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Anaphyactic shock
- 1. ANAPHYLACTIC SHOCK Dr.Sanjeev kumar, juniorresident govt. medical college Amritsar
- 2. • Anaphylaxis isan acute immunologic reaction characterised by cutaneous , gastrointestinal , respiratory and cardiovascular signs and symptoms that can rapidly progress to shock and death .
- 3. DEATHS DUE TOALLERGIC REACTIONS ARE RARE.
- 4. • Most deathsoccur within 1 to 2 hours and are preceded by signs and symptoms suggesting hyperacute bronchial asthma .
- 5. • Sometimes deathsare delayed for several hours with nervous symptoms such as coma or with symptoms of circulatory failure resembling traumatic shock.
- 6. • Allergic reactionsmay occur due to ; 1. Drugs :Penicillin , asprin , horse serum products , vaccines , iodine containing agents . 2. Insect bites . 3. Foods :fish , eggs, nuts , fruits . 4. Hormones : ACTH 5. Enzymes : Trypsin. Aetiology
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- 11. The anaphylactic syndrome •This is caused by local and systemic release of endogenous active substances . These include Leukotrienes , C,D,E or histamine , eosinophilic chemotactic factor and other vasoactive substances such as bradykinin and Kallikrein .
- 12. • This isdue to bronchospasm with contraction of smooth muscle of lungs , vasodilation and increase capillary permeability . Death occurs due to laryngeal oedema , bronchospasm and vasodilation . ANAPHYLACTIC SHOCK
- 13. Serum tryptase level •Serum tryptase levels are an indicator of mast cell activation and if elevated suggest an allergic mediator release , particularly in anaphylaxis . • Peak level of tryptase occurs in 1 to 2 hours after anaphylaxis and then decline with half-life of about 2 hours.
- 14. Sign and Symptoms Theonset of symptoms is within 15 to 20 min. • GENERAL MALAISE • WEAKNESS • SENSE OF ILLNESS • OEDEMA OF FACE
- 15. • Dermal injectionmarks with surrounding wheals , skin rashes , urticaria , pruritus , erythema . • Mucosal :Periorbital oedema ,nasal congestion , angio-oedema , cyanosis . • Respiratory symptoms :sneezing ,rhinorrhoea ,dyspnoea . • Upper airway:Laryngeal oedema , Hoarseness , stridor , oedema of tongue and pharynx .
- 16. • Lower Airways:Dyspnoea , acute emphysema , asthma , bronchospasm . • G.I. :Nausea , vomiting , dysphagia , abdominal cramps , diarrhoea . • C.V.S : Tachycardia , palpitations , shock . • C.N.S: Anxiety , Convulsions .
- 19. Management • Stop orremove inciting agent . • Place the person in supine position with legs elevated . • IV fluid volume resuscitation .
- 20. • Airway: Use highflow oxygen with nebulized salbutamol. Intubate if any indication of impending airway obstruction or angioedema . Remember with angioedema these may be difficult intubations—BE PREPARED FOR CRICOTHYROTOMY .
- 21. • If normotensivecan use standard RSI Protocol. • If hypotensive use shock intubation protocol.
- 22. RSI PROTOCOL • Rapidsequence induction (RSI) is a method of achieving rapid control of the airway whilst minimising the risk of regurgitation and aspiration of gastric contents. Intravenous induction of anaesthesia, with the application of cricoid pressure, is swiftly followed by the placement of an endotracheal tube (ETT).
- 23. • Performance ofan RSI is a high priority in many emergency situations when the airway is at risk, and is usually an essential component of anaesthesia for emergency surgical interventions. RSI is only required in patients with preserved airway reflexes. In arrested or completely obtunded patients, an endotracheal tube can usually be placed without the use of medications.
- 24. • Cricoid pressureis the application of force to the cricoid cartilage of the patient . The rationale is that the upper oesophagus is occluded by being compressed between the trachea and the cervical vertebrae, preventing passive reflux of gastric contents and subsequent development of aspiration pneumonitis. CRICOID PRESSURE
- 26. • In hypotensiveshock intubation protocol is managed by ketamine not by propofol .
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- 28. H1 Antagonists - Antihistamines. • These help itch and hives but do not treat upper airway bronchoconstriction .
- 29. H2 Antagonists • Helpwith itch but also have no benefit in treating anaphylaxis • If used give ranitidine 50mg IV.
- 30. CORTICOSTERIODS • There areno clinical trials showing benefit in treatment of acute anaphylaxis. • Take several hours to be of any benefit • Rationale for using is to prevent the biphasic response in anaphylaxis . • if used give methylprednisone 1-2mg/kg daily PO.
- 31. Medicolegal importance • Mostanaphylactic deaths occur due to drugs like penicillin . Even individuals who test negative for hypersensitivity to penicillin in a patch test have an anaphylactic reaction to the drug. • Medical negligence charges.
- 32. • On August2018; Allergic Reaction to CT Contrast: Batra Hospital to pay Rs 8 lakh for negligence. • New Delhi: Holding medical negligence on the part of the hospital, that led to the death of a female patient, a Delhi Consumer Forum has asked Batra Hospital and Medical Centre in Tughlakabad to pay a compensation of Rs 8 lakh Case Study
- 33. For the mediacontrast CT, one injection was administered to her by a nurse and after 15 minutes she came out of the room. As she came out of the room she fell down on the floor and the suds (jhag) were coming out of her mouth and nose. The complainant alleged that Neither any doctor nor any nurse nor any other official of the hospital had come to her at that time, her condition started deteriorating soon leading to her death. case study
- 34. ON OCT 2013NEW DELHI; The apex court’s 24 October verdict established gross dereliction of duty by doctors in a high-profile case of medical negligence launched over the death of Anuradha Saha, a US-based psychologist who had been wrongly treated by doctors in Kolkata. At AMRI Hospitals, Anuradha was administered another steroid, Prednisolone, in a tapering dose—continuing the treatment for allergic vasculitis, which is an extreme reaction to a drug, leading to inflammation and damage to blood vessels of the skin. Case Study
- 35. Postmortem findings • EXTERNALFINDINGS • Search for injection site or sting marks. • The sting area should be excised and frozen at -70° C and submitted for antigen antibody reactions.The findings are non specific. • Cyanosis and frothing from nostrils and mouth can be seen
- 36. • There isusually oedema of larynx , oedema of epiglottis , trachea and bronchi.Lungs are hyper inflated ,emphysematous with petechial haemorrhage and congestion. Respiratory system
- 37. Central Nervous system •The brain is oedematous and shows features of cerebral hypoxia .
- 38. Histopathlogical findings. • featuresof hypersensitivity and inflammation i.e. infiltration of inflammatory markers especially eosinophils are seen .
- 39. viscera Preservation • Thesite of injection or sting should be preserved for analysis along with control skin. • Blood should be collected and preserved for analysis of tryptase . • Stomach contents should be preserved in case of food allergies are involved.
- 40. cause of Death •The cause of death is determined on the basis of history , autopsy findings and laboratory analysis of the viscera for tryptase , eosinophils etc. Any other disease condition should also be ruled out.
- 41. • The Essentialsof Forensic Medicine & Toxicology • Dr. K.S. NARAYAN REDDY • DR. O.P. MURTY • Forensic medicine and Toxicology ANIL AGARWAL • GOOGLE. BIBLIOGRAPHY
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