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SEMINAR ON ANAPHYLAXIS
BY
LIDIYAMOL.P.V
1ST YEAR M.SC NURSINGGOVT. CON , THRISSUR
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HISTORY OF IMMUNOLOGY:-
Immunology is a science that examines the
structure and function of the immune system.
The earliest known reference to immunity was
during the plague of Athens in 430 BC.
. Thucydides noted that people who had
recovered from a previous bout of the disease
could nurse the sick without contracting the
illness a second time.
http://en.wikipedia.org/wiki/Immunologyhttp://en.wikipedia.org/wiki/Plague_of_Athenshttp://en.wikipedia.org/wiki/Thucydideshttp://en.wikipedia.org/wiki/Thucydideshttp://en.wikipedia.org/wiki/Plague_of_Athenshttp://en.wikipedia.org/wiki/Immunology7/31/2019 Seminar on Anaphylaxis 7-6-12
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HISTORY OF IMMUNOLOGY:-
CONTD
Immunology made a great advance towards
the end of the 19th century, through rapid
developments, in the study ofhumoral
immunity and cellular immunity. Particularly
important was the work ofPaul Ehrlich, who
proposed the side-chain theory to explain the
specificity of the antigen-antibody reaction
http://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Cell-mediated_immunityhttp://en.wikipedia.org/wiki/Paul_Ehrlichhttp://en.wikipedia.org/wiki/Side-chain_theoryhttp://en.wikipedia.org/wiki/Side-chain_theoryhttp://en.wikipedia.org/wiki/Side-chain_theoryhttp://en.wikipedia.org/wiki/Side-chain_theoryhttp://en.wikipedia.org/wiki/Paul_Ehrlichhttp://en.wikipedia.org/wiki/Cell-mediated_immunityhttp://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Humoral_immunity7/31/2019 Seminar on Anaphylaxis 7-6-12
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FACTORS THAT DETERMINE AN
ALLERGIC RESPONSE:-
Responsiveness of the host to the allergen:
Amount of allergen:
Nature of the allergen: Route of entrance of the allergen
Timing of exposure to the allergen
Site of the allergen immune mediatorreaction
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FACTORS THAT DETERMINE AN
ALLERGIC RESPONSE:- CONTD
Hosts threshold of reactivity
The hosts immune system can be
changed by factors such as stress, fatigue, or
infection, all of which can decrease the
responsiveness of immune system to potential
allergens.
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CLASSIFICATION OF HYPERSENSITIVITY
REACTIONS:-
IMMEDIATE HYPERSENSITIVITY (B-CELL ORANTIBODY MEDIATED)
Anaphylaxis
Atopy Antibody mediated cell damage
Arthus phenomenon
Serum sickness
DELAYED HYPERSENSITIVITY (T- CELL MEDIATED) Infection (tuberculin)
Contact dermatitis
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Coombs and Gell (1963) classification
of hypersensitivity reactions
Type I (anaphylactic, IgE or reagin dependent):
Antibodies (cytotropic IgE antibodies ) are
fixed on the surface of tissue cells ( mast cells
and basophils ) in sensitised individuals. The
antigen combines with the cell fixed antibody
leading to release of vasoactive amines which
produces clinical reactions.
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Coombs and Gell (1963) classification
of hypersensitivity reactions
Type II (cytotoxic or cell stimulating):
This type of reaction is initiated by IgE (OR
rarely IgM) antibodies that reacts with the
cell surface or tissue antigen. Cell or
tissuedamage occurs in the presence of
complement or mononuclear cells. Type II
reactions are intermediate betweenhypersensitivity and auto immunity.
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Coombs and Gell (1963) classification
of hypersensitivity reactions
Type III ([mmune complex or toxic complex
disease)
Here the damage is caused by antigen
antibody complexes. These may precipitate in
and around small blood vessels, causing
damage to cells secondarily, or on
membranes, interfering with their function
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Coombs and Gell (1963) classification
of hypersensitivity reactions
Type IV (ddelayed or cell mediated )
This is a cell mediated response. The
antigen activates specifically sensitised CD4
AND CD8 T cells, leading to the secretion of
lymphokines, with fluid and phagocyte
accumulation.
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DEFINITION
Type I Reactions:-
These occur in two forms : the acute,potentially fatal, systemic form called
anaphylaxis and the chronic or recurrent, non-
fatal, typically localised form called atopy.
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DEFINITION:-
. Anaphylaxis is defined as "a
serious allergic reaction that is rapid in onset
and may cause death". It typically results in a
number of symptoms including an itchy rash,
throat swelling, and low blood pressure.
Common causes include insect bites, foods,
and medications.
http://en.wikipedia.org/wiki/Allergic_reactionhttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Allergic_reaction7/31/2019 Seminar on Anaphylaxis 7-6-12
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DEFINITION
. Anaphylaxis is an acute, potentially fatal,
multiorgan system reaction caused by the
release of chemical mediators from mast cells
and basophils. The classic form involves priorsensitization to an allergen with later re-
exposure, producing symptoms via an
immunologic mechanism.
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DEFINITION
Anaphylaxis is a clinical response to an
immediate (type I hypersensitivity)
immunological reaction between a specific
antigen and antibody. The reaction result fromIgE antibody.
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ETIOLOGY
Food
Medication
Venom Risk factors
People with atopic diseases such
as asthma, eczema, or allergic rhinitis are athigh risk of anaphylaxis from food, latex,
and radiocontrast
http://en.wikipedia.org/wiki/Atopichttp://en.wikipedia.org/wiki/Asthmahttp://en.wikipedia.org/wiki/Eczemahttp://en.wikipedia.org/wiki/Allergic_rhinitishttp://en.wikipedia.org/wiki/Latexhttp://en.wikipedia.org/wiki/Radiocontrasthttp://en.wikipedia.org/wiki/Radiocontrasthttp://en.wikipedia.org/wiki/Latexhttp://en.wikipedia.org/wiki/Allergic_rhinitishttp://en.wikipedia.org/wiki/Eczemahttp://en.wikipedia.org/wiki/Asthmahttp://en.wikipedia.org/wiki/Atopic7/31/2019 Seminar on Anaphylaxis 7-6-12
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immune system
LAYERED DEFENSE:-
physical barriers prevent pathogens such
as bacteria and viruses from entering the
organism. If a pathogen breaches these
barriers, the innate immune system provides
an immediate, but non-specific response
http://en.wikipedia.org/wiki/Bacteriahttp://en.wikipedia.org/wiki/Virushttp://en.wikipedia.org/wiki/Innate_immune_systemhttp://en.wikipedia.org/wiki/Innate_immune_systemhttp://en.wikipedia.org/wiki/Virushttp://en.wikipedia.org/wiki/Bacteria7/31/2019 Seminar on Anaphylaxis 7-6-12
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immune system
If pathogens successfully evade the innate
response, vertebrates possess a second layer
of protection, the adaptive immune system,
which is activated by the innate response.
http://en.wikipedia.org/wiki/Adaptive_immune_systemhttp://en.wikipedia.org/wiki/Adaptive_immune_system7/31/2019 Seminar on Anaphylaxis 7-6-12
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IMMUNE SYSTEM
SURFACE BARRIERS
Mechanical, chemical, and biological
barriers.
INNATE IMMUNE SYSTEM
The innate response is usually triggered
when microbes are identified by pattern
recognition receptors
http://en.wikipedia.org/wiki/Pattern_recognition_receptorshttp://en.wikipedia.org/wiki/Pattern_recognition_receptorshttp://en.wikipedia.org/wiki/Pattern_recognition_receptorshttp://en.wikipedia.org/wiki/Pattern_recognition_receptors7/31/2019 Seminar on Anaphylaxis 7-6-12
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Humoral and chemical barriers
Inflammation
Inflammation is one of the first responses ofthe immune system to infection. The
symptoms of inflammation are redness,
swelling, heat, and pain, which are caused by
increased blood flow into tissue.
http://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Blood7/31/2019 Seminar on Anaphylaxis 7-6-12
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. Complement system
The complement system is a biochemical
cascade that attacks the surfaces of foreign
cells
Complement is the major humoral component
of the innate immune response
http://en.wikipedia.org/wiki/Biochemical_cascadehttp://en.wikipedia.org/wiki/Biochemical_cascadehttp://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Biochemical_cascadehttp://en.wikipedia.org/wiki/Biochemical_cascade7/31/2019 Seminar on Anaphylaxis 7-6-12
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In humans, this response is activated by
complement binding to antibodies that have
attached to these microbes or the binding of
complement proteins to carbohydrates on thesurfaces ofmicrobes. This
recognition signal triggers a rapid killing
response
http://en.wikipedia.org/wiki/Carbohydratehttp://en.wikipedia.org/wiki/Microbehttp://en.wikipedia.org/wiki/Cell_signalinghttp://en.wikipedia.org/wiki/Cell_signalinghttp://en.wikipedia.org/wiki/Microbehttp://en.wikipedia.org/wiki/Carbohydrate7/31/2019 Seminar on Anaphylaxis 7-6-12
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Adaptive immune system
The adaptive immune response is antigen-
specific and requires the recognition of
specific "non-self" antigens during a process
called antigen presentation. Antigenspecificity allows for the generation of
responses that are tailored to specific
pathogens or pathogen-infected cells.
http://en.wikipedia.org/wiki/Antigen_presentationhttp://en.wikipedia.org/wiki/Antigen_presentation7/31/2019 Seminar on Anaphylaxis 7-6-12
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Adaptive immune system
Lymphocytes
The cells of the adaptive immune system arespecial types of leukocytes,
called lymphocytes. B cells and T cells are themajor types of lymphocytes and are derivedfrom hematopoietic stem cells in the bonemarrow. B cells are involved in the humoralimmune response, whereas T cells areinvolved in cell-mediated immune response
http://en.wikipedia.org/wiki/Lymphocytehttp://en.wikipedia.org/wiki/B_cellhttp://en.wikipedia.org/wiki/T_cellhttp://en.wikipedia.org/wiki/Hematopoietic_stem_cellhttp://en.wikipedia.org/wiki/Bone_marrowhttp://en.wikipedia.org/wiki/Bone_marrowhttp://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Cell-mediated_immunityhttp://en.wikipedia.org/wiki/Cell-mediated_immunityhttp://en.wikipedia.org/wiki/Cell-mediated_immunityhttp://en.wikipedia.org/wiki/Cell-mediated_immunityhttp://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Humoral_immunityhttp://en.wikipedia.org/wiki/Bone_marrowhttp://en.wikipedia.org/wiki/Bone_marrowhttp://en.wikipedia.org/wiki/Hematopoietic_stem_cellhttp://en.wikipedia.org/wiki/T_cellhttp://en.wikipedia.org/wiki/B_cellhttp://en.wikipedia.org/wiki/Lymphocyte7/31/2019 Seminar on Anaphylaxis 7-6-12
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Adaptive immune system
Killer T cells
Killer T cell are a sub-group of T cells that kill
cells that are infected with viruses (and other
pathogens), or are otherwise damaged or
dysfunctional.
http://en.wikipedia.org/wiki/Cytotoxic_T_cellhttp://en.wikipedia.org/wiki/Cytotoxic_T_cell7/31/2019 Seminar on Anaphylaxis 7-6-12
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Adaptive immune system
Helper T cells
Helper T cells regulate both the innate and
adaptive immune responses and help determinewhich immune responses the body makes to aparticular pathogen. These cells have no cytotoxicactivity and do not kill infected cells or clear
pathogens directly. They instead control theimmune response by directing other cells toperform these tasks.
http://en.wikipedia.org/wiki/T_helper_cellhttp://en.wikipedia.org/wiki/T_helper_cell7/31/2019 Seminar on Anaphylaxis 7-6-12
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Adaptive immune system
T cells
T cells possess an alternative T cell
receptor (TCR) as opposed to CD4+ and CD8+
() T cells and share the characteristics of
helper T cells, cytotoxic T cells and NK cells.
The conditions that produce responses from
T cells are not fully understood
http://en.wikipedia.org/wiki/Gamma/delta_T_cellshttp://en.wikipedia.org/wiki/Gamma/delta_T_cellshttp://en.wikipedia.org/wiki/T_cell_receptorhttp://en.wikipedia.org/wiki/T_cell_receptorhttp://en.wikipedia.org/wiki/T_cell_receptorhttp://en.wikipedia.org/wiki/T_cell_receptorhttp://en.wikipedia.org/wiki/Gamma/delta_T_cellshttp://en.wikipedia.org/wiki/Gamma/delta_T_cellshttp://en.wikipedia.org/wiki/Gamma/delta_T_cells7/31/2019 Seminar on Anaphylaxis 7-6-12
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Adaptive immune system
B lymphocytes and antibodies
A B cell identifies pathogens when antibodies onits surface bind to a specific foreign antigen. This
antigen/antibody complex is taken up by the Bcell and processed by proteolysis into peptides.The B cell then displays these antigenic peptideson its surface MHC class II molecules. This
combination of MHC and antigen attracts amatching helper T cell, whichreleases lymphokines and activates the B cell.
http://en.wikipedia.org/wiki/B_cellhttp://en.wikipedia.org/wiki/Proteolysishttp://en.wikipedia.org/wiki/Lymphokinehttp://en.wikipedia.org/wiki/Lymphokinehttp://en.wikipedia.org/wiki/Proteolysishttp://en.wikipedia.org/wiki/B_cell7/31/2019 Seminar on Anaphylaxis 7-6-12
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Adaptive immune system
Immunological memory
When B cells and T cells are activated and
begin to replicate, some of their offspring
become long-lived memory cells. Throughout
the lifetime of an animal, these memory cells
remember each specific pathogen
encountered and can mount a strongresponse if the pathogen is detected again.
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PATHOPHYSIOLOGY:-
Type I hypersensitivity are mediated by the IgE
class of immunoglobulin. In genetically, pre
disposed people, initial exposure to an
allergen prompts B lymphocytes to produceIgE antibodies, which sensitize the person to
the allergen. This initial contact with the
allergen is known as the sensitizing dose
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PATHOPHYSIOLOGY
Once the person is fully sensitized, subsequentexposure ( termed the shocking dose orchallenging dose) results in the allergencombined with the specific IgE antibodies thatare bound to receptor sites on tissue mast cellsand blood basophils. This antigen antibodyreaction results in a rapid release of potent vaso
active mediators such as histamines, kinins,chemo tactic factors, and active products ofarachidonic acid metabolism
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PATHOPHYSIOLOGY
Anaphylaxis is caused by the interaction of aforeign antigen with specific IgE antibodies foundon the surface membrane of mast cells andperipheral blood basophils. The subsequentrelease of histamine and other bioactivemediators cause activation of platelets,eosinophils, and neutrophils and coagulation
cascade. Smooth muscle spasm, bronchospasm,mucosal eddema, and inflammation, andincreased capillary permeability
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CLINICAL FEATURES Localised reactions:-
Hives angioedema
Systemic anaphylaxis:-
Apprehension
Edema of the hands, face, or other parts of the body Dyspnoea
Respiratory collapse
Vascular collapse with shock Rapid, regular pulse Falling blood pressure
Cyanosis
Death
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DIAGNOSTIC MEASURES
The health history including an environmental
assessment,
Skin testing and radio allergo sorbent test
(RAST) may be helpful
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MEDICAL MANAGEMENT
Management depends on the severity of the
reaction. Initially, respiratory and
cardiovascular functions are evaluated
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TREATMENT
Simple BLS (O2, position, etc)
Anti Histamines
Benadryl (IV 25-50 mg, PO 50 mg adult, 25 mg ped)
Corticosteroids
Decadron, Solu-medrol, etc
Treat Hypotension
IV fluids
Dopamine 5-20 mcg/min
Epi Drip 2-10 mcg/min
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TREATMENT
Broncheodiators
Albuterol MDI or Neb
Observe for a minimum 8-12 hours
Benadryl for 24 hours.
Rebound or persitant S/S
Repeat epinephrine if Sx persist or increase after 10-15
minutes
Repeat antihistamine H2 blocker if Sx persist
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TREATMENT
Avoidance therapy, in which the patient is
thought to reduce exposure to trigerring
antigens, is the most effective treatment to
decrease allergic attacks
Immunotherapy is often useful in reducing
symptoms in patients who cannot avoid
antigens such as dust mites or pollen
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PREVENTION
EDUCATE
Teach avoidance measures
Accidents are never planned
Stress importance of:
Immediate treatment
Emphasize the need for follow-up care
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NURSING MANAGEMENT
ASSESSMENT:-
Health history:-
Assessment data to be collected as part of thehealth history of a patient with allergy includes:
History of allergic reactions in the past ( e.g., type,frequency or perceived causes)
Familial history of allergies
Recent exposure to sensitizing substances (chemicals,drugs)
Changes in living, working, or environmental conditions
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NURSING MANAGEMENT
Characteristics of present environment (house, clothing,plants, trees or animals)
Increased stress in recent past ( stress aggrevates asthmaticresponse)
Types of symptoms experienced: respiratory, dermal,gastrointestinal or general
Alleviating factors, either prescribed, herbal, or over thecounter
All patients should be questioned about allergies and
sensitivities to drugs before any drug therapy is initiated. Ifthere is a positive history, the physician is consulted beforea new drug is given, the patient is monitored closely forallergic responses.
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Physical examination:-
Important aspects of the physical examination ofthe patient with allergy include inspection andobservation for :
Rashes (location, and colour) Mouth breathing (nasal obstruction)
Flaring nares
Difficulty hearing (plugged Eustachian tubes)
Pale, bluish turbinates that are oedematous withclear secretions
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PHYSICAL EXAMINATION
Tearing
Dark areas under the eyes ( venous dilation ofthe skin)
Scleral or conjunctival infections Increased respiratory rate
Audible wheezing
Use of accessory muscles for breathing Anxious depression
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NURSING DIAGNOSES:-
Ineffective airway clearance related to excess
secretion production and bronchoconstriction.
Decreased cardiac output related to
inadequate venous return to heart, peripheral
vasodilation.
Deficient knowledge related to inadequate
information about allergy control andtreatments.
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Airway clearence:-
Cardiac output:-
Nurse should be alert for the clinical manifstatios
of anaphylactic shock. At the first sign ofanaphylaxis, the patient is given epinephrine1:1000 solution 0.3 to 0.5 ml s/c or im
Risk for allergy response:-
High risk patients are instructed to wear aidentification bracelet.
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INTERVENTIONS
Provide supplemental oxygen and observe. Ifhypoxia continues, prepare to help insert anartificial airway.
Insert an I.V. line for giving emergency drugs and
volume expanders. Continually reassure the patient and explain all
tests and treatments to reduce fear and anxiety.
If the patient undergoes skin or scratch testing.Keep emergency resuscitation equipment nearbyduring and after the test.
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INTERVENTIONS
Continuously assess the patients response to
treatment.
Monitor vital signs and cardiopulmonary
and neurologic function. Observe for complications associated with
anaphylaxis, such as vascular collapse and acuterespiratory insufficiency or obstruction.
Closely observe a patient with known allergies foranaphylaxis when giving a drug with highanaphylactic potential.
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COMPLICATIONS
The primary complication of type I
hypersensitivity are anaphylactic shock, which
can leads to death within minutes without
emergency treatment.
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