Presentation

1. PEDIATRIC ANAPHYLAXIS
PEDIATRIC STAGE
FACULTYOF MEDICINE CHRISTIAN UNIVERSITYOF INDONESIA
23 SEPTEMBER – 16 NOVEMBER
PHILJEUWBENS ADITYA RAHANTOKNAM
0761050016

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

3. Etiology
Food Peanuts and other legumes,nuts, eggs, cow’s milk,
shellfish, seeds, and fruits
Foods Food dyes
Medications Antibiotics (eg, penicillin and sulfonamides), NSAIDs,
aspirin,protamine, and anesthetic agents
Envenomations Fire ants and hymenoptera, such as bees and wasps
Immunotherapy Allergen extracts
Blood product infusion
Latex
Vaccines
Radiographic media
Idiopathic
Exercise

5. The Causes Of Anafilactic
0
5
10
15
20
25
30
35
Food Drug/Bio Sting Allergen Exercise Idiopathic
PercentofCases

6. Factors That Increase Risk of an
Event or Potentiate Its Severity
Infants
Cannot describe their
symptoms
Adolescents and
young adults
Increased risk-taking
behaviors
Labor and delivery
Risk from medications
(eg, antibiotic to prevent
neonatal group B
strep infection)
Elderly
Increased risk of
fatality from
medication or venom-
triggered anaphylaxis

9. Diagnosis
TABLE 3. Clinical Criteria for Diagnosing Anaphylaxis
1 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.

10. 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

11. SKIN
ITCHING FLUSHING
HIVES (URTICARIA) SWELLING

12. Eye
ITCHING CRY (TEARS)
REDNESS SWELLING

13. Nose and Mouth
SNEEZING RUNNY NOSE NASAL CONGESTION
SWELLING OF TOGUE METALICTASTE

14. Lungs and Throat
DIFFICULTY BREATHING COUGHING CHESTTIGHTNESS WHEEZING OR OTHER SOUND
INCREASED MUCUS PRODUCTION
THROAT SWELLING
OR ITCHING
CHANGE INVOICES OR SENSATION
OF CHOCKING

15. Heart and circulation
DIZZINESS FAINTINGWEAKNESS
RAPID, SLOW, IRREGULER
HEART RATE
LOW BLOOD PRESSURE

16. Digestive System
NAUSEA VOMITTING
CRAMPS DIARRHEA

17. Nervous System
ANXIETY CONFUSION

18. 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

19. 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

21. Pediatric Assessment Triangle (PAT)

22. 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.

23. Rapid Cardiopulmonary Assessment
Airway
Breathing
Circulation
Should take less than 30 seconds to complete

24. Airway Assessment

25. Breathing
 RR
 Respiratory Mechanics
 Retractions, Accessory
Muscles use and
NasalFlaring
 Head Bobbing
 Grunting
 Stridor
 Wheezing
 Air Entry
 Chest Expansion
 Breath Sounds
 Color

26. ASSESSING BREATHING

27. Color – cyanosis indicates poor oxygenation

28. 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 – 40
Infant 6 – 12 month 80 – 140 20 – 30
Toddler 1 – 3 month 80 – 130 20 – 30
Presschooler 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

29. 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

30. Assessing Circulation
Brachial pulse
Femoral pulse

31. 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

32. EPINEPHRINE
α1 – adregergic
receptor
α2 – adrenergic
receptor
β1 – adrenergic
receptor
β2 – adrenergic
receptor
↑Vasoconstriction
↑ Peripheral vascular
resistance
↑ Heart rate
↓ Mucosal edema
↓ Insulin release ↑ Inotropy
↑ Chronotropy
↑ Bronchodilation
↑Vasodilation
↑ Glycogenolysis
↓ Mediator release
Action Of Epinephrine

33. DIFFERENTIAL DIAGNOSIS
Common 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 III
ACE 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 cell
disorders
Basophilic leukemia
Shock
•Hypovolemik
•Cardiogenic
•Distributive
•Septic