PEDIATRIC ANAPHYLAXIS

PEDIATRIC STAGEFACULTY OF MEDICINE CHRISTIAN UNIVERSITY OF

INDONESIA23 SEPTEMBER – 16 NOVEMBER

PHILJEUWBENS ADITYA RAHANTOKNAM0761050016

Definition

‘‘Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death.

Etiology

Food Peanuts and other legumes,nuts, eggs, cow’s milk, shellfish, seeds, and fruits

Foods Food dyesMedications Antibiotics (eg, penicillin and sulfonamides),

NSAIDs, aspirin,protamine, and anesthetic agents

Envenomations Fire ants and hymenoptera, such as bees and wasps

Immunotherapy Allergen extractsBlood product infusion Latex Vaccines Radiographic mediaIdiopathic Exercise

The Causes Of Anafilactic

Food Drug/Bio Sting Allergen Exercise Idiopathic0

5

10

15

20

25

30

35

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Factors That Increase Risk of an Event or Potentiate Its Severity

InfantsCannot describe their

symptoms

Adolescents andyoung adults

Increased risk-takingbehaviors

Labor and deliveryRisk from medications

(eg, antibiotic to preventneonatal group Bstrep infection)

ElderlyIncreased risk of

fatality frommedication or venom-triggered anaphylaxis

DiagnosisTABLE 3. Clinical Criteria for Diagnosing Anaphylaxis1 Acute onset (minutes to several hours) of illness with involvement of skin

and/or mucosal tissue and at least one of the following: Respiratory compromise (eg, dyspnea, wheeze, stridor, and hypoxemia). Reduced SBP or associated symptoms of end-organ hypoperfusion (eg, syncope, incontinence, and hypotonia)

2 Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (onset of minutes to several hours): Skin and/or mucosal involvement (eg, hives; itch-flush; and swollen lips, tongue, or uvula) Respiratory compromise. Reduced SBP or associated symptoms of end-organ hypoperfusion. Persistent gastrointestinal symptoms

3 Reduced SBP after exposure to known allergen for that patient (onset of minutes to several hours): Infants aged 1 month to 1 yr, < 70 mm Hg Children aged 1 yr up to 10 yrs, < (70 mm Hg + [2 age in yrs]) Children aged 11 yrs and adults, <90 mm Hg or >30% decrease from patient’s baseline

SBP indicates systolic blood pressure. Adapted from Sampson et al.4 Copyright 2006, with permission from American Academy of Allergy, Asthma and Immunology.

Clinical Manifestattion

Cutaneous system

Diaphoresis, flushing, pruritus, urticaria, sensation of warmth, and angioedema

Respiratory system

Throat; mouth or lip tingling or itching; throat or chest tightness; hoarseness; stridor; wheezing; dyspnea; and respiratory distress, failure, and arrest

Gastrointestinal system

Nausea, abdominal cramps, diarrhea (sometimes bloody), and vomiting

Cardiovascular system

Arrhythmias, hypotension, cardiovascular collapse (shock), and cardiac arrest

Neurological system

Dizziness, visual disturbances, tremor, disorientation, syncope, and seizures

Other system Impending sense of doom (angor animi), uterine cramps, metallic taste, rhinorrhea, and increased lacrimation

SKIN

ITCHING FLUSHING

HIVES (URTICARIA) SWELLING

Eye

ITCHING CRY (TEARS)

REDNESS SWELLING

Nose and Mouth

SNEEZING RUNNY NOSE NASAL CONGESTION

SWELLING OF TOGUE METALIC TASTE

Lungs and Throat

DIFFICULTY BREATHING COUGHING CHEST TIGHTNESSWHEEZING OR OTHER SOUND

INCREASED MUCUS PRODUCTIONTHROAT SWELLING

OR ITCHINGCHANGE IN VOICES OR

SENSATION OF CHOCKING

Heart and circulation

DIZZINESS FAINTINGWEAKNESS

RAPID, SLOW, IRREGULERHEART RATE

LOW BLOOD PRESSURE

Digestive System

NAUSEA VOMITTING

CRAMPS DIARRHEA

Nervous System

ANXIETY CONFUSION

Patient with sign and symptoms anaphylaxisA

Asses and support airway breathing and circulationB

Continuous CR monitor Vital sign including BP administer oxygenC place patients supine and elevate legs or trendelenberg if hipotensive

IM epinephrine, anterolateral thigh 1 : 1000 solution, 0,01 mg/kg (0.01 mL/kg) maximum – 0,3 mg (0,3 mL)D repeat every 5 – 15

minutes as necessary

Reassess airway, breathing and circulation

Airway support may require : Early intubation

·Cricothyrotomy

·Nebulized

·Anesthesiology assistance

·Nebulized albuterol for broncospasm

Management and Treatment

If hypotension persisit despite IM epinephrine and IV fluids, initiate a continous infusiion of epinephrine, or vasopresor

agentE, or glucagonF

Once patient is stabilized persist despite, administer adjuntive medication such as H1 and H2 antihistaminesG and

corticosteroidsH

In-hopital observation

Obtain IV or access Administer IV fluids (NS or LR), 20 mL/kg bolus rapid push; repeat to a total maximum of 60 mL/kg as needed for

hypotension

Management and Treatment

Pediatric Assessment Triangle (PAT)

Assessing Mental Status

Use the AVPU method of assessing mental status, taking the child’s age and developmental characteristics into account. You may need to raise your voice to elicit a response to verbal stimuli. Tap or pinch the patient to test for response to painful stimulus. Never shake and infant or child.

Rapid Cardiopulmonary Assessment

AirwayBreathingCirculation

Should take less than 30 seconds to complete

Airway Assessment

Breathing

RR Respiratory

Mechanics Retractions,

Accessory Muscles use and NasalFlaring

Head Bobbing Grunting Stridor Wheezing

Air Entry Chest Expansion Breath Sounds

Color

ASSESSING BREATHING

Color – cyanosis indicates poor oxygenation

Age Pulse rate per minute

Resp. rate per minute

Blood pressure normal range in mmHg

Newborn 120 – 160 30 – 50 Infant 0 – 5 month 90 – 140 25 – 40Infant 6 – 12 month 80 – 140 20 – 30 Toddler 1 – 3 month 80 – 130 20 – 30Presschooler 3 – 5 month

80 – 120 20 – 30 Systolic : 78 – 116, diast0lic : 65

School age 6 – 10 years

70 – 110 15 – 30 Systolic : 80 – 122, diastolic : 69

Adolescent 11 – 14 years

60 – 105 12 – 20 Systolic : 88 – 140, diastolic : 76

Circulation

Heart rate BP

Vol/strength of central pulses

Peripheral pulses Present/absent Volume/strength

Skin perfusion Cap.refill time

Color Mottling

Temperature CNS perfusion

Responsiveness Recognizes parents Muscle tone Pupil size Posturing

Assessing Circulation

Brachial pulse

Femoral pulse

Treatment and management

Antihistamines Block H1 and H2 receptors

Epinephrine for bronchospasms stimulates the reformation of tight

junctions between endothelial cells IV fluids to support blood pressure Desensitization

EPINEPHRINE

α1 – adregergic receptor

α2 – adrenergic receptor

β1 – adrenergic receptor

β2 – adrenergic receptor

↑ Vasoconstriction↑ Peripheral vascularresistance↑ Heart rate↓ Mucosal edema

↓ Insulin release ↑ Inotropy↑ Chronotropy

↑ Bronchodilation↑ Vasodilation↑ Glycogenolysis↓ Mediator release

Action Of Epinephrine

DIFFERENTIAL DIAGNOSISCommon diagnostic dillemmas• Accute asthma• Syncope (faint)• Anxiety /panic attack • Aspiration of a foreign body •Cardiovascular (myocardial infarction, pulmonary embolus)•Neurological events (seizure, cerebrovascular event)

Flush syndrom •Peri-menopause•Caricinoid syndome•Autonmic epilepsy •Medularry cacinoma of the thyroid

Other •Nonallergic angioedema Hereditary angioedema types I, II, and IIIACE inhibitor-asscociated angiodedema•Systemic capillary leak syndrome•Red man syndrome (vancomycin)•Pheochromocytoma (paradoxical response)

Postprandial syndromes•Scombroidosis•Pollen-food allergy syndrome•Monosodyum glutamate•Sulfites •Food poisoning

Nonorganic Disease•Vocal cord dysfunction•Hyperventilation •Psychosomatic episode

Excess endogenous histamin Mastocytosis/clonal mast celldisordersBasophilic leukemia

Shock •Hypovolemik •Cardiogenic•Distributive •Septic

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