Anaphylactic shock: symptoms, emergencyhelp, prevention

Update: February 2019

Anaphylactic shock (from Greek “reverse protection”) is
generalized rapid allergic reaction threatening
human life because it can develop during 
a few minutes. The term has been known since 1902 and was first described.
in dogs.

This pathology occurs in men and women, children and the elderly.
equally often. Mortality in anaphylactic shock is
примерно 1% из всех patients.

Causes of anaphylactic shock

Anaphylactic shock can occur under the influence of many
factors, whether food, drugs or animals.
Основные причины анафилактического shock:

Group of allergens Major allergens
Medications
  • Antibiotics – penicillins, cephalosporins, fluoroquinolones,
    sulfonamides
  • Hormones – insulin, oxytocin, progesterone
  • Contrasting substances – barium mixture, iodine-containing
  • Serum – anti-tetanus, anti-diphtheria,
    rabies rabies
  • Vaccines – anti-influenza, tuberculosis,
    antihepatitis
  • Enzymes – pepsin, chymotrypsin, streptokinase
  • Muscle relaxants – tracrium, norkuron, succinylcholine
  • Nasteroid anti-inflammatory drugs – Analginum,
    amidopyrine
  • Blood substitutes – albulin, polyglukin, reopolyglukin,
    Refortan, Stabizol
  • Latex – medical gloves, instruments, catheters
Animals
  •  Insects – bites of bees, wasps, hornets, ants, mosquitoes;
    ticks, cockroaches, flies, lice, bugs, fleas
  • Helminths – roundworms, whipworms, pinworms, toksokary,
    trichinella
  • Pets – wool of cats, dogs, rabbits, marine
    pigs, hamsters; feathers of parrots, pigeons, geese, ducks, chickens
Plants
  •  Herbs – ambrosia, wheat grass, nettle, wormwood,
    dandelion, quinoa
  • Coniferous trees – pine, larch, fir, spruce
  • Flowers – rose, lily, daisy, carnation, gladiolus,
    orchid
  • Deciduous trees – poplar, birch, maple, linden, filbert,
    ash
  • Cultivated plants – sunflower, mustard, castor oil,
    hops, sage, clover
Food
  •  Fruits – citrus, bananas, apples, strawberries, berries,
    dried fruits
  • Proteins – whole milk and dairy products, eggs, beef
  • Fish products – crayfish, crabs, shrimps, oysters, crayfish,
    tuna, mackerel
  • Grains – rice, corn, pulses, wheat, rye
  • Vegetables – red tomatoes, potatoes, celery, carrots
  • Food additives – some dyes, preservatives, flavoring and
    aromatic additives (tartrazine, bisulfites, agar-agar,
    glutamate)
  • Chocolate, coffee, nuts, wine, champagne

 What happens in the body with shock?

The pathogenesis of the disease is quite complicated and consists of three
consecutive stages:

  • immunological
  • pathochemical
  • pathophysiological

The basis of the pathology is the contact of a specific allergen with
cells of the immune system, after which the specific
antibodies (Ig G, Ig E). These antibodies cause a huge release
inflammatory factors (histamine, heparin,
prostaglandins, leukotrienes, and so on). Further factors
inflammations penetrate all organs and tissues, causing disturbance
circulation and blood clotting in them until the development of acute
heart failure and cardiac arrest.

Usually, any allergic reaction develops only when
re-contact with the allergen. Anaphylactic shock is dangerous because
what can develop even with the initial ingress of an allergen in
human organism.

Symptoms of anaphylactic shock

Варианты течения diseases:

  • Malignant (fulminant) – characterized by very fast
    development in the patient of acute cardiovascular and respiratory
    failure, despite the ongoing therapy. Exodus 90%
    cases – lethal.
  • Long – develops with the introduction of long-term drugs
    actions (for example, bitsillin), therefore intensive therapy and
    patient monitoring must be extended to several
    days
  • Abortive – the easiest option, the patient’s condition is nothing
    threatened. Anaphylactic shock is easily relieved and does not cause
    residual effects.
  • Recurrent – characterized by recurring episodes
    of this condition due to the fact that the allergen continues to flow into
    the body without the patient’s knowledge.

In the process of developing symptoms of the disease, doctors identify three
period:

  • Precursor period

Initially, patients feel general weakness, dizziness,
nausea, headache, skin rash and
mucous membranes in the form of urticaria (blisters). Patient complains
feeling anxious, discomfort, lack of air, numbness of the face and
hands, blurred vision and hearing.

  • Peak period

Characterized by loss of consciousness, a fall in the arterial
pressure, general pallor, increased heart rate (tachycardia), noisy
breathing, cyanosis of the lips and limbs, cold sticky sweat,
the cessation of urine or urinary incontinence,
itching.

  • Period of shock

Может продолжаться в течение нескольких days У patients
weakness, dizziness, lack of appetite.

The severity of the condition

Easy flow Moderately severe Heavy current
Arterial pressure Reduced to 90/60 mmHg Снижается до 60/40 mmHg Not determined
Precursor period 10-15 minutes 2-5 minutes Seconds
Loss of consciousness Brief faint 10-20 minutes More than 30 minutes
Treatment effect Well treatable The effect is slow, requires long observation No effect
With easy flow

Precursors with mild shock usually develop during
10-15 minutes:

  • skin itch, erythema, rash urticaria
  • feeling hot and burning all over
  • if the larynx swells, the voice becomes hoarse, right up to
    aphonia
  • Quincke’s edema of different localization

On the sensations at easy anaphylactic shock the person
manages to complain to others:

  • Feel headache, dizziness, chest pain, decrease
    vision, general weakness, lack of air, fear of death, noise in
    ears, numbness of tongue, lips, fingers, back pain,
    the stomach.
  • Cyanotic or pale skin is noted.
  • Some people may have bronchospasm – wheezing is heard on
    distance, difficulty exhaling.
  • In most cases, vomiting, diarrhea, abdominal pain,
    involuntary urination or an act of defecation.
  • But even so, the patients faint.
  • The pressure is drastically reduced, thready pulse, heart sounds are deaf,
    tachycardia
With moderate flow

Harbingers:

  • Just like with mild, general weakness, dizziness,
    anxiety, fear, vomiting, heart pain, suffocation, angioedema,
    hives, cold sticky sweat, cyanosis of the lips, pallor of skin
    integuments, dilated pupils, involuntary defecation and
    urination.
  • Часто —  тонические и клонические судороги, после чего
    there is a loss of consciousness.
  • Давление низкое или не определяется, tachycardia или
    bradycardia, pulse thready, heart sounds deaf.
  • Rarely – gastrointestinal, nosebleed, uterine
    bleeding.
Heavy current

The rapid development of shock does not allow the patient to complain
on their sensations, because in a few seconds there is a loss
of consciousness. A person needs instant medical care otherwise.
sudden death occurs. The patient has a sharp pallor,
foam from the mouth, large drops of sweat on the forehead, diffuse skin cyanosis
integuments, pupils dilate, tonic and clonic convulsions,
wheezing with prolonged exhalation, blood pressure is not
determined, heart sounds are not heard, the pulse is thready, almost
not detectable.

There are 5 clinical forms of pathology:

  • Асфиктическая – при этой форме у patients преобладают симптомы
    respiratory failure and bronchospasm (shortness of breath, difficulty
    breathing, hoarseness), Quincke’s edema often develops (edema
    larynx until complete cessation of breathing);
  • Abdominal – the predominant symptom is abdominal pain,
    imitating the symptoms of acute appendicitis or perforated gastric ulcer
    (due to spasm of smooth muscles of the intestine), vomiting, diarrhea;
  • Cerebral – a feature of this form is the development of edema.
    brain and meninges, manifested in the form of cramps, nausea,
    vomiting, not bringing relief, state of stupor or coma;
  • Hemodynamic – the first symptom is pain in the area
    heart resembling myocardial infarction and a sharp drop
    blood pressure;
  • Generalized (typical) – found in most
    cases, includes all common manifestations of the disease.

Diagnosis of anaphylactic shock

Diagnosis of pathology should be carried out as soon as possible.
therefore, the prognosis for a patient’s life depends on experience.
a doctor. Anaphylactic shock is easily confused with other diseases.
the main factor of diagnosis is the correct collection
history!

  • In general, blood tests reveal anemia (a decrease in the number
    erythrocytes), leukocytosis (increase of leukocytes) with eosinophilia
    (increased eosinophils).
  • In the biochemical analysis of blood is determined by the increase in hepatic
    enzymes (AST, ALT, ALP, bilirubin), kidney tests (creatinine,
    urea).
  • At a survey radiography of the chest revealed
    interstitial pulmonary edema.
  • ELISA is used to detect
    specific antibodies (Ig G, Ig E).
  • If a пациент затрудняется ответить, после чего у него развилась
    allergic reaction, he is advised to consult an allergist with
    conducting allergy tests.

First aid pre-medical – an algorithm for action
anaphylactic shock

  • Lay the patient on a flat surface, lift the legs
    (for example, put a blanket rolled up under them);
  • Turn your head to the side to prevent aspiration of vomitus,
    remove dentures from the mouth;
  • Provide fresh air in the room (open the window,
    a door);
  • Carry out activities to stop the receipt of the allergen in
    the body of the victim – remove the sting with poison, attach to the place
    bite or injection with an ice bag, put a pressure bandage higher
    bite sites and such.
  • To probe the patient’s pulse: first on the wrist, if he
    is missing, then on the carotid or femoral arteries. If a пульса
    No, start conducting an indirect heart massage – close your arms in
    lock and put on the middle part of the sternum, hold rhythmic
    points depth 4-5 cm;
  • Check patient for breathing: see if
    chest movement, attach a mirror to the patient’s mouth. If a
    breathing is absent, it is recommended to start artificial respiration
    by breathing air into the patient’s mouth or nose through a tissue or
    handkerchief;
  • Call an ambulance or transport yourself
    patient to the nearest hospital.

Emergency Algorithm for Anaphylactic Shock
(health care)

  • Monitoring vital functions – measurement
    blood pressure and pulse, determination of oxygen saturation,
    electrocardiography.
  • Ensuring airway patency – removal from the mouth
    emetic masses, the removal of the lower jaw on the triple reception Safar,
    tracheal intubation. With spasm of the glottis or angioedema
    recommended conicotomy (held in emergency
    cases by a doctor or medical assistant, the essence of the manipulation is
    cut the larynx between the thyroid and cricoid cartilage to
    provide air flow) or tracheotomy (performed only in
    conditions of the medical institution, the doctor makes the dissection of the rings
    trachea).
  • The introduction of adrenaline – 1 ml of 0.1% solution of epinephrine hydrochloride
    diluted with up to 10 ml of saline. If a есть непосредственное место
    the introduction of the allergen (bite, injection), preferably chipped him
    diluted adrenaline sc. Then you must enter 3-5 ml
    solution intravenously or sublingually (at the root of the tongue, since
    it is abundantly supplied with blood). The rest of the adrenaline solution
    You must put in 200 ml of saline and continue the introduction
    intravenous drip under the control of blood pressure.
  • Introduction of glucocorticosteroids (adrenal hormones) –
    Dexamethasone is generally used at a dosage of 12–16 mg or
    преднизолон  в дозировке 90-12 мг.
  • The introduction of antihistamine drugs – first injection,
    then move to tablet form (diphenhydramine, suprastin,
    tavegil).
  • Inhalation of moistened 40% oxygen at a rate of 4-7 liters per
    a minute
  • In severe respiratory failure, administration is indicated.
    methylxanthines – 2.4% aminophylline 5-10 ml.
  • Due to the redistribution of blood in the body and the development
    acute vascular insufficiency is recommended
    crystalloid (ringer, ringer-lactate, plasmalite, sterofundin) and
    colloid (gelofusin, neoplasmazhel) solutions.
  • To prevent swelling of the brain and lungs, diuretics are prescribed.
    drugs – furosemide, torasemide, minnitol.
  • Anticonvulsant drugs for cerebral disease –
    25% magnesium sulfate 10-15 ml, tranquilizers (sibazon, Relanium,
    seduksen), 20% sodium hydroxybutyrate (GHB) 10 ml.

Consequences of anaphylactic shock

Any disease does not go away without a trace, including
anaphylactic shock. After stopping the cardiovascular and
respiratory failure in a patient may be the following
symptoms:

  • Inhibition, lethargy, weakness, pain in the joints, pain in
    muscle, fever, chills, shortness of breath, heart pain, and pain in
    stomach vomiting and nausea.
  • Long hypotension (low blood pressure) –
    stopped by prolonged vasopressor administration: adrenaline,
    mezaton, dopamine, norepinephrine.
  • Heart pain due to ischemia of the heart muscle – recommended
    the introduction of nitrates (isoket, nitroglycerin), antihypoxic drugs
    (thiotriazolin, mexidol), cardiotrophic (riboxin, ATP).
  • Headache, decreased intellectual function due to
    prolonged hypoxia of the brain – used nootropic
    drugs (piracetam, citicoline), vasoactive substances (Cavinton,
    ginkgo biloba, cinnarizine);
  • With the appearance of infiltrates at the site of the bite or injection is shown
    topical treatment – hormonal ointments (prednisone,
    hydrocortisone), gels and ointments with absorbable effect
    (heparin ointment, troksevazin, lioton).

Sometimes there are late complications after anaphylactic
shock:

  • hepatitis, allergic myocarditis, neuritis, glomerulonephritis,
    vestibulopathy, diffuse damage to the nervous system – which is
    cause of death of the patient.
  • 10-15 days after shock, Quincke’s edema may occur,
    recurrent urticaria, develop bronchial asthma
  • with repeated contact with allergenic drugs such
    diseases like periarteritis nodosa, systemic red
    lupus.

General principles of prevention of anaphylactic shock

Primary shock prevention

It provides for the prevention of human contact with
allergen:

  • exclusion of bad habits (smoking, drug addiction,
    substance abuse);
  • control over the quality production of medicinal
    drugs and medical devices;
  • chemical pollution control
    production;
  • ban on the use of certain food additives (tartrazine,
    bisulfites, agar-agar, glutamate);
  • struggle with the simultaneous appointment of a large number
    medications by doctors.

Secondary prevention

Promotes early diagnosis and timely treatment
diseases:

  • timely treatment of atopic allergic rhinitis
    dermatitis, pollinosis, eczema;
  • conducting allergy tests to identify specific
    allergen;
  • careful collection of allergic history;
  • indication of intolerable drugs on the title
    a sheet of case history or an outpatient card with red paste;
  • sensitivity tests before i / v or i / m administration
    drugs;
  • monitoring patients after injection for at least half an hour.

Tertiary prevention

Предотвращает рецидивирование diseases:

  • personal hygiene
  • frequent cleaning of premises for removing house dust, mites,
    insects
  • indoor airing
  • removal of extra furniture and toys from the apartment
  • precise control of food intake
  • use of sunglasses or masks during the flowering period
    of plants

How can physicians minimize the risk of shock
a patient?

For the prevention of anaphylactic shock main aspect
is a carefully collected history of the patient’s life and illness.
To minimize the risk of its development from taking medication
follows:

  • To appoint any drugs strictly according to indications, optimum
    dosage, given the portability, compatibility
  •  Do not administer several medicines at the same time, only one
    a drug. Making sure of portability, you can assign
    following
  • The patient’s age should be considered, as the daily and
    single doses of cardiac, neuroplegic, sedative, hypotensive
    funds for older people need to be reduced by 2 times than
    doses for middle-aged patients
  • When prescribing several drugs that are similar in
    farm action and chemical composition, taking into account the risk of cross
    allergic reactions. For example, in case of intolerance to promethazine
    antihistamine-derived promethazine cannot be administered (diprazine
    and pipolfen), if you are allergic to procaine and anesthesin, the risk
    intolerance to sulfonamides.
  • It is dangerous to appoint patients with fungal diseases.
    penicillin antibiotics because in fungi and penicillin
    community of antigenic determinants.
  • Antibiotics must be prescribed taking into account microbiological
    research and determine the sensitivity of microorganisms
  • For antibiotic solvents, it is better to use saline or
    distilled water, since procaine often leads to
    allergic reactions
  • Assess liver and kidney function
  • Monitor the content of leukocytes and eosinophils in the blood
    patients
  • Before starting treatment for patients at high risk of development
    anaphylactic shock, 30 minutes and 3-5 days before administration
    the planned drug, prescribe antihistamines 2 and 3
    generations (Claritin, Sempreks, Telfast), calcium supplements,
    indications corticosteroids.
  • To be able to apply a tourniquet above the injection site in
    In the event of shock, the first injection of the drug should be given (1/10
    doses for antibiotics less than 10,000 U) enter into the top 1/3
    shoulder. If you experience symptoms of intolerance impose tight
    harness above the point of injection before the cessation of the pulse below
    harness, chop the injection site with a solution of adrenaline (9 ml
    saline solution with 1 ml of 0.1% adrenaline), attach to the injection area
    hot water bottle or ice
  • Procedural rooms should be equipped with anti-shock
    first-aid kits and have a table with a list of medicines that give
    allergic cross-reactions, with common antigenic
    determinants
  • There should not be a ward of patients near the manipulation cabinets.
    with anaphylactic shock, and do not place patients with shock in
    history in the wards where patients are, who are administered those drugs
    which cause allergies in the first.
  • In order to avoid the phenomenon of Artyus-Sakharov, a place
    injection should be monitored (skin itching, swelling,
    redness, later with repeated administrations of drugs necrosis
    skin)
  • Those patients who suffered anaphylactic shock with
    inpatient treatment at discharge on the title page of history
    the disease is put in red pencil mark “medicinal
    allergy “or” anaphylactic shock “
  • После выписки patients с анафилактическим шоком на лекарства
    should be directed to a specialist in a place of residence, where they
    will be located at the dispensary and
    получать иммунокорригирующее и гипосенсибилизирующее
    treatment.

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