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BEE STING & ANAPHYLAXIS. I ntroduction. วันที่ 27 พ.ค. 2553 เวลาประมาณ 15.00 น. รพ.ปทุมธานีได้รับแจ้งเหตุ นักเรียน ประมาณ 70 คน ถูกผึ้งต่อยที่วัดสุวรรณจินดาราม ขณะไปเวียนเทียนที่วัด. Hymenoptera sting.

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slide2

Introduction

วันที่ 27 พ.ค. 2553 เวลาประมาณ 15.00 น.

รพ.ปทุมธานีได้รับแจ้งเหตุ นักเรียน ประมาณ 70 คน ถูกผึ้งต่อยที่วัดสุวรรณจินดาราม ขณะไปเวียนเทียนที่วัด

hymenoptera sting
Hymenoptera sting
  • Local reactions: pain ,edema ,bleeding ,pruritus ,warmth ,N/V , peripheral nerve block
  • Urticaria without systemic symptoms
  • Generalized reactions : Anaphylaxis
anaphylaxis
Anaphylaxis

Sign & Symptom

  • Cutaneous : urticaria , angioedema , flushing , pruritus without rash
  • Respiratory : dyspnea ,wheezing ,bronchospasm ,upper airway angioedema ,rhinitis
  • Abdominal : N/V , diarrhea , cramping pain
  • CVS : hypotension , syncope
anaphylaxis1
Anaphylaxis
  • Diagnosis :any one of the following 3 criteria is fulfilled
  • Criteria 1The acute onset of illness (minutes to several hours), with involvement of the skin, mucosal tissue, or both and at least one of the following:
    • Respiratory symptoms
    • Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia , syncope, oliguria)
anaphylaxis2
Anaphylaxis
  • Criteria 2Two or more of the following that occur rapidly after exposure to a common allergen(minutes to several hours):
        • Involvement of the skin or mucosal tissue
        • Respiratory symptom
        • Reduced BP or associated symptoms
        • Persistent GI symptom
  • Criteria 3 Reduced BP after exposure to a known allergen for that patient (minutes to several hours)
triage
Triage
  • V/S
  • Conscious
  • หน้า,ปาก,ตา บวมมาก ผื่นขึ้นทั่วตัว
  • โดนต่อยหลายจุด
  • อาเจียนมาก
management
หลักในการ management
  • Identify Anaphylaxis , Anaphylactic shock
  • Pain control
  • Supportive & symptomatic Rx
  • Prevent late complication eg. Renal failure , secondary bacterial infection
admission criteria
Admission Criteria
  • Anaphylaxis
  • Angioedema/Urticaria
  • > 5 sting site
  • Critical area
  • Other : fever , N/V
case 1
Case ตัวอย่าง-1
  • เด็กผู้ชาย อายุ 11 ปี นน. 23 kg ไม่มีโรคประจำตัว ไม่มีประวัติภูมิแพ้ โดนผึ้งต่อยบริเวณกกหู แก้มด้านขวา คาง คอ รวม 7 จุด ปวดบวมแดงบริเวณที่โดนต่อยมีอาการแน่นหน้าอก หายใจไม่อิ่ม ปวดท้องเล็กน้อย ไม่เห็นผื่นชัดเจน
  • V/S T 38.2 BP 100/60 pulse 136 RR 26
  • GA : alert ,mild dyspnea ,no angioedema & urticaria ,mild swelling at face
  • Heart : normal S1S2
  • RS : no stridor , wheezing both lower lung
  • Abd : soft ,not tender
case 11
Case ตัวอย่าง-1
  • Dx R/O anaphylaxis
  • Management
    • Supine position
    • On O2 cannula
    • Adrenaline (1:1000) 0.23 mg(0.01 mg/kg) IM stat
    • Salbutamol 0.4 ml + NSS 3 ml NB stat then q 3-4 hr
    • NSS 1000 ml IV drip 60 ml/hr
case 12
Case ตัวอย่าง-1
  • Management(ต่อ)
    • Hydrocortisone 120 mg IV drip in 30 min q 6 hr
    • CPM 5 mg IV q 6 hr
    • Paracetamol (500) ½ tab prn q 4-6 hr
    • Record v/s q 15 min
    • Observe clinical
    • Blood for BUN ,Cr ,Electrolyte ,CBC
    • Admit
case 13
Case ตัวอย่าง-1
  • Progression
    • (28/5/53) ไม่มีอาการเหนื่อยแน่นหน้าอกแล้ว ไข้ลง ไม่มีอาเจียนผื่นยุบลงเจ็บบริเวณที่โดนต่อยน้อยลง V/S stable lung :clear ผลlab BUN,Cr,Electrolyte อยู่ในเกณฑ์ปกติ CBC มีWBC สูงขึ้นเล็กน้อย
    • (29/5/53)ไม่มีไข้ บวมลดลง หายใจปกติ D/C นัด 2/6/53 ตรวจ UA HM: Prednisolone(5) 1x3 5วัน Atarax(10) ½x4 Paracetamol(500) ½ tab prn
case 2
Case ตัวอย่าง-2
  • เด็กหญิง อายุ 12 ปี นน. 49 kg ไม่มีโรคประจำตัว ไม่มีประวัติภูมิแพ้มาก่อน โดนผึ้งต่อยที่หน้าด้านซ้าย 2 จุด มีอาการตาบวม 2 ข้าง และปากบวม ไม่หอบเหนื่อย มีคลื่นไส้อาเจียน 1 ครั้ง ไม่ปวดท้อง ปวดบริเวณที่โดนต่อยมาก
  • V/S T 37.4 BP 113/67 pulse 110 RR 24
  • GA : alert ,no dyspnea ,swelling at both lips ,eye lids ,no tongue&uvula edema ,no urticaria
  • Heart : normal S1S2
  • RS : no stridor ,no wheezing
  • Abd : soft ,not tender
case 21
Case ตัวอย่าง-2
  • Dx angioedema c R/O anaphylaxis
  • Management
    • Adrenaline(1:1000) 0.5 ml IM stat
    • Hydrocortisone 250 mg IV drip in 30 min q 6 hr
    • CPM 10 mg IV q 6 hr
    • Dimenhydrinate 50 mg IV prn for N/V q 6 hr
    • Paracetamol(500) 1 tab prn q 4-6 hr
    • Record v/s q 1 hr
    • Observe clinical
    • Blood for BUN ,Cr ,Electrolyte ,CBC
    • Admit
case 22
Case ตัวอย่าง-2
  • วันรุ่งขึ้นผู้ป่วยอาการดีขึ้น ตายุบบวมลง ไม่คลื่นไส้อาเจียน ผลตรวจทางห้องปฏิบัติการอยู่ในเกณฑ์ปกติ
  • D/C นัด 2 วัน UA
    • Home med : Prednisolone 2x3

Atarax 1x4

Paracetamol

case 3
Case ตัวอย่าง-3
  • เด็กหญิง อายุ 6 ปี นน. 15 kg ไม่มีโรคประจำตัว โดนผึ้งต่อยที่หน้าผากและคอจำนวน 2 จุด มีอาการปวดบวมไม่มาก ไม่มีผื่นขึ้น ไม่หอบเหนื่อย มารพ.ได้ Prednisolone 1x3 และ Paracetamol กลับไปกิน
  • หลังกลับบ้านไปช่วงเช้ามืดวันรุ่งขึ้นมีอาการบวมที่ตาทั้งสองข้าง มีไข้ ไม่หอบเหนื่อย ไม่มีปวดท้องหรืออาเจียน กลับมารพ.
case 31
Case ตัวอย่าง-3
  • V/S T 38.0 BP 90/67 pulse 97 RR 20
  • GA : alert ,no dyspnea ,swelling & redness at both eye lids ,no tongue&uvula edema ,no urticaria , mild swelling at sting site
  • Heart : normal S1S2
  • RS : no stridor ,no wheezing
  • Abd : soft ,not tender
case 32
Case ตัวอย่าง-3
  • Management
    • Hydrocortisone 80 mg IV drip in 30 min q 6 hr
    • CPM 1.5 mg IV q 6 hr
    • Cloxacillin 1½ tsp oral q 6 hr
    • Paracetamol 1½ tsp prn q 4-6 hr
    • Record v/s q 1 hr
    • Observe clinical
    • Blood for BUN ,Cr ,Electrolyte ,CBC
    • Admit
case 33
Case ตัวอย่าง-3
  • วันรุ่งขึ้นผู้ป่วยไม่มีไข้ ตายุบบวมลง ไม่เหนื่อย ไม่มีผื่น ผลCBC มีPMN สูงเล็กน้อย ,BUN , Cr ,Electrolytes อยู่ในเกณฑ์ปกติ
  • D/C นัด 2 วัน UA
    • Home med : Prednisolone 1x3

Atarax ¾ tsp oral tid

Paracetamol

Cloxacillin 1½ tsp oral q 6 hr

anaphylaxis3
Anaphylaxis
  • Anaphylaxis is a severe allergic reaction that is rapid in onset and may cause death
  • 500-1000 fatal cases of anaphylaxis per year in the United States.
  • A recent review concluded that the lifetime prevalence of anaphylaxis is 1-2% of the population
  • The incidence of anaphylaxis appears to be increasing, especially cases in children attributed to food allergy.
pathophysiology
Pathophysiology
  • IgE mediated-hypersensitivity
  • Allergen exposure
  • antigen (allergen) binds to antigen-specific immunoglobulin E (IgE) attached basophils and mast cells
  • release of mediators : histamine, leukotriene C4, prostaglandin D2, and tryptase
pathophysiology1
Pathophysiology
  • increased secretion from mucous membranes, increased bronchial smooth muscle tone, decreased vascular smooth muscle tone, and increased capillary permeability
  • Airway edema , Bronchospasm , Rhinitis , Hypotension , GI symptom ,Urticaria , Angioedema
anaphylactoid reaction
Anaphylactoid reaction
  • produces a very similar clinical syndrome but is not immune-mediated
  • exposure to an inciting substance causes direct release of mediators, a process that is not mediated by IgE
  • Common cause: NSAIDs ,Radiocontrast media ,opiates ,muscle relaxant
  • Treatment for both conditions is similar
cause
Cause
  • Food (peanut ,egg ,seafood ,cow’s milk ,soy ,fruit)
  • Bites & stings
  • Drugs (NSAIDs ,Antibiotics ,paracetamol ,anesthetic agent)
  • Latex
  • Vaccine
  • Radiocontrast media
hymenoptera sting1
Hymenoptera sting
  • Wasps and bees cause 30-120 deaths yearly in the United States
  • 50% of deaths occur within 30 minutes of the sting, and 75% occur within 4 hours
  • Large local reactions occur in 17-56% of stung. In one study, 1-2% experienced a generalized reaction
  • Individuals with large local reactions have a 5-10% risk of development of a severe systemic reaction if re-stung.
risk factor
Risk factor
  • Underlying allergic disease
  • Previous history of anaphylaxis
  • Age
  • Women
  • Parenteral medication
  • Systemic mastocytosis
complications
Complications

Complications from anaphylaxis are rare ,and most patients completely recover.

  • Myocardial ischemia result from hypotension and hypoxia
  • Ischemia or arrhythmias may result from treatment with pressors
  • fall or other injury from syncope
  • Brain injury due to prolonged hypoxia
differential diagnosis
Differential diagnosis
  • Angioedema
  • Urticaria
  • Asthma
  • Vasovagal reflex
  • Myocardial Infarction
  • Anxiety
  • Pulmonary Embolism
  • Serum sickness
  • Mastocytosis
investigation
Investigation
  • Serum mast cell tryptase : released from mast cells in both anaphylactic and anaphylactoid reactions
    • Tryptase levels may aid in later diagnosis and treatment.
    • Consider the test in cases for which diagnosis of anaphylaxis is uncertain.
  • Cardiac monitoring : patients with severe reactions ,underlying cardiovascular disease
  • Pulse oximetry
management1
Management
  • Initial assessment : ABC
  • Early diagnosis of Anaphylaxis is important!!!
  • Epinephrine administration
  • high-flow oxygen
  • Airway management
  • IV access & Isotonic crystalloid resuscitation
  • cardiac monitoring
  • Tourniquet proximal to injection site
epinephrine
Epinephrine
  • Drug of choice for patients with systemic manifestations of anaphylaxis
  • When the intravenous route is not indicated, the intramuscular route is preferred
  • The anterolateral thigh is the preferred site
  • Patients taking beta-blockers :
    • administered larger than usual doses
    • addition of Glucagon 0.02 mg/kg IV/IM may be effective but not as a subtitute
epinephrine1
Epinephrine
  • Epinephrine(1:1000)
    • Adult
      • 0.3-0.5 ml IM(preferred) or SC q15min
      • 1 ml in 10 ml NSS via ETT
      • IV infusion: 0.1-1 mcg/kg/min
    • Pediatric
      • 0.01 ml/kg (minimum 0.1 ml) IM(preferred) q15min
      • 0.01 ml/kg (minimum 0.1 ml) in 1-3 ml NSS via ETT
      • IV infusion: 0.1-1 mcg/kg/min
  • Continuous infusion may be administered in cases of refractory shock
antihistamines
Antihistamines
  • H1-blocker should be administered for all patients with anaphylaxis or generalized urticaria
    • Diphenhydramine(Benadryl):1-2 mg/kg IV q4-6h 2 mg/kg PO q4-6h
    • Chlorpheniramine: 0.35 mg/kg/day IV
    • continue for 2-3 days after treatment of the acute anaphylactic event
antihistamines1
Antihistamines
  • H2-blocker

should not be first-line therapy but some evidence suggests that combining H1 and H2 blockers may be more effective than H1-blockers alone

    • Ranitidine 1-3 mg/kg/dose IM/IV q 6 hr
    • Cimetidine 5-10 mg/kg PO/IV/IM q6h
inhaled beta agonists
Inhaled beta-agonists

used to counteract bronchospasm and should be administered to patients who are wheezing

Salbutamol

    • Adult
      • 0.5 mL 0.5% soln in 2.5 cc NS nebulized q15min
    • Pediatric
      • 0.03-0.05 mL/kg 0.5% soln in 2.5 cc of NS via nebulizer q15min
  • Refractory bronchospasm : corticosteroids Aminophylline
corticosteroids
Corticosteroids
  • Used primarily to decrease the incidence and severity of delayed or biphasic reactions
  • have a delayed onset of action and do not reverse the cardiovascular effects of anaphylaxis
  • usually are administered IV in patients with anaphylaxis for presumed rapidity of effect
corticosteroids1
Corticosteroids
  • Hydrocortisone 5-10 mg/kg/day IV,IM q 6 hr
  • Methylprednisolone 1-2 mg/kg/dose IV,IM q 6 hr
  • Prednisolone 1 mg/kg/day PO
  • continue for 2-3 days after treatment of the acute anaphylactic event
vasopressors
Vasopressors
  • In case of refractory hypotension that treatment with epinephrine & IVF is not effective

Dopamine : 400mg in 5%D/W IV 2-20 mcg/kg/min

further inpatient care
Further inpatient care
  • Most patients with anaphylaxis may be treated successfully in the ED and followed by a short period of observation
  • The purpose of observation is to monitor for recurrence of symptoms (ie, biphasic anaphylaxis)
further inpatient care1
Further inpatient care

Hospital admission is required for patients who:

  • fail to respond fully / persistent hypotension
  • have severe respiratory symptoms/ need intubation
  • experience a significant injury from syncope
  • have a recurrent reaction or a secondary complication (eg, myocardial ischemia)
further outpatient care
Further Outpatient Care
  • Continue antihistamines & corticosteroids for 2-5 days to prevent recurrence
    • H1-Blockers
      • Diphenhydramine (Benadryl) - Adults: 25 mg PO q6h for 2-5 d; Children: 1 mg/kg PO q6h for 2-5 d
      • Hydroxyzine (Atarax) - Adults: 25 mg PO q8h for 2-5 d; Children: 1 mg/kg PO q8h for 2-5 d
    • Corticosteroids
      • Prednisone - Adults: 20-80 mg PO qd for 2-5 d; Children: 1-2 mg/kg PO qd for 2-5 d
further outpatient care1
Further Outpatient Care
  • Patients who experience severe reactions to bites, stings, food, or other possibly unavoidable causes and likely to be encountered after discharge should carry self-injectable epinephrine. These injectors may be packaged as kits that also contain an oral antihistamine
further outpatient care2
Further outpatient care
  • The key to prevention is identification & avoidance of the inciting agent
  • Prophylactic or preventative therapies (i.e Desensitization) may be employed when re-exposure cannot be avoided
patient education
Patient education
  • warn patients of the possibility of recurrent symptoms, and instruct them to seek further care if this occurs
  • Sting avoidance
    • avoid use of perfumes or hygiene products that include perfumes
    • Brightly colored clothing attracts bees and other pollinating insects
    • Avoid locations of known hives or nests, and avoid using equipment that disturbs the hive
slide47

Medicolegal Pitfalls

  • Claims of medical negligence related to the emergency treatment of anaphylaxis are not common. Potential pitfalls are as follows:
    • Failure to consider the diagnosis in patients with unexplained syncope or shock
    • Failure to warn the patient of avoidance or preventive measures
    • Prescription or administration of a drug to which the patient is known allergic
    • Failure to appreciate the potentially serious nature of symptoms, such as syncope or throat tightness, in a patient with an allergic reaction
    • Complications of epinephrine administration in patients without clear indication