1. ANAPHYLAXIS
ANAPHYLACTIC SHOCK
Andreas Eliades
Pediatric Intensivist

2. Anaphylaxis
 Serious allergic reaction that is rapid in onset and
may cause death
 The rate of occurrence is increasing in
industrialized countries
 it can mimic many other conditions and is variable
in its presentation
 The diagnosis of anaphylaxis is clinical and based
primarily upon clinical symptoms and signs
 Most anaphylaxis episodes are triggered through
an immunologic mechanism involving IgE
 Foods are the most common trigger in children

6. shock
Υγρά NaCl
Επιμευρίμη
Ντοποσταμίμη Διασωλήμωση
μτοπαμίμη Μηταμικός
αερισμός
Σύστημα συνεχούς
παρακολούθησης της
καρδιακής παροχής

8. New diagnostic criteria for anaphylaxis were published by a
multidisciplinary group of experts in 2005 and 2006 –
Was it necessary?
 Help clinicians to easily recognize signs and symptoms
 Unrecognized and undertreated
 Early recognition and treatment with EPINEPHRINE
 Recognition of atypical presentation
 Minimize use of less effective drugs
(antihistamines and glucocorticoids)
 Sampson, HA, Muñoz-Furlong, A, Campbell, RL, et al. Second symposium on the definition and management of anaphylaxis:
summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network
symposium. J Allergy Clin Immunol 2006; 117:391.)

9. Anaphylaxis is highly likely when any ONE of the
following 3 criteria is fulfilled
1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both
(eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula)
AND AT LEAST ONE OF THE FOLLOWING
A. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF in older children and adults, hypoxemia)
B. Reduced BP* or associated symptoms of end-organ dysfunction (eg, hypotonia, collapse, syncope, incontinence)
2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to a likely allergen for that
patient (minutes to several hours):
A. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula)
B. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF in older children and adults, hypoxemia)
C. Reduced BP* or associated symptoms (eg, hypotonia, collapse, syncope, incontinence)
D. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)
3. Reduced BP* after exposure to a known allergen for that patient (minutes to several hours):
A. Infants and children: low systolic BP (age specific)
B. Adults: systolic BP of less than 90 mm Hg or greater than 30 percent decrease from that person's baseline

10. Criterion 1
 Acute onset of an illness
(over minutes to several hours) involving the skin,
mucosal tissue or both)
AND AT LEAST ONE OF THE FOLLOWING:
 Respiratory compromise (eg, dyspnea, wheeze-
bronchospasm, stridor, hypoxemia)
 Reduced blood pressure (BP) or associated
symptoms of end-organ dysfunction
 Note: Cutaneous symptoms are present in up to 90 percent of anaphylactic reactions. This
criterion will therefore be used most frequently to make the diagnosis

11. Criterion 2
 TWO OR MORE OF THE FOLLOWING that occur rapidly
after exposure to a likely ALLERGEN (min to hours)
 Involvement of the skin-mucosal tissue
(eg, generalized hives, itch-flush, swollen lips-tongue)
 Respiratory compromise
(eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak
expiratory flow, hypoxemia)
 Reduced BP or associated symptoms
(eg, hypotonia [collapse], syncope)
 Persistent gastrointestinal symptoms
(eg, abdominal pain, vomiting)
10 to 20 percent of people with anaphylaxis lack skin symptoms.

12. Criterion 3
 Reduced BP after exposure to a known allergen
(minutes to several hours):
 In infants and children, reduced BP is defined as low
systolic BP (age specific)*
 Reduced BP in adults is defined as a systolic BP of less than 90 mmHg
Low systolic BP for children is defined as:
 Less than 70 mmHg from 1 month up to 1 year
 Less than (70 mmHg + [2 x age]) from 1 to 10 years
 Less than 90 mmHg from 11 to 17 years

13. hypotension is defined as a systolic blood pressure that is less
than the fifth percentile of normal for age
- Less than 70 - Less than 70 - Less than 90
- Less than 60
mmHg in mmHg + (2 x mmHg in
mmHg in
infants (1 age in years) in children 10
term neonates
month to 12 children 1 to 10 years of age or
(0 to 28 days)
months) years older

14. Most common symptoms and signs
CARDIOVASCULAR cutaneous
Urticaria
RESPIRATORY
Angioedema
GASTROINTENSTINAL
flushing
pruritus

15. The most common signs and symptoms
of anaphylaxis
 Cutaneous symptoms, -90 %
(flushing, itching, urticaria, and angioedema
(including periorbital edema and conjunctival swelling)
 Respiratory symptoms, -70 %,
(nasal discharge, nasal congestion, change in voice quality,
sensation of choking, cough, wheeze, and dyspnea)
 Gastrointestinal symptoms, -40 %
(nausea, vomiting, diarrhea, and crampy abdominal pain)
 Cardiovascular symptoms, -35 %
(dizziness, tachycardia, hypotension)

17. SHOCK
 The shock syndrome is characterized by a
continuum of physiologic stages beginning with an
initial inciting event that causes a systemic
disturbance in tissue perfusion
 Subsequently, shock may progress if not
successfully treated in end-organ
damage, irreversible shock, and death

18. STAGES OF SHOCK
Compensated shock
Hypotensive shock
Irreversible shock

19. CLASSIFICATION OF SHOCK
Hypovolemic Distributive Cardiogenic
shock shock shock

20. Distributive shock or vasodilatory shock
 Decrease in SVR
 Abnormal distribution of blood flow within the
microcirculation
 Inadequate tissue perfusion
 Hypovolemia with decreased preload
 Normal or increased cardiac output.

21. Causes of distributive shock
 Sepsis is the most common etiology of distributive
shock among children
 Anaphylaxis is an immediate, potentially life-
threatening systemic reaction to an exogenous
stimulus, typically an allergic, IgE-mediated
immediate hypersensitivity reaction
 Neurogenic shock is a rare, usually transient
disorder that follows acute injury to the spinal cord
or central nervous system, resulting in loss of
sympathetic venous tone

22. hypotension is defined as a systolic blood pressure that is less than
the fifth percentile of normal for age
- Less than 70 - Less than 70 - Less than 90
- Less than 60
mmHg in mmHg + (2 x mmHg in
mmHg in
infants (1 age in years) in children 10
term neonates
month to 12 children 1 to 10 years of age or
(0 to 28 days)
months) years older

23. Treatment-Prompt recognition and
treatment are critical in anaphylaxis
 Assess airway, breathing, circulation, and adequacy of
mentation (ABCD)
 Call for help
 Stop/remove the inciting agent (if still present)
 Place the patient in the supine position (if tolerated) with lower
extremities elevated
 Administer epinephrine by intramuscular injection
 Establish intravenous access with 2 large-bore catheters or IO
 Immediate intubation is indicated if stridor or respiratory
arrest is present, and should be performed by the most
experienced clinician available.
Median times to death are 5 minutes in iatrogenic anaphylaxis, 15 minutes in stinging insect
venom-induced anaphylaxis, and 30 minutes in food-induced anaphylaxis.

25. Danger signs
 Rapid progression of symptoms
 Evidence of respiratory distress
(eg wheezing, increased work of breathing,
retractions, persistent cough, stridor)
 Signs of poor perfusion,
 Dysrhythmia
 Syncope

26. ACUTE MANAGEMENT (1) Airway
 Oxygen: Give 6 to 8 liters per
minute via face mask, or up to
100 percent oxygen as needed
 INTUBATION: Immediate
intubation if evidence of
impending airway obstruction
from angioedema delay may lead
to complete obstruction
 Intubation can be difficult and
cricothyrotomy may be necessary

28. Σημεία και ζςμπηώμαηα αναπνεςζηικήρ
δςζσέπειαρ ζε ζσέζη με ηην ενηόπιζη
ζςμπηώμαηα Εξωθωπακική Ενδοθωπακική Ενδοθωπακική παπεγσςμαηική
/ενηόπιζη εξωπνεςμονική ενδοπνεςμονική
τατύπνοια - + + ++++
Σσριγμός ++++ - - -
γογγσσμός - - - ++++
Εισολκές ++++ ++ ++ ++
Σσρίττοσσα - ++ ++++ -
Αναπνοή

29. Αναπνεςζηική ανεπάπκεια πος οδηγεί ζε
καπδιακή ανακοπή

30. Ανηίζηαζη αεπαγωγών

31. Κπικοθςπεοειδοηομή

32. ACUTE MANAGEMENT (2)
 Albuterol: For bronchospasm resistant to IM
epinephrine, give albuterol 0.15 mg per kilogram
(minimum dose: 2.5 mg) in 3 mL saline inhaled via
nebulizer; repeat as needed
 H1 antihistamine: Give diphenhydramine 1 to 2 mg
per kilogram (max 50 mg) IV; can give IM if symptoms
are less severe
 H2 antihistamine: Consider giving ranitidine 1 to 2
mg per kilogram (max 50 mg) IV
 Glucocorticoid: Consider giving methylprednisolone
2 mg per kilogram (max 125 mg) IV

33. Normal saline VIA IV or IO line
 Rapid bolus:
 Treat signs of poor perfusion with rapid infusion of
20 mL /Kg
 Re-evaluate and repeat fluid boluses
(20 mL per kilogram) as needed
 Monitor urine
 Massive fluid shifts with severe loss of
intravascular volume can occur output

37. IM Epinephrine (1 mg/mL preparation)
 Give epinephrine 0.01 mg per kilogram
intramuscularly (maximum per dose: 0.5
mg), preferably in the mid-anterolateral thigh, can
repeat every 3 to 5 minutes as needed.
 If signs of poor perfusion are present or symptoms
are not responding to epinephrine
injections, prepare IV epinephrine for infusion

38. TREATMENT OF REFRACTORY SYMPTOMS
 Epinephrine infusion
 Patients with inadequate response to IM
epinephrine and IV saline, give epinephrine
continuous infusion at 0.1 to 1 microgram per
kilogram per minute, titrated to effect and with
constant hemodynamic monitoring

39. Vasopressors
 Patients may require large amounts of IV
crystalloid to maintain blood pressure
 if response to epinephrine and saline is
inadequate
 dopamine (5 to 20 micrograms per kilogram per
minute) can be given as continuous
infusion, titrated to effect and with constant
hemodynamic monitoring

40. TREATMENT ERRORS
 Failure or delay to administer epinephrine promptly due to over-
reliance on antihistamines, albuterol, glucocorticoids.
 Epinephrine should be administered as soon as possible once
anaphylaxis is recognized.
 Delayed administration has been implicated in contributing to fatalities
 H1-antihistamines are useful only for relieving itching and urticaria
 They do NOT relieve stridor, shortness of
breath, wheezing, gastrointestinal symptoms, or shock, and should not be
substituted for epinephrine
 Bronchodilator treatment with nebulized albuterol should be given in
individuals with severe bronchospasm, as an adjunctive treatment to
epinephrine
 Albuterol does NOT prevent or relieve upper airway edema or shock and
should not be substituted for epinephrine in the treatment of anaphylaxis

41. Differential diagnosis of anaphylaxis
common disorders
 Vasovagal reaction (faint)
 Acute generalized urticaria
 Acute angioedema
 Acute asthma exacerbation
 Vocal cord dysfunction
 Anxiety disorders
 Other causes of acute respiratory distress in
children
 Myocardial infarction or stroke in adults
 Other forms of shock

42. Other disorders mimic anaphylaxis
 Medications (including
vancomycin, cephalosporins, griseofulvin, niacin, l
evodopa, amyl nitrate, and bromocriptine)
 Alcohol (ethanol)(alcohol-induced flushing may
be exacerbated by certain medications)
 Tumors (carcinoid, intestinal tumors secreting VIP
or substance P, pheochromocytoma, medullary
carcinoma of the thyroid)

43. Rare disorders
 Histamine excess syndromes
 Mastocytosis
 Other clonal mast cell disorders
 Certain leukemias
 Hydatid cyst rupture
 Capillary Leak Syndrome

44. Epinephrine- auto injector
 Administered into the mid-anterolateral thigh
using an auto-injector
 Available in 0.15 mg and 0.3 mg doses
 Children weighing less than 25 to 30 kilograms
should receive the 0.15 mg dose
 EpiPen Jr® 0.15 mg or Adrenaclick 0.15 mg or
Twinject® 0.15 mg per dose (pediatric dose)

45. The mnemonic "SAFE"
 remind clinicians of the four basic action steps
suggested for patients with anaphylaxis who have
been treated and are subsequently leaving the
emergency department or hospital
 The SAFE counseling has been incorporated into
printable patient information materials

46. SAFE APPROACH
 Seek support — Advise the patient
 Allergen identification and avoidance
 Follow-up with specialty care
 Epinephrine for emergencies

47. Anaphylaxis Emergency Action Plan

48. Faster action
Recognize quickly
Give EPINEPHRINE