201111122348anaphylaxis 過敏性休克 全身性過敏反應 (from Rosen 5th edition p 1619)

2016-12-19 from 張志華醫師

http://www.emnote.org/emnotes/anaphylaxis


References:
1. http://daniellesbrainbits.blogspot.tw/
2. http://www.totalem.org/
3. http://iconpediatrics.com/
4. http://emergencymedicinecases.com/

2016-05-28 修改

BOX 119-7

Emergency Measures (taken simultaneously)

移除造成過敏的來源, 如果是蜂螫或注射藥物, 可在近端綁上止血帶. 將患肢位置放低於心臟. 

讓病患頭低腳高

接上生理監視器. 給予 NRM 氧氣. 打上大號點滴. 抽血. 做 ECG. 照 CXR. 

保持呼吸道通暢. 必要時插管. 視情況使用其他設備輔助插管. 

給予消旋腎上腺素 或左旋腎上腺素, 2.25% 0.5cc + NS 2.5cc 噴霧吸入

大量注射生理食鹽水

Remove any triggering agent. If the patient had a sting or immunization injection, place a loose tourniquet proximal to the site; if the reaction site is on an extremity, place the extremity in dependent position.
Place patient in the Trendelenburg position if hypotensive.
Begin cardiac monitoring, pulse oximetry, and blood pressure autonomic monitoring; apply oxygen non-rebreather mask, establish large-bore intravenous lines, draw blood, obtain stat electrocardiogram and portable chest radiograph.
Establish a patent airway.
Open the airway by head tilt/chin lift or jaw thrust as clinically appropriate.
Be prepared for endotracheal intubation with or without rapid sequence intubation.
Be prepared to use adjunct airway technique (laryngeal mask airway, fiberoptic, jet ventilation, surgical airway) as per local custom.
Administer racemic epinephrine (L-epinephrine acceptable) 0.5 mL of 2.25% solution in 2.5 mL of NS by nebulizer while awaiting definitive airway management. 
Start rapid infusion of isotonic crystalloid (NS): 500 mL in the first 5 minutes in the adult; several liters of NS may be required.

 

跟第五版相同. 腎上腺素是第一線用藥. 成人. 每 3-5 分鐘 肌肉注射 0.3-0.5 cc. 在使用 epipen 注射大腿肌肉時. 不需要脫褲子. 

靜脈注射腎上腺素. 一隻 1mg epinephrine 稀釋一百倍. 抽 10cc(內含 0.1mg epinephrine), 靜脈注射 10 分鐘. 持續監測血壓. 

VENA. 成人 50mg IV STAT. 或口服 150 mg(通常一顆 10mg. 一次可吃 15顆)

Ranitidine: intravenous  ==Adult: 50 mg IV 

噴霧藥物 Albuterol 2.5mg + NS 2cc. 

類固醇劑量往下調了. Methylprednisolone =Adult: 125-250 mg IV

Corticosteroids 類固醇作用時間約需要 4-6 小時. 所以在緊急處理幫忙不大. 但可以治療頑固性過敏. 避免治療過後又再次惡化, 極少數病患可能對類固醇過敏. 
Along with epinephrine and antihistamines, systemic corticosteroids are commonly administered in the treatment of anaphylaxis. A typical regimen involves an initial intravenous loading dose of methylprednisolone (Solu-Medrol, 125 to 250 mg) or oral prednisone (0.5-1 mg/kg). Steroids have an onset of action of approximately 4 to 6 hours after administration and therefore are of limited benefit in the acute treatment. They are most useful for
protracted symptoms and may confer theoretic benefits in preventing the biphasic reaction. Rare cases of deterioration after corticosteroid administration may be the result of the patient’s hypersensitivity reaction to steroid.

 

Antianaphylactic Drugs
Epinephrine is the first-choice drug, to be given simultaneously with the above general emergency measures, at the first suspicion of an anaphylactic reaction.
Intramuscular (1 : 1000 concentration)
==Adult: 0.3-0.5 mL every 5 minutes, more often as clinically indicated, titrated to effects
==Pediatric: 0.01 mL/kg, every 5 minutes as necessary, titrated to effects
Alternatively, epinephrine (EpiPen, 0.3 mL; or EpiPen Jr, 0.15 mL) can be administered into anterolateral thigh.
Removal of clothing is unnecessary.
Intravenous (1 : 100,000 concentration; 0.1 mL of 1 : 1000 epinephrine in 10 mL of NS)
Continuous hemodynamic monitoring required 10 mL of 1 : 100,000 during 10 minutes, titrated to effects; repeat as necessary


Antihistamines
Diphenhydramine: intravenous (intramuscular acceptable)
==Adult: 50 mg, up to 400 mg/24 hr, titrated to effects
==Pediatric: 1 mg/kg, up to 300 mg/24 hr, titrated to effects

Ranitidine: intravenous
==Adult: 50 mg IV (150 mg oral)
==Pediatric: 1 mg/kg IV or oral


Aerosolized beta-agonists
==Adult
==Albuterol: 2.5 mg, diluted to 3 mL of NS; may be given continuously
==Levalbuterol: 0.625-1.25 mg, diluted to 3 mL of NS; may be given continuously 
==Ipratropium: 0.5 mg in 3 mL of NS; repeat as necessary
==Pediatric
==Albuterol: 2.5 mg, diluted to 3 mL of NS; may be given continuously
==Levalbuterol: 0.31-0.625 mg, diluted to 3 mL of NS; may be given continuously
==Ipratropium: 0.25 mg in 3 mL of NS; repeat as necessary


Methylprednisolone
==Adult: 125-250 mg IV
==Pediatric: 1-2 mg/kg IV

 

Special Situations
Refractory Hypotension
Consider continuous epinephrine drips
Dilute 1 mg (1 mL 1 : 1000) in 250 mL D5W to yield a concentration of 4 μg/mL 
Infuse this diluted solution at 1 to 4 μg/min, up to 10 μg/min, titrated to effects
Glucagon: 1-5 mg IV during 5 minutes, followed by 5-15 μg/min continuous infusion
Consider vasopressors:
Dopamine, 5-20 μg/kg/min continuous infusion and/or
dobutamine 5-20 μg/kg/min continuous infusion, titrated to effects
Norepinephrine: 8-12 μg/min (2-3 mL/min; 4 mg added to 1000 mL of D5W provides a concentration of 4 μg/mL), titrated to effects
Phenylephrine, 40-180 μg/min, titrated to effects 
Vasopressin, 2-4 IU/hr, titrated to effects
Patients Receiving Beta-Blockade
Glucagon: 1-5 mg IV during 5 minutes, followed by 5-15 μg/min
continuous infusion
Transcutaneous pacing for bradycardia
Atropine for bradycardia
Adult: 0.3-0.5 mg IV or subcutaneous, to a maximum of 3 mg
Pediatric: 0.02 mg/kg IV or subcutaneous, to a maximum of 2 mg

==END

 

anaphylaxis 過敏性休克 全身性過敏反應 (from Rosen 5th edition p 1619) 寫於 2011年11月12日 22:42

anaphylaxis rosen p 1619

ana=against

phylax=guard or protect

定義:在先前已經有暴露於過敏原的病患,發生全身性過敏反應,可以有很多種不同臨床症狀
definition: severe systemic allergic reaction in a previously sensitiazed patient, a syndrome associated with variable clinical features.

 

和一般過敏反應作區分的主要特徵:急性呼吸困難與休克(低血壓、血管衰竭)
the distinguishing features are acute respiratory difficulty and vascular collapse, within seconds to minutes after exposure to the offending  agent.

其他症狀包括:

PRUTIRIC ERYTHEMATOUS RASH 搔癢性紅疹

CONJUNCTIVITIS 結膜炎

URTICARIA 蕁麻疹

ANGIOEDEMA 血管性浮腫

LARYNGEAL EDEMA 喉頭水腫

RHINITIS 流鼻水

NAUSEA/VOMITING 噁心 嘔吐

ABDOMINAL PAIN 腹痛

PALPITATION 心悸

LIGHTHEADEDNESS 頭重腳輕

SYNCOPE 暈厥

 

治療:P 1632

1. EPINEPHRINE:第一線藥物(最重要的藥物)

皮下注射:用於血壓正常症狀輕微的病患(有呼吸道黏膜腫脹但血壓還好)

肌肉注射:如果全身皮膚蕁麻疹很嚴重的病患不適合打皮下,此時應打肌肉

使用方式, 1支1mg的腎上腺素=1CC,每公斤打0.01CC。50公斤重成人一次給半支。最大劑量半支 0.5CC。

應將總量的0.1~0.2CC打入接觸過敏原的部位(例如被蜜蜂螫傷處、打藥物造成過敏處)

原文:A fraction of the total dosage (0.1 to 0.2 mL) should be administered at the site of antigenic exposure if accessible (such as a bee sting or antigen injection in an extremity)

 

靜脈注射:用於嚴重呼吸道阻塞、急性呼吸衰竭、休克(收縮壓小於80mmHg)且沒有VT的病患。

靜脈注射可能導致:SVT、VT、心肌缺血、STUNNED HEART SYNDROME

避免不良反應的措施:稀釋+緩慢給藥

1支=1mg EPINEPHRINE 稀釋一百倍,抽10CC靜脈滴注 10 分鐘。
 
如果單次給予沒有效果,需考慮連續靜脈滴注

1支=1mg EPINEPHRINE泡D5W 250CC (每CC=4ug),每小時 15~60CC(用PUMP給藥)

 嬰幼兒給的劑量 0.1 ug/kg/min(每小時每公斤 6 ug),最大給到 1.5 ug/kg/min (每小時每公斤 90 ug)

如果無法建立靜脈管路,可考慮從舌下注射、骨內注射、經氣管蒸汽吸入。這些途徑的藥物劑量與靜脈注射相同(跟ACLS教的不一樣喔)

 

2. 氣管擴張劑

 

3. 抗組織胺:所有病患都應該使用(雖然在嚴重過敏反應的角色比較有限)

vena(H1 BLOCKER) 25-50mg q4h~q6h (台灣通常一支30mg)

兒科劑量 vena 5 mg/kg/day 分次給予 (10公斤兒童一天給50mg = 1.6CC ==> 0.4cc q6h)

 

可同時給予H1和H2阻斷劑,持續有症狀的病患應考慮給予cimitidine

cimetidine 300mg iv stat , then 300mg po q6h x 2 days

 

4. 類固醇:作用時間要4-6小時,比較慢,但可以持續作用比較久

LOADING DOSE:solu-cortef 250mg~1000mg iv stat 或 solu-medrol 125~500mg iv stat

然後給予口服PREDNISOLONE 7-10天
 

5. 昇壓劑:

CVP 小於 12mmHg 時要灌水(也可以給膠體溶液,例如 5% ALBUMIN)+ DOPAMINE 5 ug/kg/min

CVP 大於 12mmHg 時要給予DOPAMINE。

如果合併肺高壓,要給予過渡換氣、高濃度氧氣、大劑量類固醇

如果所有治療都沒效果,可以給NOREPINEPHRINE、METARAMINOL
 

6. glucagon 昇糖劑(我們醫院沒有進)

服用BETA阻斷劑的病患可考慮使用

傳統治療無效的病患也可以考慮使用

成人 1mg iv/im/sc 之後連續靜脈注射 1-5mg/hr

小兒 0.5mg iv/im/sc

副作用:噁心嘔吐、低血鉀、高血糖

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