100 mg IV difenhidramin slowly to relieve pruritus (itching).
- When the patient returned give corticosteroids.

d. Tracheal intubation / tracheostomy / krikotiroidotomi for giving oxygen.
e. External cardiac compression.

According to dr. Ery LEKSANA, SpAn.KIC (2004): the action to be performed on patients as soon as possible anaphylactic shock are:
v Put the patient with the shock position (feet higher).
v Adrenaline: 0, 3-0, 5 mg sc adult; children 0.01 mg / kg sc (1:1000 solution).
v Connect the 0.9% NaCl infusion.
v Corticosteroids: dexamethasone 0.2 mg / kg iv.
v If there bronkospasme, give aminophylline 5-6 mg / kg IV bolus slowly and continue drip 0, 4-0, 9 mg / kg / min.
Adrenal function is to increase myocardial contractility, vascular vasoconstriction (narrowing of the diameter of blood vessels), increased blood pressure, and bronkodilatasi (widening of respiratory tract).

According Rifki AZ (1999): anaphylactic shock response requires quick action because the patient is in critical condition. In fact, treatment of anaphylactic shock is not hard, long available drugs and tools emerjensi emergency resuscitation and done as quickly as possible. This is necessary because we are racing with a short time to avoid death or permanent disability of organs.
If complications occur anaphylactic shock after conceded a drug or chemical substances, either peroral or parenteral, then action needs to be done is:
1. Soon the patient lying on a hard base. Feet up higher than his head to increase blood flow through the vein, in an effort to improve cardiac output and raise blood pressure.
2. Assessment of A, B, C from cardiac pulmonary resuscitation phases, namely:
A. Airway 'airway assessment'. The airway should be kept free, there is no blockage at all. For patients who are not aware, the position of the head and neck set so that the tongue does not fall backward over the airways, namely by extension the head, pulling the mandible forward, and open your mouth.
B. Breathing support, immediately provide artificial breathing assistance if there are no signs of breathing, either through the mouth to mouth or mouth to nose. In the shock that accompanied anafilaktik larynx udem, could cause total airway obstruction or in part. Patients who experience airway obstruction in part, in addition to being helped with medication, should also be given help breathing and oxygen. Patients with total airway obstruction, should be helped by more active, through intubation endotrakea, krikotirotomi, or tracheotomies.
C. Circulation support, ie when no palpable pulse in large arteries (carotid artery or femoral artery), immediately external cardiac compression did.
Assessment of A, B, C is an assessment of the need for basic life support in accordance with the protocol Rx cardiac pulmonary resuscitation.
3. Immediately give adrenaline 1:1000 solution of 0, 3-0, 5 mg for adult patients, or 0.01 mg / kg for patients with children, intramuscular. Giving can be repeated every 15 minutes until the situation improves. Some authors recommend continuous adrenaline infusion 2-4 ug / min.
4. If there is spasm of the bronchi, where the provision of adrenaline or less to respond, can be added aminophylline 5-6 mg / kgBB initial dose intravenously transmitted 0, 4-0, 9 mg / kgBB / min in the intravenous fluids.
5. May be given corticosteroids, eg hydrocortisone 100 mg or 5-10 mg intravenous dexamethasone as therapy to overcome the effects of supporting information from anaphylactic shock or shock to be naughty.
6. If blood pressure remains low, the line installation is required for correction of hypovolemia due to fluid loss ekstravaskular space as a primary goal in dealing with anaphylactic shock. Fluid will increase blood pressure and cardiac output and overcome the lactic acidosis. The selection of liquid between crystalloid and colloid solutions remain a debate based on gains and losses since the increase in capillary permeability or leakage. Basically, if given crystalloid solution, then the required amount of 3-4 times the estimated plasma volume deficiency. Typically, the shock is anafilaktik heavy losses estimated 20-40% of the volume of plasma. Whereas if given colloidal solution, may be given by an amount equal to the estimated loss of plasma volume. But, to think also that the plasma protein colloid solution or dextran can also release histamine.
7. In an emergency, it is not wise if the person is in shock anafilaktik sent to the hospital, they may die in transit. If I have done, then the handling of patients at the scene had to be as much as possible in accordance with the available facilities and transportation must be guarded by people with a doctor. The position taken time to remain in the supine position with feet higher than the heart.
8. If the shock is resolved, patients do not quickly released, but must be supervised or observed first for about 4 hours. Whereas patients who had received therapy for more than 2-3 adrenaline injection, should be treated in hospital overnight for observation.
Diagnosis Banding
Some disorders (disorders) are common in the ICU is similar to anaphylactic shock and anafilaktoid reaction is:
1. Myocardial infarction
2. Ischemic infarction
3. Septic shock
4. Pulmonary embolism (pulmonary embolism)
5. Choking when eating or being fed (aspiration of feedings)
6. Bronchitis
7. Acute exacerbations of chronic lung disease obtruktif / COPD (acute exacerbation of COPD)
8. Disturbance / seizures (seizure disorders)
9. Hypoglycemia
10. Stroke (= CVA, cerebrovascular accidents, apoplexies)
11. Scombroid poisoning, which occurred within 30 minutes after eating stale fish (spoiled fish), including tuna, mackerel, or dolphin (mahi-mahi).
12. Angioedema
13. Asthma attack (asthma attacks)
14. Panic disorder
15. Vasovagal reactions.

Complications
If not addressed, anaphylactic shock can progress to irreversible shock and various organ damage.

The prognosis (disease Growth Predicted)
Prognosis is influenced by several factors, among others:
1. Weighing the disease.
2. Power handling.
3. Equipment and the availability of drugs.
4. Time (fast-precise) handling.
5. Allergen exposure time, while the entry of allergens with the onset of symptoms, more and more easily helped.
6. How to administering medication and dose allergens; provision of high-dose intravenous and then a bad prognosis.
7. The frequency of anaphylactic reactions to the incident the same antigen, the more often the worse the prognosis.
Mortality (death rate) reached 3-9%, 50-80% in the first hour.

Prevention
1. In buying drugs, particularly antibiotics, in accordance with the prescriptions and doctor's instructions.
2. Individuals who have a history of asthma and a history of allergy to many drugs, have a higher risk to the possibility of anaphylactic shock. Should he noted a history of illness and any medication that made her allergic to and inform the doctor during treatment.
3. Avoiding risky foods that cause allergies, such as: seafood, shrimp, shellfish, milk, eggs, etc..
4. It is important to realize that a negative skin test, in general, giving patients can tolerate these drugs, but by no means certain patients will not experience anaphylactic reaction. People with a negative skin test and a positive allergy history is still likely to experience anaphylactic reactions by 1-3%. If the skin test is positive, then the chances will increase to 60%.
5. Always available antidote to anticipate the possibility of anaphylactic reaction and the presence of assistive devices resuscitation gravity.
Reference
1. American Heart Association. Circulation. Part 10.6: Anaphylaxis. 2005; 112; IV-143-IV-145.

2. Bongard FS, Sue DY. Current Critical Care Diagnosis & Treatment. Second Edition. Lange Medical Books / McGraw-Hill. USA. 2003; 11:259-261.

3. Fauci, Braunwald, Kasper, Hauser, et al (Ed). Harrison's Principles of Internal Medicine. 17th Edition. The McGraw-Hill Companies, Inc.. 2008. Chapter 311.

4. Greenberg MI (Ed). Greenberg's Text-Atlas of Emergency Medicine. Lippincott Williams & Wilkins. USA. 2005.

5. LEKSANA E. Fluid and Electrolyte Therapy. SMF / Part Anesthesia and Intensive Therapy. Faculty of Medicine Diponegoro University. Semarang. 2004:19.

6. Mubin H. Practical Guide Medicine: Diagnosis and Therapy. 2nd edition. EGC. Jakarta. 2008:729-733.

7. Rifki AZ. Shock and handling. A day Symposium: Some Aspects of Clinical Giving In Rational Parenteral Fluids. PAPDI Cab. Padang, 18 September 1999.

Software Support
8. Electronic Dictionary of Medicine v1.0. Peter Collin Publishing. Teddington. UK. 1999.

9. 2:04 dictionaries. Freeware by Ebta Setiawan 2006-2009.

10. Lewis A. WordWeb 3:01. Freeware by Princeton University. 2004.

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