Anaphylactic (allergic)

shock
BY DR BAJJI AYOUB
Hypersensitivity Disorders & Allergic
Emergencies : Lecture Objectives
ƒ Describe & compare :
–Anaphylaxis & anaphylactoid reactions
–Angioneurotic edema
–Drug allergies
ƒ Describe emergent Rx & followup
outpatient Rx for anaphylactic & other
allergic reactions
 Allergic Reactions
Definitions of Terms
ƒ Anaphylaxis (Greek = "backward protection")
–Rapid generalized immunologic reaction after
exposure to antigens in a sensitized person, with at
least 2 of :
ƒ resp. or airway compromise from swelling or

wheezing
ƒ hypotension or cardiovascular collapse

ƒ diffuse cutaneous findings (urticaria, angioedema,

+/- erythroderma)
 Allergic Reactions
Definitions of Terms (cont.)
ƒ Anaphylactoid reaction :
–Syndrome presenting similar to anaphylaxis, expressed
by similar mediators, but not triggered by IgE & not
necessarily due to prior exposure to the inciting agent
ƒ Urticaria :
–Diffuse patchy erythematous pruritic rash with raised
borders
ƒ Angioedema :
–Non-pitting subcutaneous tissue swelling
–Often of the face, mouth, or peri-airway tissue
Pathophysiology of Allergic
Reactions
ƒ Mast cell
–Final common pathway of all allergic reactions
–Present in most tissues
–When activated, release (from cell granules) :
ƒ Histamine

ƒ Bradykinins

ƒ Prostaglandins

ƒ Leukotrienes

–Clinical effects are due to these above

mediators
Four Mechanisms that Lead to Mast
Cell Degranulation (Release of Mediators)
ƒ Immunoglobulin E (IgE) mediated
hypersensitivity
ƒ Complement cascade activation
ƒ Direct stimulation of mast cell by
anaphylactoid substances
ƒ Inhibition of arachidonic acid pathway
Sequence of Events in IgE Mediated
Hypersensitivity Reactions
ƒ 1. Initial exposure to allergen
ƒ 2. IgE antibody produced in reponse
to allergen
ƒ 3. Re-exposure of patient to same
allergen
ƒ 4. Preformed IgE cross links on mast
cell surface
ƒ 5. Mediators (esp. histamine) released
by mast cell
Histamine Receptors
ƒ 3 types with the following effects
when stimulated :
–H1 : brochoconstriction, vascular
permeability, smooth muscle contraction
–H2 : gastric acid secretion, cardiac
chronotropy & inotropy
–H3 : inhibition of histamine formation &
release
General Clinical Effects of
Release of Allergic Mediators
ƒ Mucocutaneous :
–pruritis, flushing, erythema, urticaria, angioedema
ƒ Respiratory :
–upper airway angioedema
–bronchoconstriction
–pulmonary hyperinflation +/- pulm. edema
ƒ Cardiovascular :
–vasodilatation, increased vascular permeability,
intravascular volume depletion, vasogenic shock,
myocardial contractile dysfunction
ƒ Gastrointestinal :
–cramping, vomiting, diarrhea
 Causes of Anaphylactic and
Anaphylactoid Reactions
ƒ IgE mediated allergies :
–Beta lactams, hymenoptera stings, food, latex
ƒ Direct mast cell degranulation :
–Xray contrast media, opiates, mannitol,
neuromuscular blockers
ƒ Altering bradykinin metabolism :
–angiotensin converting enzyme (ACE) inhibitors
ƒ Affecting metabolism of arachidonic acid :
–aspirin, NSAID's
 Considerations About Beta
Lactam Antibiotic Allergies
ƒ Penicillin is most common cause
ƒ Incidence of hypersensitivity about 4 %
ƒ Anaphylaxis in 1 per 10,000 administrations
ƒ 100 to 500 deaths per year in U.S.
ƒ Co-reactivity with cephalosporins < 5%
ƒ Can undergo desensitization process but risky
and many alternative antibiotics now available
ƒ Can occur from topical exposure (mother preparing
antibiotic suspension for child)
 Considerations About Allergy
to Hymenoptera Stings
ƒ Hymenoptera include bees, wasps, ants
ƒ Mostly cause local allergic reactions
ƒ 10 % have regional swelling
ƒ 1 % have anaphylaxis
–Causes 40 to 50 deaths per year in U.S.
ƒ Content of venom variable so re-sting may not
cause same reaction as before
 Treatment of Allergic Reactions
from Hymenoptera Stings
ƒ If local reaction only :
–Ice pack, pain med, diphenhydramine
–Watch at least 30 minutes to be sure systemic
reaction does not occur
ƒ If systemic reaction :
–O2, epi, IV fluid bolus, IV diphenhydramine, IV
steroids, observe at least 4 hours
ƒ For both types :
–Check sting site & remove stinger if imbedded (scrape, don't
squeeze), update tetanus, consider antibiotic if ? cellulitis
 Considerations About Allergic
Reactions to Foods
ƒ Most commonly due to :
–legume vegetables (peanuts, soybeans, peas, beans)
–crustaceans
–mollusks
–cow's milk
–eggs (may also react to MMR vaccine)
–nitrites or sulfite preservatives in foods
ƒ Must differentiate seafood allergy from
scombroid poisoning (due to ingestion of spoiled fish
containing histamine)
Considerations About Latex
Allergy
ƒ An increasingly recognized recent
problem
ƒ Can result in fatal anaphylaxis
ƒ High incidence in pts. with spina
bifida & congenital urologic problems
ƒ Be careful to select non-latex gloves
& catheters for pts. with this allergy
Allergic Reactions to
Radiocontrast Media
ƒ Occur in 1 % of cases
ƒ 10 % of occurences are severe
ƒ About 500 ( ? ) fatal reactions in U.S.
annually
ƒ Risk factors :
–prior reaction (30 % recurrence rate)
–advanced age
–renal or hepatic dysfunction
–asthma
 Allergic Reactions to
Radiocontrast Agents (cont.)
ƒ High osmolarity agents (Hypaque, Renografin,
Conray)
–Tri-iodinated, ionic
ƒ Low osmolarity agents :
–non-ionic dimers
–produce less histamine release & less vascular
endothelial irritation
–Much more expensive (5 X)
–Recent reports show reduction in complications of contrast
studies using these agents, but reactions still occur in 30%
 Allergic Reaction Prophylaxis
for Radiocontrast Agent Use
ƒ Pretreatment reduces recurrent allergic
reaction rate to 1%
ƒ One suggested regimen :
–Hydrocortisone 200 mg IV just prior to & 4 hours
after contrast, & cimetidine 300 mg IV &
diphenhydramine 50 mg IV just prior to contrast
–Should have epi & resus. equipment available
ƒ Pre-Rx indicated for pt. requiring a contrast
study with prior Hx of reaction or renal
dysfunction
Angioedema Due to ACE
Inhibitors
ƒ Occurs in 0.2 % of pts. on ACE inhibitors
ƒ Can occur even after prolonged use of ACE
inhibitors without a prior reaction
ƒ Predeliction for head & neck angioedema
so airway compromise possible
ƒ Rx by stopping the ACE inhibitor, epi,
steroids, diphenhydramine, +/- airway
management
Severe angioedema
Same patient on prior
slide after treatment
Spectrum of Presentations of
Allergic Reactions
ƒ Time to onset, intensity, & duration of
reaction vary, depending on :
–degree of sensitivity of pt.
–route of exposure
–amount ("dose") of antigen
ƒ Rarely pts. may have "biphasic"
reaction with reexacerbation of Sx 4
to 8 hours after the initial reaction
Clinical Manifestations of
Systemic Allergic Reactions
ƒ Diffuse pruritis, urticaria, angioedema,
erythroderma
ƒ Anxiety, dizziness, sense of doom,
altered mental status
ƒ Dyspnea, stridor, wheezing
ƒ Dysphagia, dysarthria, drooling
ƒ Vomiting, diarrhea, abd. cramps
ƒ Urinary incontinence
ƒ Hypotension +/- bradycardia
 Differential Dx of Severe
Allergic Reaction
ƒ Sudden loss of consciousness :
–vasovagal syncope, seizures, dysrhythmias, CVA
ƒ Acute respiratory distress :
–status asthmaticus, upper airway infection, foreign
body aspiration, pulm. embolus
ƒ Cardiovascular collapse :
–intraabdominal bleed, acute MI
ƒ Systemic disorders :
–mastocytosis, hereditary angioedema (C1 esterase
deficiency syndrome) , carcinoid syndrome, scromboid
poisoning, MSG syndrome
Clinical criteria for the diagnosis of anaphylaxis
Figure 3, From the
“WAO Guidelines for
the Assessment &
Management of
Anaphylaxis”
Simons FER et al. World Allergy
Organization Journal 2011; 4:13–37
http://www.waojournal.org/conten
t/4/2/13

Note: Use of this figure is restricted by

copyright law.

Warning: The WAO Guidelines are

intended for physician use only. All
others, please contact your physician
regarding preparation, treatment, and
prevention of anaphylaxis.

Posters and laminated pocket cards

available from WAO.
Access the order form at:
http://www.worldallergy.org/UserFiles/file
/PocketCardPosterOrderForm.pdf
Basic management of anaphylaxis
Figure 4, From the “WAO
Guidelines for the
Assessment &
Management of
Anaphylaxis”
Simons FER et al. World Allergy
Organization Journal 2011; 4:13–37
http://www.waojournal.org/content/
4/2/13

Note: Use of this figure is restricted by

copyright law.

Warning: The WAO Guidelines are

intended for physician use only. All
others, please contact your physician
regarding preparation, treatment, and
prevention of anaphylaxis.
Posters and laminated pocket cards
available from WAO.
Access the order form at:
http://www.worldallergy.org/UserFiles/file
/PocketCardPosterOrderForm.pdf
Discharge management and prevention of future
anaphylaxis recurrences in the community
Figure 5, From the “WAO
Guidelines for the
Assessment & Management
of Anaphylaxis”

Simons FER et al. World Allergy

Organization Journal 2011; 4:13–37
http://www.waojournal.org/content
/4/2/13

Note: Use of this figure is restricted by

copyright law.

Warning: The WAO Guidelines are

intended for physician use only. All
others, please contact your physician
regarding preparation, treatment, and
prevention of anaphylaxis.
Thank you