Diagnostic and Diagnostic and emergency care for life-emergency care for life-

threatening allergic threatening allergic conditionsconditions

Prepared by:Prepared by: C.m.s., assistant professor C.m.s., assistant professor

of outpatient therapy of outpatient therapy and emergency medical and emergency medical

emergency KSMUemergency KSMUA.R. AlpyssovaA.R. Alpyssova

The purpose of the lecture:The purpose of the lecture:

After completing the lecture, students After completing the lecture, students

should focus on issues of diagnosis and should focus on issues of diagnosis and

emergency treatment for life-threatening allergic emergency treatment for life-threatening allergic

conditions in the volume of the first medical care conditions in the volume of the first medical care

(doctor's line crews), and depending on the (doctor's line crews), and depending on the

patient - in the amount of specialized patient - in the amount of specialized

care (intensive care team, intensive care team).care (intensive care team, intensive care team).

The plan of the lecture:The plan of the lecture:

Allergic rhinitis, allergic conjunctivitis, urticaria, Allergic rhinitis, allergic conjunctivitis, urticaria, angioedemaangioedema

The etiology, pathogenesis, classification, The etiology, pathogenesis, classification, clinical pictureclinical picture

Action on the call, treatment, common errorsAction on the call, treatment, common errors General non-specific hypoallergenic diet for A.D.General non-specific hypoallergenic diet for A.D.

((А.Д.А.Д.) Ado) Ado anaphylactic shockanaphylactic shock The etiology, pathogenesis, clinical The etiology, pathogenesis, clinical

presentation, differential diagnosispresentation, differential diagnosis Action on the call, treatment, common errorsAction on the call, treatment, common errors

ALLERGIC RHINITIS, ALLERGIC ALLERGIC RHINITIS, ALLERGIC CONJUNCTIVITIS, URTICARIA, ANGIOEDEMACONJUNCTIVITIS, URTICARIA, ANGIOEDEMA

Acute allergic diseases Acute allergic diseases are caused are caused by hypersensitivity of immune system to by hypersensitivity of immune system to

various exogenous antigens (allergens). They are various exogenous antigens (allergens). They are characterized by sudden onset, characterized by sudden onset,

unpredictable currents, high risk of unpredictable currents, high risk of developing life-threatening conditions.developing life-threatening conditions.ETIOLOGY AND PATHOGENESISETIOLOGY AND PATHOGENESISThe most common allergens:The most common allergens:

food (fish, seafood, nuts, honey, milk, eggs, fruits, food (fish, seafood, nuts, honey, milk, eggs, fruits, legumes, etc.);legumes, etc.);

medication (analgesics, antibiotics, sulfonamides, medication (analgesics, antibiotics, sulfonamides, vitamins, etc.);vitamins, etc.);

pollen;pollen; household (latex, perfumes, household dust, pet household (latex, perfumes, household dust, pet

dander);dander); substances that enter the body substances that enter the body

by stinging insects.by stinging insects.

Acute allergic disease is usually caused by Acute allergic disease is usually caused by immediate immediate hypersensitivity reactions, hypersensitivity reactions, consisting of consisting of several stages:several stages:

contact with the allergen (not dangerous in contact with the allergen (not dangerous in themselves material, such as pollen, household themselves material, such as pollen, household dust particles, drugs, etc.);dust particles, drugs, etc.);

synthesis of specific lgE (Immunoglobulin E);synthesis of specific lgE (Immunoglobulin E); fixation IgE on the surface of mast cells, fixation IgE on the surface of mast cells, TI-k (TI-k (кл-к) )

(sensitization);(sensitization); repeated contact with the same allergen;repeated contact with the same allergen; antigen binding to IgE on the surface of mast cells;antigen binding to IgE on the surface of mast cells; release of mediators from activated mast release of mediators from activated mast

cells (histamine, prostaglandins, leukotrienes, platelet cells (histamine, prostaglandins, leukotrienes, platelet activating factor, etc.);activating factor, etc.);

action of mediators on tissues and organs, leading to action of mediators on tissues and organs, leading to the rapid development of the external manifestations the rapid development of the external manifestations of an allergic reaction (early phase);of an allergic reaction (early phase);

6-8 hours or more may develop later phase due to 6-8 hours or more may develop later phase due to the re-release of mediators from other the re-release of mediators from other cells, attracted to the site of the allergen.cells, attracted to the site of the allergen.

CLASSIFICATIONCLASSIFICATION Adrift and at risk of developing life-threatening Adrift and at risk of developing life-threatening

conditions, acute allergic diseases are conditions, acute allergic diseases are divided into divided into two types.two types.

Lungs: Lungs: allergic rhinitis, allergic conjunctivitis, locallergic rhinitis, allergic conjunctivitis, localized  urticaria.alized  urticaria.

HeavyHeavy (prognostically unfavorable):  (prognostically unfavorable): generalized urticaria, angioedema (angioedema), generalized urticaria, angioedema (angioedema), anaphylactic shock.anaphylactic shock.

CLINICAL PICTURECLINICAL PICTURE Allergic Allergic

rhinitisrhinitis manifests profuse rhinorrhea, nasal block manifests profuse rhinorrhea, nasal blockage due to swelling of the mucous membranes, age due to swelling of the mucous membranes, itching of the nose, sneezing and repeated often, itching of the nose, sneezing and repeated often, anosmia.anosmia.

Allergic conjunctivitisAllergic conjunctivitis is characterized  is characterized by hyperemia and edema conjunctival, swelling by hyperemia and edema conjunctival, swelling of eyelids, restriction of eye slits, itching, watery of eyelids, restriction of eye slits, itching, watery eyes, sometimes photophobia.eyes, sometimes photophobia.

In a significant number of cases noted the In a significant number of cases noted the combination of allergic rhinitis and conjunctivitis combination of allergic rhinitis and conjunctivitis (rinokonyunktivit).(rinokonyunktivit).

Localized urticariaLocalized urticaria manifests by the sudden  manifests by the sudden appearance in a limited area of appearance in a limited area of skinurticarial elements (rising above the surface skinurticarial elements (rising above the surface of the skin) with clear boundaries, usually red, of the skin) with clear boundaries, usually red, with a diameter of several millimeters to with a diameter of several millimeters to several centimeters, against several centimeters, against congestion, accompanied by skin itch.congestion, accompanied by skin itch.

Generalized urticariaGeneralized urticaria is characterized  is characterized by lesions throughout the skin, often by lesions throughout the skin, often observed merging of the above items.observed merging of the above items.

Angioedema Angioedema (angioedema) (angioedema) shows local swelling of the shows local swelling of the skin, subcutaneous tissueskin, subcutaneous tissue and / or mucous and / or mucous membranes. Chalice develops in the lips, cheeks, membranes. Chalice develops in the lips, cheeks, eyelids, forehead, scalp, scrotum, palms, dorsal eyelids, forehead, scalp, scrotum, palms, dorsal surface of the foot. Allergic mucosal edemasurface of the foot. Allergic mucosal edema

Gastrointestinal tract Gastrointestinal tract is accompanied is accompanied by intestinal cramps, nausea, by intestinal cramps, nausea, vomiting. Ifangioedema is localized in the vomiting. Ifangioedema is localized in the larynx may develop life-threatening condition. In larynx may develop life-threatening condition. In this case, there this case, there are cough, hoarseness, swallowing are cough, hoarseness, swallowing disturbances, asthma, breathings tridoroznoe.disturbances, asthma, breathings tridoroznoe.

ADVICES FOR CALLERADVICES FOR CALLER If breathing is difficult to help the patient to If breathing is difficult to help the patient to

breathe freely (undo his collar, give a comfortable breathe freely (undo his collar, give a comfortable position);position);

When an insect sting or reaction to an injection When an insect sting or reaction to an injection of local use cold or burning;of local use cold or burning;

To take antiallergic medication from a home kit.To take antiallergic medication from a home kit. When life is threatened should be When life is threatened should be

given instructions for the resuscitation given instructions for the resuscitation and liaiseas necessary for their.and liaiseas necessary for their.

ACTION IN CHALLENGEACTION IN CHALLENGE

DiagnosisDiagnosis

OBLIGATORY QUESTIONSOBLIGATORY QUESTIONS Have had an allergic reaction?Have had an allergic reaction? If "yes", If "yes",

what caused them and how they manifest?what caused them and how they manifest? What medications are used for treatment What medications are used for treatment

(antihistamines, corticosteroids, adrenaline)?(antihistamines, corticosteroids, adrenaline)? What could cause the development of an allergic What could cause the development of an allergic

reaction to this time (the food product, not part of reaction to this time (the food product, not part of the normal diet, medication, insect bite, etc.)?the normal diet, medication, insect bite, etc.)?

What steps have been taken by ill on their What steps have been taken by ill on their own, whether they were effective?own, whether they were effective?

INSPECTION ANG PHYSICAL EXAMINATIONINSPECTION ANG PHYSICAL EXAMINATION Assess skin color (pale or congested), the severity Assess skin color (pale or congested), the severity

of nasal secretion and tearing, check of nasal secretion and tearing, check for obstructed nasal respiration (in some cases the for obstructed nasal respiration (in some cases the patient is breathing by mouth), and sneezing.patient is breathing by mouth), and sneezing.

Assess the skin and the conjunctiva for the presence Assess the skin and the conjunctiva for the presence of congestion, the elements of a of congestion, the elements of a rash, swelling, rash and edema is rash, swelling, rash and edema is characterized morphologically, but also characterized morphologically, but also indicate their location and prevalence.indicate their location and prevalence.

Inspect the oropharynx, evaluate sonority voice, the Inspect the oropharynx, evaluate sonority voice, the ability of swallowing to prevent life-ability of swallowing to prevent life-threatening swelling of the mouth and pharynx.threatening swelling of the mouth and pharynx.

Check the airway, assess the presence Check the airway, assess the presence of stridor, dyspnea, wheezing, shortness of breath, of stridor, dyspnea, wheezing, shortness of breath, or apnea.or apnea.

Auscultated  lung area and assess the presence Auscultated  lung area and assess the presence of airflow obstruction.of airflow obstruction.

Spend palpation the abdomen (including the Spend palpation the abdomen (including the

spleen) and lymph nodes.spleen) and lymph nodes. Clarify the presence of gastrointestinal symptoms Clarify the presence of gastrointestinal symptoms

(nausea, abdominal pain, diarrhea).(nausea, abdominal pain, diarrhea). Measure heart rate and pulse rate.Measure heart rate and pulse rate. Measure blood pressure. The sharp decline Measure blood pressure. The sharp decline

in blood pressure <100 mm Hg or 30-in blood pressure <100 mm Hg or 30-

50 mm Hg from the source regarded as a sign of 50 mm Hg from the source regarded as a sign of

anaphylactic shock.anaphylactic shock. Measure body temperature.Measure body temperature.

TreatmentTreatment Prior to initiation of therapy should be Prior to initiation of therapy should be

discontinued contact with the patient's discontinued contact with the patient's causative allergens and follow these steps.causative allergens and follow these steps.

Stop the parenteral administration of drugs.Stop the parenteral administration of drugs. Remove from insect sting wounds with a Remove from insect sting wounds with a

needle. Removal with tweezers or your fingers is needle. Removal with tweezers or your fingers is undesirable, since it is possible extrusion of the undesirable, since it is possible extrusion of the poison of the sting left in the poison of the sting left in the tank poisonous insect glands. Go to the site of tank poisonous insect glands. Go to the site of injection drugs or insect stings an ice injection drugs or insect stings an ice pack or heating pad with cold water for 15 pack or heating pad with cold water for 15 minutes.minutes.

To To prick 5-6 points, and infiltrate the prick 5-6 points, and infiltrate the injection stings or insect 0.5 ml of 0.1% injection stings or insect 0.5 ml of 0.1% epinephrine solution (adrenaline) with epinephrine solution (adrenaline) with 5 ml 0.9% sodium chloride solution.5 ml 0.9% sodium chloride solution.

Allergy therapyAllergy therapyIn light In light HAPHAP ((ОАЗОАЗ))  (allergic rhinitis, allergic conjunctivitis,  (allergic rhinitis, allergic conjunctivitis,

localized urticaria):localized urticaria): Monotherapy with oral antihistamines II-Monotherapy with oral antihistamines II-

III generation acrivastine 8 mg or cetirizine10 mg.III generation acrivastine 8 mg or cetirizine10 mg. If you can not use oral drugs uses parenteral If you can not use oral drugs uses parenteral

antihistamines of I generation: intramuscularly 1-2 antihistamines of I generation: intramuscularly 1-2 ml of 2% solution hloropiramina.ml of 2% solution hloropiramina.

In severe HAPIn severe HAP ( (ОАЗОАЗ))  (generalized urticaria, angioedema): (generalized urticaria, angioedema): Glucocorticoids:Glucocorticoids: parenter-prednisolone 60- parenter-prednisolone 60-

150 mg but (children 12.2 months:2-3mg / kg, 1-14 years: 150 mg but (children 12.2 months:2-3mg / kg, 1-14 years: 1 to 2 mg / kg body weight) intravenous jet.1 to 2 mg / kg body weight) intravenous jet.

In relapsing period as generalized urticaria expediently In relapsing period as generalized urticaria expediently should use 7-14 mg of betamethasone or 1-2 ml (for should use 7-14 mg of betamethasone or 1-2 ml (for children 1-5 years: 2 mg or 0.5 ml, 6-12 yrs: 4 mg or 1 children 1-5 years: 2 mg or 0.5 ml, 6-12 yrs: 4 mg or 1 ml), deep intramusculatory.ml), deep intramusculatory.

To prevent the influence of new portions To prevent the influence of new portions of histamine in tissues, oral: acrivastine 8 of histamine in tissues, oral: acrivastine 8 mg or cetirizine 10 mg.mg or cetirizine 10 mg.

If you have or suspect laryngeal edema or anaphylactic If you have or suspect laryngeal edema or anaphylactic shock, immediately implement intramusculatory (allowed shock, immediately implement intramusculatory (allowed under skin injection) 0.3-0.5 ml 0.1% solution under skin injection) 0.3-0.5 ml 0.1% solution ofof  epinephrine.epinephrine.

Symptomatic therapySymptomatic therapy With the development of bronchospasm shown inhalation β2-With the development of bronchospasm shown inhalation β2-

agonists (salbutamolnebulized by 2.5-agonists (salbutamolnebulized by 2.5-5 mg inhalation aerosol 200 mcg).5 mg inhalation aerosol 200 mcg).

When cyanosis, dyspnea, wheezing in the presence of When cyanosis, dyspnea, wheezing in the presence of dry lung also shows oxygen therapy.dry lung also shows oxygen therapy.

In addition to drug therapy should be monitored heart In addition to drug therapy should be monitored heart rate, blood pressure, be ready for rate, blood pressure, be ready for the ventilation and resuscitation events.the ventilation and resuscitation events.

INDICATIONS FOR HOSPITALIZATIONINDICATIONS FOR HOSPITALIZATION In a generalized urticaria, angioedema, all patients should be In a generalized urticaria, angioedema, all patients should be

hospitalized for further treatment and / or surveillance of the hospitalized for further treatment and / or surveillance of the threat of late phase of acute allergic reaction.threat of late phase of acute allergic reaction.

With allergic rhinitis, allergic With allergic rhinitis, allergic conjunctivitis, urticaria localized hospitalization is conjunctivitis, urticaria localized hospitalization is shown when the out-patient treatment was shown when the out-patient treatment was ineffective and the patient's conditionineffective and the patient's condition worsened.worsened.Recommendations for abandoned homes of patientsRecommendations for abandoned homes of patients

Exclusion of receiving drugs, except for essentialExclusion of receiving drugs, except for essential Treatment to the clinicTreatment to the clinic Getting advice allergist.Getting advice allergist.

General non-specific hypoallergenic dietGeneral non-specific hypoallergenic diet acc.to A.D. Ado.acc.to A.D. Ado. Foods that are recommended to exclude: citrus fruits (oranges, Foods that are recommended to exclude: citrus fruits (oranges,

tangerines, lemons, grapefruit and other fruits), nuts (peanuts, tangerines, lemons, grapefruit and other fruits), nuts (peanuts, hazelnuts, almonds and other nuts), fish and fish products hazelnuts, almonds and other nuts), fish and fish products (fresh and salted fish, fish broth, canned fish , caviar and other (fresh and salted fish, fish broth, canned fish , caviar and other products), poultry (goose, duck, turkey, chicken and other products), poultry (goose, duck, turkey, chicken and other species) and its products, chocolate and chocolate species) and its products, chocolate and chocolate products, coffee, smoked foods, vinegar, mustard,products, coffee, smoked foods, vinegar, mustard, mayonnaise, mayonnaise, spices, horseradish, radish, radishes, tomatoes, eggplant, spices, horseradish, radish, radishes, tomatoes, eggplant, mushrooms, eggs, raw milk, strawberries, cantaloupe, mushrooms, eggs, raw milk, strawberries, cantaloupe, pineapple, pastry, honey.pineapple, pastry, honey.

Products that can be consumed: boiled lean beef, cereals Products that can be consumed: boiled lean beef, cereals and vegetable soups (beef broth to the and vegetable soups (beef broth to the secondary and vegetative), butter, olive oil, sunflower oil, boiled secondary and vegetative), butter, olive oil, sunflower oil, boiled potatoes, buckwheat, oat and rice porridge, one-day dairy potatoes, buckwheat, oat and rice porridge, one-day dairy products (cheese, yogurt, buttermilk ), cucumber, parsley, products (cheese, yogurt, buttermilk ), cucumber, parsley, dill, baked apples, watermelon, tea, sugar, compote of apples, dill, baked apples, watermelon, tea, sugar, compote of apples, plums, currants, cherries, dried fruits, white bread inedible.plums, currants, cherries, dried fruits, white bread inedible.

The diet should have an approximate energy value 2000kkal, The diet should have an approximate energy value 2000kkal, which corresponds to15g protein, 200g carbs and 150g of fat. It which corresponds to15g protein, 200g carbs and 150g of fat. It is strictly forbidden to use any alcoholic drinks.is strictly forbidden to use any alcoholic drinks.

COMMON ERRORSCOMMON ERRORS 1. Isolated appointment of antihistamines for 1. Isolated appointment of antihistamines for

severe HAP (generalized urticaria,severe HAP (generalized urticaria, angio-angio-neurotic edema) and broncho-obstructive syndrome is neurotic edema) and broncho-obstructive syndrome is ineffective andineffective and prehospital only leads to unnecessary loss of prehospital only leads to unnecessary loss of time.time.

2. Later, glucocorticoids and the use of unreasonably low 2. Later, glucocorticoids and the use of unreasonably low doses of these drugs for severe HAP.doses of these drugs for severe HAP.

3. Renunciation of the use of inhaled β2-3. Renunciation of the use of inhaled β2-agonists in bronchospasm.agonists in bronchospasm.

4. The use of calcium gluconate and calcium chloride are 4. The use of calcium gluconate and calcium chloride are not shown due to theirnot shown due to their inefficiency inefficiency and unpredictable influence on the further course of an and unpredictable influence on the further course of an allergic reaction, as well as the need for additional allergic reaction, as well as the need for additional manipulation and unreasonablemanipulation and unreasonable economic costs. With economic costs. With intravenous injection of these drugs may developintravenous injection of these drugs may develop hypotension, bradycardia, and the rapid hypotension, bradycardia, and the rapid introduction - ventricular fibrillation.introduction - ventricular fibrillation. Calcium Calcium chloride causes hot flashes, facial flushing, and in contact chloride causes hot flashes, facial flushing, and in contact with the skinwith the skin has a strong local irritant effect until the has a strong local irritant effect until the development of local tissue necrosis.development of local tissue necrosis.

ANAPHYLACTIC SHOCKANAPHYLACTIC SHOCK Anaphylactic shock - the most severe form of Anaphylactic shock - the most severe form of

allergic reaction of immediate type, which allergic reaction of immediate type, which develops as a result of repeated exposure to the develops as a result of repeated exposure to the allergen and is characterized allergen and is characterized by severe hemodynamic instability, which leads by severe hemodynamic instability, which leads to circulatory failureto circulatory failure and hypoxia of vital organs.and hypoxia of vital organs.

ETIOLOGY AND PATHOGENESISETIOLOGY AND PATHOGENESISThe most common The most common causes causes of anaphylaxis are:of anaphylaxis are: drugs: antibiotics, NSAIDs, and etc.;drugs: antibiotics, NSAIDs, and etc.; food allergens: nuts, fish, fruits, and etc.;food allergens: nuts, fish, fruits, and etc.; substances that enter the body substances that enter the body

by stinging insects;by stinging insects; allergens used in everyday life (latex, allergens used in everyday life (latex,

household chemicals).household chemicals).

When exposed to allergens develop IgE-When exposed to allergens develop IgE-mediated systemic hypersensitivity reaction, at mediated systemic hypersensitivity reaction, at which time a significant amount which time a significant amount of activated effector cells. As a result, of activated effector cells. As a result, release of mediators of release of mediators of allergy (early phase) develops collapse, increased allergy (early phase) develops collapse, increased microvascular permeability, which contributes microvascular permeability, which contributes to exit the liquid part of blood into the to exit the liquid part of blood into the tissues and thickening. As a result, the BCC is tissues and thickening. As a result, the BCC is reduced, the heart is involved in the disease reduced, the heart is involved in the disease process is secondary. After 6-8 hours or more may process is secondary. After 6-8 hours or more may develop later phase due to the re-release develop later phase due to the re-release of biologically active substances from other of biologically active substances from other cells recruited to the site of action of allergen.cells recruited to the site of action of allergen.

CLASSIFICATIONCLASSIFICATION At the outpatient differentiation At the outpatient differentiation AshAsh on the clinical  on the clinical

course does not hold.course does not hold.

CLINICAL PICTURECLINICAL PICTURE Symptoms of anaphylactic shock occur within the Symptoms of anaphylactic shock occur within the

first minutes after the injection of drugs or within first minutes after the injection of drugs or within 2 hours after meals, and speed the deployment of 2 hours after meals, and speed the deployment of symptoms directly related to the severity symptoms directly related to the severity of shock. In some cases, signs of shock develop of shock. In some cases, signs of shock develop within a few seconds. In less severe patients within a few seconds. In less severe patients complain of dizziness, tinnitus, weakness, complain of dizziness, tinnitus, weakness, sensation of heat, while decreases in blood sensation of heat, while decreases in blood pressure. For heavy flow is characterized by loss pressure. For heavy flow is characterized by loss of consciousness, a sharp fall in BP to of consciousness, a sharp fall in BP to undetectable values. In 30% of patients develop a undetectable values. In 30% of patients develop a delayed reaction (late phase) to an allergen: delayed reaction (late phase) to an allergen: Symptoms gradually subside anaphylactic shock, Symptoms gradually subside anaphylactic shock, but after 2-24 h worse again.but after 2-24 h worse again.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS Differential diagnosis between systemic ASH and Differential diagnosis between systemic ASH and

system anaphylactoid reactions (caused system anaphylactoid reactions (caused by allergic reactions in other types that can develop is the by allergic reactions in other types that can develop is the first introduction of some drugs) does first introduction of some drugs) does not hold, because in both states want to conduct the not hold, because in both states want to conduct the same set ofsame set of urgent remedial measures.urgent remedial measures.

A distinctive feature is the frequent presence A distinctive feature is the frequent presence of ASH cutaneous manifestations in the form of a of ASH cutaneous manifestations in the form of a rash, erythema, edema, or bronchoconstriction before or rash, erythema, edema, or bronchoconstriction before or simultaneously with hemodynamic impairment. Other simultaneously with hemodynamic impairment. Other symptomssymptoms of ASH are nonspecific and characteristic of ASH are nonspecific and characteristic for any other type of shock.for any other type of shock.

ADVICES FOR CALLERADVICES FOR CALLER If breathing is difficult to eliminate all factors that If breathing is difficult to eliminate all factors that

could impede free breathing (undo his collar, give a could impede free breathing (undo his collar, give a comfortable position).comfortable position).

When an insect sting or reaction When an insect sting or reaction to injection drug use or local cold temporary tourniquet.to injection drug use or local cold temporary tourniquet.

Provide the patient with antiallergic agent of the home kit.Provide the patient with antiallergic agent of the home kit. With the threat of life to give instructions for resuscitation.With the threat of life to give instructions for resuscitation.

ACTION IN CHALENGEACTION IN CHALENGEDiagnosisDiagnosis

Most often, allergic history collection is possible Most often, allergic history collection is possible only after the relief of acute symptoms.only after the relief of acute symptoms.

OBLIGATORY QUESTIONSOBLIGATORY QUESTIONS Have had an allergic reaction?Have had an allergic reaction? What caused them?What caused them? How are they manifested?How are they manifested? What drugs were used (antihistamines, What drugs were used (antihistamines,

glucocorticoids, norepinephrine)?glucocorticoids, norepinephrine)? That preceded the development of this allergic That preceded the development of this allergic

reaction (unusual food product, reaction (unusual food product, medication, insect bite, etc.)?medication, insect bite, etc.)?

What steps have been taken by ill on their What steps have been taken by ill on their own, their effectiveness?own, their effectiveness?

INSPECTION AND PHYSICAL EXAMINATIONINSPECTION AND PHYSICAL EXAMINATION Assess the state of consciousness (the state of stupor, Assess the state of consciousness (the state of stupor,

unconsciousness).unconsciousness). Inspect the skin (pale, with a bluish tint)Inspect the skin (pale, with a bluish tint) Assess the skin and the conjunctiva for the presence Assess the skin and the conjunctiva for the presence

of erythema, rash, swelling, symptoms of rhinitis of erythema, rash, swelling, symptoms of rhinitis and conjunctivitis.and conjunctivitis.

Are assessing the PS-filiform, measured heart rate-Are assessing the PS-filiform, measured heart rate-tachycardiatachycardia

Examine the oropharynx (swelling of the tongue, soft Examine the oropharynx (swelling of the tongue, soft palate), assess the presence of difficulty in swallowing.palate), assess the presence of difficulty in swallowing.

Assess the airway by the presence Assess the airway by the presence of stridor, dyspnea, wheezing, shortness of breath, of stridor, dyspnea, wheezing, shortness of breath, or apnea.or apnea.

Measure blood pressure. Lower blood pressure by 30-Measure blood pressure. Lower blood pressure by 30-50 mmHg from the source regarded as a sign of 50 mmHg from the source regarded as a sign of anaphylactic shock. In severe AD is not defined.anaphylactic shock. In severe AD is not defined.

In addition to these activities, necessarily clarify In addition to these activities, necessarily clarify the presence of symptoms such as vomiting, involuntary the presence of symptoms such as vomiting, involuntary defecation and / or urination, bloody vaginal discharge.defecation and / or urination, bloody vaginal discharge.

TreatmentTreatmentCessation of allergen further into the body.Cessation of allergen further into the body. Depending on the etiology, this stage consists of Depending on the etiology, this stage consists of

the following:the following: Stop parenteral drugs, impose Stop parenteral drugs, impose

a tourniquet above the injection site for a tourniquet above the injection site for 25 minutes (every 10 minutes weaken 25 minutes (every 10 minutes weaken the rope for 1-2 minutes).the rope for 1-2 minutes).

Remove the stinger from the wound the Remove the stinger from the wound the insect with a needle.insect with a needle.

Removal with tweezers or by hand is not Removal with tweezers or by hand is not desirable, since this method may extrude from desirable, since this method may extrude from the remaining poison in the the remaining poison in the sting venom gland reservoir of insect.sting venom gland reservoir of insect.

Go to the site of injection drugs or stings apply Go to the site of injection drugs or stings apply a ice pack or heating pad in cold water for 15 a ice pack or heating pad in cold water for 15 minutes.minutes.

Cut away by 5-6 points, and infiltrate the Cut away by 5-6 points, and infiltrate the injection stings or 0.5 ml of 0.1% p-raepinephrine injection stings or 0.5 ml of 0.1% p-raepinephrine (adrenaline) with 5 ml of isotonic NaCl solution(adrenaline) with 5 ml of isotonic NaCl solution

Antishock measuresAntishock measures Ensure the airway: a patient is placed (with a Ensure the airway: a patient is placed (with a

lowered head part), turn his head to the side to lowered head part), turn his head to the side to avoid aspiration of vomitus, push the lower jaw the avoid aspiration of vomitus, push the lower jaw the patient, removepatient, remove dentures if present.dentures if present.

Immediately injected 0.3-0.5 ml of 0.1% solution of Immediately injected 0.3-0.5 ml of 0.1% solution of epinephrine (adrenaline) intramuscularly in the epinephrine (adrenaline) intramuscularly in the lateral thigh, and allowed the introduction of a garment lateral thigh, and allowed the introduction of a garment (subcutaneous administration is permissible.) If (subcutaneous administration is permissible.) If necessary, make repeated injections every 5-20necessary, make repeated injections every 5-20 minutes, checking blood pressure.minutes, checking blood pressure.

Provide access for intravenous injection, and then begin Provide access for intravenous injection, and then begin to restore the BCC by infusing 0.9% to restore the BCC by infusing 0.9% sodium chloride injection with a volume of not less than sodium chloride injection with a volume of not less than 1 l for adults and 20 ml per 1 kg of body weight - for 1 l for adults and 20 ml per 1 kg of body weight - for children.children.

Allergy therapy. Allergy therapy. Parenteral glucocorticoids: prednisolParenteral glucocorticoids: prednisolone at a dose of 90 - 150 mg(children 2 - 12 months - 2-one at a dose of 90 - 150 mg(children 2 - 12 months - 2-3 mg per 1 kg of body weight, children from 1 year to 3 mg per 1 kg of body weight, children from 1 year to 14 years - a rate of 1-2 mg / kg body 14 years - a rate of 1-2 mg / kg body weight) intravenously jet .weight) intravenously jet .

Symptomatic therapySymptomatic therapy With persistent hypotension, after filling theWith persistent hypotension, after filling the VCB (volume of VCB (volume of

circulatory blood) are used to achieve systolic blood circulatory blood) are used to achieve systolic blood pressure> 90 mm  Hg: dopamine intravenously pressure> 90 mm  Hg: dopamine intravenously drip at 4.10 mg / kg / min, but no more than 15-drip at 4.10 mg / kg / min, but no more than 15-20 mg / kg /min. Solution was prepared at the rate of 200 20 mg / kg /min. Solution was prepared at the rate of 200 mg of dopamine in 400 ml of 0.9% solution of sodium mg of dopamine in 400 ml of 0.9% solution of sodium chloride or 5% glucose solution, infusion performed at a chloride or 5% glucose solution, infusion performed at a speed of 11.2 drops per minute.speed of 11.2 drops per minute.

With the development of bradycardia - atropine 0.5 With the development of bradycardia - atropine 0.5 mg subcutaneously, if necessary - is administered the same mg subcutaneously, if necessary - is administered the same dose again after 5-10 min.dose again after 5-10 min.

In the manifestation of bronchospasm shown inhalation B2-In the manifestation of bronchospasm shown inhalation B2-agonists (salbutamol 2.5-5.0 mg, preferably after nebulizer).agonists (salbutamol 2.5-5.0 mg, preferably after nebulizer).

In the case of cyanosis, dyspnea, or appearance of In the case of cyanosis, dyspnea, or appearance of dry rales on auscultation showsdry rales on auscultation shows oxygen therapy. In the case oxygen therapy. In the case of respiratory arrest shows an artificial ventilation.of respiratory arrest shows an artificial ventilation.

Necessary to carry out continuous permanent control after Necessary to carry out continuous permanent control after the respiratory function,the respiratory function, cardiovascular condition, with the cardiovascular condition, with the system (by measuring heart rate and blood pressure).system (by measuring heart rate and blood pressure).

Be prepared for the ventilation and resuscitation.Be prepared for the ventilation and resuscitation.

INDICATIONS FOR HOSPITALIZATIONINDICATIONS FOR HOSPITALIZATION Anaphylactic shock - an absolute indication Anaphylactic shock - an absolute indication

for hospitalization of patients in the emergency for hospitalization of patients in the emergency department and intensive care.department and intensive care.

COMMON ERRORSCOMMON ERRORS Hypodiagnosis of anaphylactic shock.Hypodiagnosis of anaphylactic shock. Unassigned epinephrine (adrenaline) with a decrease Unassigned epinephrine (adrenaline) with a decrease

in blood pressure against the stored mind.in blood pressure against the stored mind. It is unacceptable intravenous epinephrine (adrenaline) on It is unacceptable intravenous epinephrine (adrenaline) on

UMC (urgent medical care), because epinephrine in UMC (urgent medical care), because epinephrine in anaphylactic shock should be administered immediately, anaphylactic shock should be administered immediately, even before providing venous access, also inject to even before providing venous access, also inject to vein  should be under constant monitoring of blood vein  should be under constant monitoring of blood pressure and ECG in the risk of development of pressure and ECG in the risk of development of various arrhythmias in including ventricularvarious arrhythmias in including ventricular

The use of unreasonably low-dose glucocorticoids.The use of unreasonably low-dose glucocorticoids.

Appointment of antihistamines with reduced blood Appointment of antihistamines with reduced blood pressure. The use of promethazine (pipolfen) is pressure. The use of promethazine (pipolfen) is contraindicated because of worsening hypotension.contraindicated because of worsening hypotension.

The use The use of calcium gluconate and calcium chloride are of calcium gluconate and calcium chloride are not shown due to their inefficiency not shown due to their inefficiency and unpredictable influence on the further course of and unpredictable influence on the further course of the disease.the disease.

Appointment Appointment of diuretics pathogenetically unreasonably, as in of diuretics pathogenetically unreasonably, as in anaphylactic shock develops BCC deficit, anaphylactic shock develops BCC deficit, hypovolemia and hypotension.hypovolemia and hypotension.

After relieving the symptoms of anaphylactic After relieving the symptoms of anaphylactic shock can not leave the patient at home, shock can not leave the patient at home, as it should be further monitored by the risk as it should be further monitored by the risk of development (30%) delayed phase of allergic of development (30%) delayed phase of allergic reaction.reaction.

THANK YOU FOR ATTENTION!!THANK YOU FOR ATTENTION!!!!