Anaphylactic shock pathogenesis clinic treatment. Anaphylaxia: etiology, pathogenesis, treatment

The main pathogenetic element of any variety of shock is generalized hypoperfusion, which is due to the maintenance of homeostatic mechanisms and leading to irreversible cellular damage. The integral indicator characterizing the circulatory status is the average blood pressure (CP AD), which is the derivative of the two components - the total peripheral vascular resistance (OPS) and the minute volume of blood circulation (IOC), which in turn is determined by the impact volume (UO) and cardiac frequency abbreviations (heart rate).

Hell CP \u003d OPS'mok \u003d OPS'O'Chss

Since shock is a symptom complex, reflecting tissue hypiperphusy, then any of the types of shock can be viewed as a violation of one or more of the above determinants. The basis of the hypovolemic shock is the shortage of circulating blood (OCC), cardiogenic - reduction of the shock volume, anaphylactic shock - a decrease in the vascular tone (reduction of the OPS), septic shock - the BCC deficiency, a decrease in the powers of the myocardium and vascular tone.

In response to a decrease in blood pressure or reduction in the right of atrium, baroreceptors of the synocarotide zone, the volumetric receptors of the right atrium, which leads to a change in the nature of the transfer of information from receptors to the vasomotor and cardio-inhibitor centers. This in turn causes the activation of the sympathetic and decrease in the activity of the parasympathetic links of the autonomous vegetative nervous system. The result of activation of the sympathetic nervous system is an increase in the plasma concentration of catecholamines (norepinenaline, adrenaline). This leads to arterial and venous vasoconstriction and, accordingly, an increase in OPS with the redistribution of the BCC due to the muscular, bone, liver, renal and splashing perfusion in the favor of prioritarian organs is impoverished. (CNS, heart, lungs, adrenal glands). Differences in vasoconstrictions of different regions depend on the "density" of catecholaminic receptors in vessels of different organs. Due to the activation of the sympathetic level of the vegetative nervous system, CSS and UO increase.

Sympathetic activation of the humoral regulatory system when shocked manifests itself:

- an increase in emissions from adrenal brainstabs in the systemic blood flow of adrenaline and norepinephrine;

- an increase in the secretion of antidiuretic hormone by a pituitary gland, vasopressin hypothalamus (which enhances systemic vasoconstriction and increases the reabsorption of water in the kidney channels);

- activation of the renin-angiotensin-aldosterone system in response to a decrease in renal perfusion pressure, which ultimately leads to systemic vasoconstrictions with an increase in OPS.

Ash is the most severe option of an allergic reaction of an immediate type. The basis of anaphylactic shock is the development of acute vascular and adrenal insufficiency. As a result of the rapidly occurring hyperoergic reaction in a sensitized organism, biologically active substances - histamine, serotonin, acetylcholine, etc., which leads to generalized paralysis of small vessels and a sharp drop in blood pressure. The increasing collapse with the deposit of a large amount of blood in the peripheral channel is accompanied by the inclusion and spasm of large vessels, including those feeding vital organs (brain, heart, liver, kidney). Violation of circulation, ischemia and brain hypoxia lead to disregulation of various organs and systems, which may be incompatible with life.

In the pathogenesis of the anaphylactic shock, 3 stages are distinguished: immunological, Patochimic and pathophysiological.

IN immunological stages Sensitization is formed (increased sensitivity of the body). It begins with the moment of primary admission to the body of allergen, developing immunoglobulins E (Ig E) and continues to attach the latter to specific receptors of membrane cells and basophils. The sensitization phase continues on average 5-7 days, although after the introduction of finished antibodies (serums) it is reduced to 18-24 hours. The body sensitization is hidden, lasts for several years and even a lifetime.

The scheme for the development of sensitization due to the perverted immunological reaction:

IL 1 IL 4

1. AG + Macrofag®T-Helper®Plazomocyte®B-lymphocyte®Pul IGE

Since the repeated admission of allergen in the already sensitized organism begins patochemical stage. In this stage, allergen interacts with two fixed-cell philic cells or basophilic cells by IG E molecules. As a result, the presence of calcium ions there are degranulation of fat cells and basophils with the release of biologically active substances (histamine, slowly reacting substance of anaphylaxia, kininov, heparin, prostaglandins and others).

The scheme for the development of anaphylactic shock when re-introducing an antigen:

2. AG (re-) + IgE + basophil or fat cell ® Bav release

Exogenous factors launch generalized reactions through the following possible mechanisms:

1. Ig E-indirect processes.

E-antibodies formed in the IG organism are fixed mainly on target cells of allergies (fat cells and basophils). When allergen hit, a compound with antibodies fixed on target cells occurs in a sensitized organism.

The change in the spatial structure of the antibody molecule or the change in the distribution density of the antibody molecules on the cell surface is an incentive activating the cell, with the result that the cells of the formation and secretion of mediators released into the extracellular medium (histamine, platelet activation factor, the eosinophilic chemotactic factor, leukotrienes and Dr.).

2. The activation of the leukotriene system can lead to the formation of anaphylotoxins (C3A and C5A), which run histamineolyberation.

3. Direct degranulation of fat cells. It can develop as a result of the use of drugs such as narcotic analgesics, muscle relaxants, x-rays and other. System reactions can occur when first contact with such drugs without preliminary sensitization.

4. Disorders of the metabolism of arachidonic acid (the ability of acetylsalicylic acid (aspirin) and non-selective NSAIDs to cause anaphylaxcia, apparently associated with their property to suppress the synthesis of prostaglandins).

Clinical manifestations anaphyactoid reactionsand the principles of their treatment are the same as the anaphylactic shock. However, the basis of the anaphylactoid reactions is a non-reaction mechanism: direct release of histamine under the influence of xenobiotics - muscle relaxants, radiopatrants, dextrans and others. Such reactions occur without preliminary sensitization of the body. They suddenly develop in patients who did not receive such drugs previously.

Lisace is carried out by antibodies, but only in the presence of a fresh blood serum substance, which was named after complement (P. Earlich, 1900). Currently, it is known that the complement is not one substance, but a complex system whose components consistently (according to the type of cascade) are activated, forming several functional complexes with different biological purpose.

The activation of the complement system can occur in two ways: classic and alternative. In the first case, the body protects against an alien agent in the presence of antibodies to it. The alternative path of the complement activation is realized in the case when antibodies are missing, but the danger of infection (disease) and the body requires fast and effective protection (protection of a non-immunized organism).

For anaphylactic shock A complement cascade consisting of C1-C9 specific protein complexes is launched by activation C1 under the influence of an antigen antigen antigen complex ("classic path"). For anaphylactoid shock The complement cascade is launched by the activation of C3 as a result of the influence of biologically active substances - serotonin, histamine, a slowly reacting substance of anaphylaxis and other or substances of the type "Haptenov" ("Alternative path").

1. Anaphylactic- Antigen reaction - antibody.

2. Anaphyactoid - Non-line, without the participation of the complex an antigen - antibody, direct destruction of obese cells and emissions of inflammation mediators.

Clinical picture. Manifestations of anaphylactic shock are due to a complex complex of symptoms and syndromes. Shock is characterized by rapid development, rapid manifestation, severity of flow and consequences.

Conditionally, it is possible to distinguish 5 options for clinical manifestations of anaphylactic shock

- from preferably defeat cardiovascular system - the patient suddenly develops collapse, often with loss of consciousness. A particular danger in prognostic is a clinical option for loss of consciousness with involuntary urination and defecation. In this case, other manifestations of an allergic reaction (skin rashes, bronchospasm) may be absent

- from the preferably defeat system of respiratory organs in the form of acute bronchospasm (asphisical or astmoid option). This option is often combined with a chichany, a cough, a feeling of heat in the whole body, redness of the skin, urticule, pouring sweat. Be sure to join the vascular component (decreased blood pressure, tachycardia). In this regard, the painting of the face from cyanotic to pale or pale gray is changing;

- from pretty lesion of skin and mucous membranes. The patient is experiencing a sharp itching with the subsequent development of the urban or allergic edema of the type of quinque. At the same time, symptoms of bronchospasm or vascular failure can occur. A special danger represents the angioemical swelling of the larynx, manifested in initially stridorous breathing, and then the development of asphyxia.

With the above clinical variants of the anaphylactic shock, symptoms may appear, indicating the involvement in the process of the gastrointestinal tract: nausea, vomiting, sharp chic-eyed abdominal pain, bloating, diarrhea (sometimes bloody);

- with a preferably defeat of the central nervous system (cerebral version). Neurological symptoms - psychomotor arousal, fear, sharp headache, loss of consciousness and convulsions resembling epileptic status or violation of cerebral circulation are performed. There is a respiratory arrhythmia;

- from preferably defeat the abdominal organs (abdominal). In these cases, the symptoms of the "acute abdomen" (sharp pain in the epigastric region, signs of peritonean irritation), leading to the formulation of an improper diagnosis of perforation of ulcers or intestinal obstruction. The pain abdominal syndrome usually occurs after 20-30 minutes after the appearance of the first signs of shock. With an abdominal embodiment of anaphylactic shock, there are shallow disorders of consciousness, a slight decrease in blood pressure, the absence of severe bronchospasm and respiratory failure.

There is a certain pattern: the less time passed from the moment of admission of allergen to the body, the harder the clinical picture of the shock. The greatest percentage of deadly outcomes is observed in the development of the shock after 3-10 minutes from the moment of the allergen fall into the body, as well as with a lightning form.

Although in most cases the diagnosis of anaphylactic shock does not represent difficulties, it is sometimes necessary to differentiate it from acute cardiovascular insufficiency, myocardial infarction, epilepsy, solar and thermal impacts, pulmonary artery embolism, etc.

Thus, given the acute flow and severe condition of patients with anaphylactic shock, the need for emergency intensive therapy and the absence of specific data available for use in the general practice of laboratory data should be stated that diagnostics shock is based on basic typical clinical manifestations and anamnestic data.

Clinical options for the flow of anaphylactic shock.

1. Acute malignant - No complaints, a pronounced collapse, resistant to therapy, unfavorable forecast, diagnosis retrospective.

2. Acute benign - Stunning, moderate respiratory disorder and blood circulation, effective therapy.

3. Absiven - the symptomtics quickly disappears, the most favorable course.

4. Stretty - More than 6 hours, allergen prolonged action.

5. Acute recurrent flow - repeated shock after 4-5 to 10 days, the allergen prolonged action.

Treatment of anaphylactic shock It is to provide urgent assistance to the patient, since the minutes and even seconds of the delay and confusion of the doctor can lead to the death of a patient from asphyxia, a hardest collapse, brain edema, lung edema, etc.

It must be remembered that the injections of all drugs should be made by syringes that have not been used to introduce other medicines. The same requirement is presented to the drip infusion system and catheters in order to avoid repeated anaphylactic shock.

A complex of medical measures must be absolutely urgentit is carried out in a clear sequence (about opportunities at the same time) and have certain patterns:

· First of all, it is necessary to put the patient, turn it to the side to the side, push the lower jaw to prevent the spares of the language, asphyxia and prevent the aspiration by the vomit masses. If the patient has dentures, they must be removed. Provide admission to fresh air or ingold oxygen;

· Immediately enter 0.1% solution adrenaline. If there is no venous access and there is no opportunity to quickly catheterize vein, adrenaline must be administered intramuscularly in the initial dose of 0.3-0.5 ml. Intramuscular administration can be made as quickly as possible. It is noted that in many cases anaphylactic shock even intramuscular administration of mandatory anti-deposit funds is enough to fully normalize the patient's condition. It is impossible to enter into one place more than 1 ml of adrenaline, since, having a large vasoconstrictor action, it slows down and its own suction. The drug is injected with a fraction of 0.3-0.5 ml in different parts of the body every 10-15 minutes before the removal of the patient from the collaptic state or the catheterization of the vein. Mandatory control indicators when administering adrenaline must be indicators of the pulse, breathing and blood pressure;

· If possible, it is necessary to stop the further admission of allergen to the body - to stop the introduction of the drug, carefully remove the sting with a poisonous bag if it was stung by the bee. In no case cannot be squeezing or massaged the place of bite, as it enhances the suction of poison. Above the injection site (seen) to impose harness if localization allows. The place of administration of drug (sulfing) to whirl 0.1% adrenaline solution in the amount of 0.3-1 ml and attach to it to it to prevent further absorption of allergen. When an allergenic medication is injected, the nasal moves or the conjunctival bag must be rinsed with flowing water. It must be remembered if anaphylactic shock appeared in a procedural office or dressing, the air of which is saturated with pairs of various drugs, patient after injection of adrenaline, hormones and cordiamine, should be urgently placed in a separate ward or other room, and then continue intensive therapy. When oral administration, the allergens is washed with a sore stomach, if it allows its condition;

· In parallel with the initial events, it is advisable to make the vein puncture and introduce a catheter for infusion of liquids and drugs;

· In hypotension (immediately - with the availability of in / in access or after initial intramuscular administration), adrenaline is introduced intravenously slowly at a dose of 0.25 to 0.5 ml, pre-diluted in 10 ml of isotonic sodium chloride solution, or in the form of infusion 1- 4 μg / min. in adults (in children - 0.1 μg / kg / min.). It is possible to endotracheal administration - 1 ml of P-R-PA 1: 1000 per 10 ml of 0.9% p-ra chloride sodium. Conduct control of hell, pulse and breathing. If resistant hypotension is preserved against the background of pronounced tachycardia, it is necessary to establish drip administration of 1-2 ml of 0.2% norepinenenal solution in 300 ml of 5% glucose solution;

· For recovery BCC And improving microcirculation is necessary to intravenously introduce crystalloid and colloidal solutions. The increase in the BCC is the most important condition for the successful treatment of hypotension. Infusion therapy can be started with the introduction of isotonic sodium chloride solution, ringer or lactosol solution in an amount of up to 1000 ml. In the future, it is advisable to use colloidal solutions: 5% albumin solution, dextre (REOPOLIGULUKIN), hydroxyethyl starch. The amount of injected fluids and plasma substitutes is determined by the magnitude of the Hell, CVD and the patient's condition;

· corticosteroid drugs Apply from the very beginning of anaphylactic shock, as it is impossible to provide a degree of gravity and the duration of an allergic reaction. Initial doses of hormones in the acute period: hydrocortisone - 100 mg V / V or methylprednisolone 40-250 mg (1-2 mg / kg), in / every 6 hours. Preparations are administered intravenously. The duration of treatment and final doses of the drug depend on the condition of the patient and the effectiveness of the relief of the acute reaction;

· With bronchospasm, not responding to adrenaline - inhalation β-adrenomimetics. To relieve bronchospasm against the background of a built hypotension, an intravenous introduction of 2.4% solution is also recommended ehuphillinwith 10 ml of isotonic sodium chloride solution or 40% glucose solution. With the resistant bronchospasm, the dose of euphilline is 5-6 mg / kg of body weight;

· With the appearance of stridorous respiration and the absence of effect from complex therapy, it is necessary to immediately produce intubation. In some cases, life testimony do conicotomy;

· It is necessary to ensure adequate pulmonary ventilation: be sure to suck the accumulated secret from the trachea and the oral cavity, as well as up to the relief of the severe state of oxygen therapy; if necessary - IVL or VIVL;

· antihistamines It is better to introduce after the restoration of the hemodynamics indicators, as they do not immediately have actions and are not a means of salvation of life. Some of them may have a hypotensive effect, especially Pipolfen (Diprazine).

It should be noted that suprastin cannot be administered with allergies to Euphillin. The use of pipolphine is contraindicated in anaphylactic shock caused by any drug from a group of phenothiazine derivatives.

Antihistamines can be administered intramuscularly or intravenously: 1% DIDEDROL solution to 5 ml or a solution of tavergila - 2-4 ml; every 6 hours. Also introduction of H 2 histamine receptor blockers (Famotidin, Ranitidine) is also shown

· In case of convulsive syndrome with a strong excitation, it is necessary to introduce intravenously 5-10 mg of diazepama.

· If, despite the therapeutic measures taken, the hypotension remains, the development of metabolic acidosis should be assumed and to begin infusion of sodium bicarbonate solution at the rate of 0.5-1 mmol / kg of body weight, control of the COP;

· In the development of acute pulmonary edema, which is a rare complication of anaphylactic shock, it is necessary to conduct specific drug therapy. The clinician must necessarily differentiate the hydrostatic swelling of the lungs, which develops with acute left left vehicles, from edema, resulting from increasing the permeability of membranes, which is most often in an anaphylactic shock. The method of choice in patients with pulmonary swelling, developed due to an allergic reaction, is the conduct of an IVL with a positive pressure (+5 cm aqueous) at the end of the exhalation (PDKV) and the simultaneous continuation of infusion therapy until the complete correction of hypovolemia

· When the heart is stopped, the absence of pulse and the blood cardiopulmonal resuscitation is shown.

Septic shock

Patients with septic shock are a special category, according to clinical and pathophysiological features significantly different from the category of patients with cardiogenic and hemorrhagic shock. Hemodynamic status in septic shock differs significantly from hemodynamic changes characteristic of other categories of shock. Under normal conditions, the perfusion of the microvascular channel is regulated in such a way that in tissues with a higher level of metabolism, more intense blood flow is maintained. Almost 25-30% of capillaries are operating alone, in which 5-10% of the BCC is located. In the early stages of septic shock, OPS often turns out to be reduced, and Mos enlarged. The degree of peripheral vasodilation is closely correlated with the septic process, and depends on the intensity of the emission of various mediators.

The distribution of blood flow at the same time is violated: despite the increased cardiac emission, due to damage to the autoregument of peripheral blood circulation, the perfusion of tissues with a high level of exchange is insufficient to cover metabolic needs, while tissues with lower metabolic rate are perfectly excessively. A characteristic feature of septic shock is damage to the mechanism of extraction of oxygen tissues. The development of a systemic inflammatory response (SYR syndrome) leads to an increase in the energy needs of tissues and increasing oxygen debt. Disruption of tissue with oxygen, in addition to the disorders of autoreguing, is also associated with microgenation, endothelial and perivascular edema, damage to intracellular transport mechanisms. The decompensation of septic shock is characterized by the addition of hypovolemia due to leakage of the liquid from the vascular bed in tissue and heart failure. Myocardial depression, on the one hand, is due to a decrease in coronary blood flow, and on the other, the influence of septic patients with various mediators circulating in the blood, including tumor necrosis factor (TNF) and a factor inhibiting myocardium (MDF).

By defining a Conference on ACCP / SCCM consensus:

Septic shock (SS) -this sepsis with signs of tissue and organic hypoperfusion and arterial hypotension, not eliminated by infusion therapy and requiring the appointment of catecholamines.

Sepsis-syndrome of the system inflammatory response to invasion of microorganisms.

Extended diagnostic sepsis criteria

General criteria

• Fever Temperature\u003e 38 ° С
• Hypothermia temperature<36°С
• Heart rate\u003e 90 / min (\u003e 2 standard deviations from a normal age range)
• Tahipneoe
• Violation of consciousness
• Edems or the need to achieve a positive water balance (\u003e 20 ml / kg in 24 hours)
• Hyperglycemia (\u003e 7.7 mmol / l) in the absence of diabetes

Inflammatory changes

• Leukocytosis\u003e 12 × 109 / l
• Lakeing<4×109/л
• Shift towards immature forms (\u003e 10%) with normal leukocyte content
• C-jet protein\u003e 2 standard deviations from N
• ProCalcitonin\u003e 2 standard deviations from N

Hemodynamic changes

• Arterial hypotension: adsist<90 мм.рт.ст., АДср < 70 мм.рт.ст., или снижение АДсист более, чем на 40 мм.рт.ст. (у взрослых) или снижение АДсист как минимум на 2 стандартных отклонения ниже возрастной нормы
• Somaturation SRO2.< 70%
• Cardiac index\u003e 3.5 l / min / m3

Manifestations of organ dysfunction

• Arterial hypoxemia PAO2 / FIO2<300
• Outragia Oligius<0,5 мл/кг/ч
• Creatinine raising by more than 44 mmol / l (0,5mg%)
• Thrombocytopenia<100х109/л
• Disruption of coagulation: AFTV\u003e 60 sec or many\u003e 1.5
• Hyperbilirubinemia\u003e 70 mmol / l
• Intestinal obstruction (no intestinal noise)

Indicators of fabric hypoperfusion

• Hyperlactatem\u003e 1 mmol / l
• Slow filling syndrome capillaries, marble limbs

Principles of treatment

1. Sanitation of the focus of infection and antimicrobial therapy
2. Restoration of perfusion and oxygenation of tissues
3. Immunomodulation
4. Antitoxic and anticycinic therapy
5. Replacement, symptomatic, supporting therapy at polyorthane failure

1. Pathogenetic therapy of septic shock is reduced to the sanitation of foci of infection, the appointment of a wide range of action antibiotics. Sanitation of the infectious focus is the cornerstone of the therapy of septic shock. Even the most powerful antibiotics and other methods of disinfecting therapy are ineffective in the absence or insufficient focus rehabilitation. The targeted antibiotic therapy is possible after selecting the pathogen and determining its sensitivity to antibiotics, that is, at best, not earlier than 48 hours. At the same time, early antibiotic therapy (for 30 minutes from the post) significantly reduces the mortality of this category of patients. Therefore, it is advisable to use the so-called de-scale principle of antibiotic therapy with the initial purpose of antibiotics of the maximum wide range of action (carbopenmes, fluoroquinolones, the cephalosporins of the 4th generation), followed by the replacement, if possible, the antibiotic of a certain (as a result of a bacteriological study) of the spectrum.

2.1 Hemodynamic support.Infusion therapy belongs to the initial measures to maintain hemodynamics and primarily cardiac output. According to the American College and the American Critical Medicine Association, approximately 50% of septic patients, the main hemodynamic parameters can be normalized using adequate infusion therapy. The main objectives of infusion therapy in patients with sepsis are: restoration of adequate tissue perfusion, normalization of cellular metabolism, correction of homeostasis disorders, decrease in the concentration of the mediators of the septic cascade and toxic metabolites

Infusion therapy begins with the introduction of crystalloids - Bolus 20 ml / kg for 20-30 minutes, then after estimating the hemodynamic state, it is reused, at a speed of 20-30 ml / kg / h under the control of the CVD and hemodynamic parameters to a total dose of 4 liters (60 ml / kg)

For infusion therapy within the framework of a targeted IT sepsis and SS, crystalloid and colloidal infusion solutions are used in virtually the same result.

All infusion media have both their advantages and disadvantages. Taking into account the existing results of experimental and clinical studies, today there is no reason to give preference to some of the infusion environments. However, it should be borne in mind that for adequate correction of the venous return and the level of preloading requires significantly large volumes (2-4 times) of crystaloid infusion than colloids, which is associated with the features of the distribution of solutions between different sectors. In addition, crystalloid infusion is more conjugate with the risk of tissue edema, and their hemodynamic effect is less long than colloids. At the same time, crystaloids are cheaper, do not affect coagulation potential and do not provoke anaphylactoid reactions. In this regard, the qualitative composition of the infusion program should be determined by the patient's peculiarities: the degree of hypovolemia, the phase of the DVS syndrome, the presence of peripheral edema and the level of albumin blood, the severity of acute pulmonary damage.

Plasmakers (dextrans, gelatinoly, hydroxyethyl starch) are shown in pronounced BCC shortage. Hydroxyethyl strokes (HEK) with molecular weight 200 / 0.5 and 130 / 0.4 have a potential advantage over dextrans by virtue of a smaller risk of leakage through the membrane and the absence of a clinically significant effect on hemostasis. The use of albumin at critical conditions can contribute to increasing mortality. An increase in the code for the infusion of albumin is transient, and then in the conditions of "capillary leakage" syndrome, further extravagation of albumin (Rebound Syndrome) occurs. The transfusion of albumin may be useful only when the level of albumin is reduced less than 20 g / l and the absence of signs of its "leakage" in interstics. The use of cryoplasms is shown in coagulopathy consumption and reduce the coagulation potential of the blood. According to most experts, the minimum hemoglobin concentration for patients with severe sepsis should be within 90-100 g / l. During sepsis and SS, it is necessary to strive to quickly achieve (the first 6 hours after receipt) of the target values \u200b\u200bof the following parameters: FED 8-12 mm RT. Art., Garden\u003e 65 mm Hg. Art., diuresis 0.5 ml / kg / h, hematocrit more than 30%, the saturation of blood in the upper hollow vein or atrium right is at least 70%.

Low perfusion pressure requires immediate inclusion of preparations that increase the vascular tone, and / or inotropic heart function. Dopamine and / or Noradrenalinthese are preparations for priority selection of hypotension correction in patients with SS. Noraderenalin (with an initial rate of 1 μg / min. (In adults), selecting the dose to achieve systolic pressure of 90 mm Hg. Art.) Enhances the garden and increases glomerular filtering. Optimization of systemic hemodynamics under the action of norepinephrine leads to improved kidney function without the use of low doses of dopamine. The work of recent years have shown that the use of norepinephrine in comparison with a combination of dopamine in high dosages ± norepinephrine leads to a statistically significant decrease in mortality.

Adrenalin - adrenergic preparation with the most pronounced side hemodynamic effects. Adrenaline has a dose-dependent effect on heart rate, ADSR, cardiac output, left ventricle, delivery and oxygen consumption. However, this action of adrenaline is accompanied by tachyarhyrahythmias, the deterioration of the splashing blood flow, hyperlactatemia. Therefore, the use of adrenaline should be limited to cases of complete refractoriness to other catecholaminams.

Dobutaminemust be considered as a drug selection to increase cardiac output and delivery and consumption of oxygen at a normal or elevated level of preload. Thanks to the preferential action on  1-receptor Dobutamine to a greater extent than dopamine, it helps to increase these indicators.

Catecholamines in addition to supporting blood circulation can interfere during systemic inflammation, affecting the synthesis of key mediators with distant effect. Under the action of adrenaline, dopamine, norepinephrine and dobutamine decreased synthesis and secretion TNF- activated macrophages. Cancel the preparations of cardiacirculatory support should be taken 24-36 hours after stabilization of central hemodynamics.

Refractory septic shock - continuing arterial hypotension, despite adequate infusion, the use of inotropic and vasopressor support. In the case of the development of refractory septic shock, the introduction of glucocorticosteroids is shown - hydrotisut240-300mg in the first day. After stabilization of pressure, the dose can be reduced to 50 mg every 8 hours the next 48 hours. Therapy duration - 5-7 days.

2.2. Spring support.The lungs are very early become one of the first target organs involved in the pathological process during sepsis. Acute respiratory failure (ODN) is one of the leading components of polyorgan dysfunction. Clinical and laboratory manifestations of ODN under sepsis correspond to the syndrome of acute pulmonary damage, and when the pathological process is progressing, an acute respiratory distress syndrome (ORDS). Inhalation of oxygen is carried out, and according to the indications of the intubation of the trachea and IVL.

3. The feasibility of incorporating intravenous immunoglobulins (IgG and IgG + IgM) is associated with their ability to limit the excessive action of pro-inflammatory cytokines, increase the clearance of endotoxin and staphylococcal superantigne, to eliminate the anerochia, strengthen the effect of -lactam antibiotics. The most optimal results when using immunoglobulins were obtained in the early phase of shock ("warm shock") and in patients with severe sepsis. Pentaglobin (IgG and Igm), intraglobin (IgG), Ronlaikin are used.

4. In order to prevent the formation of kinine-like peptides and the accumulation of MDF, the use of protease inhibitors is shown: conflicted by 80000-150000 units per day or a distance in a dose of 200-400 kie, pentoxifyllin at a dose of 100-300 mg potentials the anti-inflammatory effect of adenosine, prostacyclin and prostaglandins class E Due to synergism when exposed to cyclic AMP.

5. Prevention and treatment of polyorgan deficiency, incl.

· correction of disorders of microcirculation and system coagulation disorders -reopolyglyukin; Heparinotherapy (unfractionated heparin, low molecular weight heparins) in combination with freshly frozen plasma; Activated protein C (drothopochin-a activated).

· control of glycemia

· prevention of the formation of stress-ulcer gastrointestinal tract.

In conclusion, it should be said that the clinical criteria for the adequacy of anti-flop therapy are:

one). Stabilization of central hemodynamic parameters (Garden 60-100 mm Hg, FLOLD 60-100 mm Water. Art., heart rate 60-100 Д. in min);

2). normalization of hemic indicators (HB 100 g / l, Nt 0.3);

3). Restoration of diuresis (0.5-1 ml / min).

It should be remembered that the output from the state of shock implies not only the restoration of normal blood circulation, but also the absence of persistent polyorgan disorders.

Independent work of students

Task number 1.

Survey the patient who entered the oar with the diagnosis of gastrointestinal bleeding. Identify the volume of blood loss. For this:

· Determine the blood pressure, pulse, CH, diuresis, FVD, Symptom of "White Spot";

· Calculate the shock index (Alghera);

· Determine the magnitude of the BCC deficiency in% of due;

· Calculate the volume of blood loss in the Moore formula.

Task number 2.

Perform an analysis of the history of the disease of the patient with severe hospital pneumonia, a systemic inflammatory response syndrome, which is in the resuscitation and intensive therapy. For this:

· Analyze the degree of hemodynamic disorders and their correction;

· Evaluate the severity of respiratory failure in a patient on dynamic observation diaries; Evaluate the proposed method of treating respiratory failure, if necessary, make adjustments and justify them;

IX. Clinical tasks

Task number 1.

In the patient who entered the hospital with a diagnosis of intra-abdominal bleeding, pulse 112 per minute, hell system. 90 mm Hg Determine the level of blood loss and appreciate it according to the classification of P.G. Bruce?

Task number 2.

The patient, 34 years old delivered to the hospital with a fire. The thermal lesion of the skin is absent, in the area of \u200b\u200bthe nose and lips - traces of soot. Objectively - shortness of time up to 28 per minute, noisy breathing, auscultative - tough, a large number of whistling wheezes. Your estimated diagnosis? Is it necessary to hospitalize the patient in Ortara?

Test control:

1) Hospitalization criteria for adults for adults:

a) Burn III degree more than 5% PPT. *

b) Burn III degree more than 15% PPT.

c) insulated thermal inflammatory injury. *

d) Burning of the II degree more than 10% PPT.

e) burns around the Toughness circle. *

f) Face burns. *

2) What is the main pathogenetic link with burn disease?

a) Violation of the function of the lungs.

b) Breeding function.

c) hypovolemia. *

d) Violation of the function of the respiratory system.

3) measures of intensive therapy during septic shock:

a) Sanitation of the focus of inflammation *

b) Infusion therapy *

c) oxygen therapy *

d) the use of vasoactive drugs *

e) antibiotic therapy *

f) epidural blockade,

g) Immunocorrigating therapy *

4) indications for the use of corticosteroids during sepsis:

a) the initial stage of septic shock with the one-time admission of infect in the blood *

b) always shown in sepsis

c) refractory septic shock *

5) with type 1 allergies, the released mediators of inflammation after the degranulation of obese cells and basophilists affect, first of all, the following organs - the target, except:

a) Smooth muscles of bronchi

b) smooth vessel muscles

c) skeletal muscles *

d) endothelius of post-cpillar veins

e) perfiric nerve endings

6) the clinical picture of the hypersensitivity of the immediate type in the smallen degree is due to the following mediator of inflammation, freed in the degranulation of fat cells and basophils:

a) Histamine

b) Prostaglandins

c) Catecholas *

d) heparin

7) during an anaphylactic reaction the following substances are exempt, except:

a) Histamine

b) anaphylaxia slow-reactive substance

c) heparin

d) adrenaline *

8) Symptom of "White Spot" is normal of:

a) 2 seconds. *

b) not more than 3 seconds.

c) 1 second.

d) not more than 4 seconds.

9) Normally, hourly diuresis is:

a) 0.5-1 ml / kg. *

b) 1-2 ml / kg.

c) 0.1-0.3 ml / kg.

d) 2-3 ml / kg.

10) In young men, the BCC is equal to:

a) 60 ml / kg.

b) 50 ml / kg.

c) 70 ml / kg. *

d) 80 ml / kg.

Answers:

Task number 1.

The data obtained is sufficient to determine the shock index of the Algöeter. Shi is 112/90 \u003d 1,2, which corresponds to the blood loss of 40% of the BCC, which is pathological view, large in volume and severe in the degree of hypovolemia.

Task number 2.

The patient has a thermal inflammatory injury, which is an indication for hospitalization in the resuscitation and intensive care unit.

Similar information.

Anaphylactic shock is the fastest and dangerous reaction of the body to the stimulus, which manifests itself in the form of an acute violation of the functioning of all organs and systems.

Most often manifests itself when the allergen is re-administered into the body, when a huge number of histamine cells are produced in the shortest possible time.

Over the past 5 years, the number of cases of the development of anaphylactic shock increased dramatically, and the main reason lies in the long-term use of certain categories of medicines. What is dangerous anaphylactic shock, its pathogenesis, diagnosis and treatment will be considered further.

Doctors are customized to systematize all the reasons that provoke an acute response of the body into several categories, depending on the factor of exposure:

1. Drug - develops against the background of drug reception. The most often anaphylactic shock is characteristic of drugs such as novocaine, iodine and drugs included in its composition, penicillin and new generation antibiotics, diphroll. Drug anaphylactic shock is characterized by a lightning course, as well as a high level of lethal outcome (89% of all cases).
2. Vaccination - the second in the degree of danger and high mortality rate, especially among children. It occurs in the form of an acute reaction to the vaccine used as vaccinations.
3. Food - meets less often, but in recent years, food allergies occurs at each fifth inhabitant of the planet. Develops against the background of individual intolerance to individual food.
4. With insect bite - it is extremely rare, but the likelihood of death is high. In most cases, it leads to the development of swelling, which leads to suffocation.
5. Under the skin samples - if a person is inclined to allergies, the doctor must make a skin sample before the introduction of a particular honey of the drug when several drops of dissolved drug drip through a small scratch on his hand.
6. Specific hyposensibilization is a feature of the body in which skin covers are sharply reacting to sudden drops of temperature, cold or heat, pollen of plants and smells.

Small children under 3 years old, suffering from diathesis, as well as people who have forced to take certain medicines for a long time to take certain medicines for a long time.

Pathogenesis of anaphylactic shock

The chimergic reaction underlying the flow of anaphylactic shock is explained by instant binding of allergens with basophilic cells.

Immunoglobulin E aggressively affects the allergen that fell from the outside, as a result of which the uncontrolled generation of histamines occurs.

The latter, in turn, procure extensive inflammation, delaying Allergen and not allowing it to move into other cells and tissues.

This, it would seem, a natural process can provoke quick death, since the outflow of lymph is disturbed, and blood ceases to fully circulate.

The high level of histamine cells in the blood increases the permeability of the vessels walls, which in turn is dangerous to the output of the plasma in the intercellular space, which explains the swelling of the skin.

Also, such a reaction causes the following processes:

1. Increasing the secretion of mucus bronchi.
2. Reducing blood reduction, sharp decrease in blood pressure.
3. Reducing the frequency of heart rate.

If you do not help a person, death may come.

Symptoms of anaphylactic shock

The symptoms and the anaphylactic shock clinic completely depends on the reaction rate:

1. Rapid reaction - develops in 7-10 seconds after the administration of allergen. Syptoms are characteristic as loss of consciousness, lack of reflexes and reactions of pupils into light, a sharp decrease in blood pressure to critical indicators, a weak pulse, convulsions. In the absence of medical care, the chances of survival are minimal. Death can come in 10-15 minutes.
2. Medium severity reaction - comes 15-30 minutes after the administration of allergen. The patient is in consciousness, skin covers are, urticaria appears. There is a difficult breathing, weakness, dizziness, panic. The mucous oxid cavity and eye dry, the language can enemy and increase in size.
3. Heavy reaction - differs not only by the speed of manifestation (5-7 minutes), but also the vastness of the defeat. Skin covers acquire a saturated red tint, noise appears in the ears, weakness.

Depending on which symptoms manifests itself in the patient, it is important to be able to correctly provide first medical care.

In most cases, the fatal outcome arises as a result of such manifestations as:

• the edema of the brain in the acute violation of cerebral blood supply;
• internal bleeding;
• choking as a result of swelling swelling;
• acute heart failure.

Since the cases of anaphylaxis have become more frequent, every person should know how to properly provide first help, which can save a person life.

In the home first aid kit, especially if there are allergic in the house, must necessarily contain a syringe with adrenaline and any antihistamine drugs in the form of injections: Supratin, Dimedrol, etc.

The rapid administration of these drugs will remove excessive swelling, and will also not allow the development of death.

Differential diagnosis

To distinguish the clinical picture of anaphylaxis from the usual loss of consciousness is extremely difficult, since the latter may be accompanied by an unconscious state. Several differential features isolated, allowing to determine the development of anaphylactic shock with accuracy:

1. Strong itching of skin, redness and swelling of the limbs.
2. Student difficulty breathing, sometimes with wheezing.
3. Acute peeling pain in the chest.
4. Arrhythmia and tachycardia.
5. Feeling lack of air, panic state.
6. Noise in the ears, seventhrough condition, extended pupils.

If a person immediately lost consciousness after the introduction of Allergen, to lead him to feeling will not be easy. Sometimes anaphylactic shock is confused with a conventional faint, losing precious minutes that should have spent on resuscitation.

The next topic will be useful for everyone :. All about toxic shock, its manifestations and methods for emergency care.

Treatment and prevention

First aid are produced according to the following scheme:

1. Fully stop the admission of allergen into the body, as well as reduce its concentration in the blood. If the drug is introduced subcutaneously, a small incision should be made and suck the injected fluid. When Allergen got into the stomach, it was recommended to clean its contents, flushing the entire gastrointestinal tract. When introducing injection in hand, you should impose harness.
2. Enter such drugs:

• 0.3-0.5 ml adrenaline is subcutaneously, after which it should be introduced 5-10 mg intravenously, repeating manipulation after 5 minutes;
• corticosteroids in the form of prednisolone and any antihistamine drugs - enter 1 ampoule to the buttock muscle;
• put a dropper with saline to reduce the concentration of allergen in the blood.

1. Introduction of sorbents in the intestines - suitable activated coal (at least 15 tablets), polysorb, white coal. Sorbents are well accumulated and neutralized slags and toxins, which are a huge amount in the intestines.
2. The introduction of Euphillin is a vasodilator, which does not allow bronchospasm.

If a person is unconscious, the trachea intubation may be required when a special tube is introduced into it, which does not allow the fuck to narrow his clearance.

The most efficient and high-speed drugs with anaphylactic shock are considered as follows:

• Prednisone;
• Hydrocortisone;
• Supratine;
• Dexamethasone;
• Pipolfen.

These medicines should always be at hand in people who have a predisposition to allergies.

Prevention consists in collecting allergological anamnesis.

If a person has a tendency to appear allergies, be a seasonal or constant, a number of surveys should be passed that will help identify all possible allergens.

Such an analysis will allow to know and beware of certain allergens that can provoke anaphylactic shock.

It has been established that sensitizing properties may be inherited, so if the parents have allergies, it is important to examine children for increased sensitivity to allergens.

People suffering from allergies, it is important to survey among the allergist every year. Some allergens can be added to the list, and some organism loses aggressive properties. The prevention of death in an anaphylactic shock is in constant self-control, as well as holding a first-aid kit, where a syringe with adrenaline and antihistamines must be necessary.

Thus, anaphylactic shock is a complex aggressive response of the body on an allergen, which can provoke death. It is important to know how to properly provide first aid, since the lightning reaction does not leave a man of great chances of life.

Video on the topic

Read: II. 4. Characteristics of antiretroviral drugs and principles of combination of groups of preparations for Waart II. General principles of immunodiagnosis of infectious diseases II. Organization of surgical service in Russia. Main types of surgical institutions. Principles of organization of work of the surgical department. III. The principles of treatment for the first time identified insulin-dependent diabetes LGE-indirect diseases. Principles of diagnosis of diseases. Features of the collection of anamnesis. Hereditary aspects of allergic diseases V 14: Semioticanous diseases and principles of their diagnosis.

Anaphylactic shock is an immediate-type allergic reaction, which occurs when the allergen is re-introduced into the body.

Causes of occurrence. Anaphylactic shock can develop with the introduction of drugs into the body, the use of specific diagnostic methods. In very rare cases, the shock state can develop as a manifestation of food allergies or as a reaction to insect bites. As for drugs, almost any of them can sensitize the body and cause anaphylactic shock. Most often, such a reaction appears on antibiotics, especially penicillin. The dose of the drug, causing anaphylactic shock, can be negligible.

Development. The rapid development of general manifestations (decrease in the blood pressure and body temperature, the violation of the function of the central nervous system, an increase in vessel permeability) is characteristic of anaphylactic shock. The time of development of a shock condition and the frequency of appearance depend on the path is administered to the allergen in the body. In parenteral administration (for injections), anaphylactic shock is observed more often and proceeds rapidly. Especially dangerous intravenous administration of the drug, in which anaphylactic shock may occur immediately ("at the tip of the needle"). Usually anaphylactic shock occurs for 1 hour, and with rectal (through the rear pass), outfit and oral (through the mouth), the use of the drug after 1-3 hours (as allergen suction). As a rule, anaphylactic shock takes place the harder than the time of the allergen administration to the development of the reaction. The frequency of cases of anaphylactic shock and its severity increases with age.

Symptoms. The first symptoms of the starting anaphylactic shock are anxiety, a feeling of fear, pulsating headache, dizziness, noise in the ears, cold sweat. In some cases, there is a sharply pronounced skin itching with a subsequent quint or urticaria. A shortness of breath appears, a feeling of constraint in the chest (a consequence of the bronchial spasm or allergic edema of the larynx), as well as the symptoms of the disturbance of the gastrointestinal tract in the form of an approached pain in the abdomen, nausea, vomiting, diarrhea. The following phenomena are also possible: foam of mouth, cramps, involuntary urination and defecation (stool), bleeding from the vagina. The blood pressure is reduced, the pulse is threaded.

In cases of anaphylactic shock, which occurs with the loss of consciousness, the patient may die within 5-30 minutes from choking or after 24-48 hours and more in connection with severe irreversible changes in vital organs. Sometimes a deadly outcome can occur and much later due to changes in the kidneys (glomerulonephritis), in the gastrointestinal tract (intestinal bleeding), in the heart (myocarditis), in the brain (swelling, hemorrhage) and other organs. Therefore, patients undergoing anaphylactic shock should at least within 12 days be in the hospital.

Treatment. Emergency care should be reasons immediately since the appearance of the first clinical signs of anaphylactic shock. The first urgent event is to stop the administration of the drug or restricting its blood flow (applying harness above the injection site or bite). 0.5 ml 0.1% of the adrenaline solution (subcutaneously or intramuscularly and the same dose - in another section is required to enter injection or bite - in severe cases, it is necessary to introduce intravenously 0.5 ml 0.1% of the adrenaline solution with 20 ml of 40% glucose solution . In the absence of a healing effect, it is recommended to repeat the injection of 0.5 ml 0.1% of the adrenaline solution subcutaneously or intramuscularly. If this way still fails to increase blood pressure, then drip intravenous infusion of norepinenaline should be applied (5ml 0.2% norepinenaline solution in 500ml 5 % glucose solution).
In the absence of effect, pathogenetic therapy is carried out to restore the volume of circulating blood using solutions of colloids, ringer solutions, isotonic solutions, etc. in combination with glucocorticoids. In complex therapy, antihistamines, heparin, sodium oxybuterte are used. Additionally, Cordiamine, caffeine, camphor, and with pronounced bronchosphasis - intravenously 10 ml 2.4% of the solution of Euphilline with 10 ml 40% glucose solution. Since the swelling of the larynx and bronchospasm is often durable, it is often necessary to re-use bronchhalytic preparations in combination with antihistamine and diuretic means. In the absence of the effect on vital indications, interturbation of tracheas is needed, carrying out artificial ventilation of the lungs together with a complex of resuscitation activities.

The forecast depends on the timeliness of therapeutic activities and severity of shock. A short-term increase in blood pressure is not a reliable sign of removing a patient from the state of shock. Anti-deposit measures should continue to fully restore effective tissue blood flow.

Prevention. It is impossible to predict the development of anaphylactic shock. Therefore, medications with severe antigenic properties should be maximized as much as possible. Persons prone to allergies or having other risk factors (professional contact with antibiotics, fungal lesions of the skin, etc.), it is recommended to produce the first injection of the antibiotic to the lower part of the body so that in the event of an asphylactic shock it is possible to impose harness above the injection site. Have a ready-made medication and tools to provide immediate assistance.

The extreme manifestation of an allergic reaction is immediately called anaphylactic shock. The term was introduced by the laureate of the Nobel Prize in the field of allergology by Charl, Rish.

The reasons

Anaphylactic shock, as well as any other manifestation of allergies, may occur on the impact of any allergen. In practice, most often it is necessary to deal with anaphylactic shock that developed for the use of any medicinal preparation. To preparations that can mostly cause anaphylactic shock include penicillins, streptomycin, thiamine, amidopyrin, analgin. In addition, anaphylactic shock may be caused by insect bite.

Pathogenesis

Pathogenesis of anaphylactic shock, as well as all allergic reactions of instant type, includes three stages: immunological, immunochemical, pathophysiological.

In the first stage An increased sensitivity of the body is formed. This stage begins at the first arrival of allergen in the body. At the same time, antibodies of immunoglobulins E. The alien agent begins to the alien agent, they are adsorbed on the surface of obese cells and basophils. Immunological stage often flows hidden, without any symptoms for years.

When the allergen is secondary, the pathogenesis of the allergic disease passes second stage - immunochemical. Allergen binds to it previously formed by antibodies that are on cell membranes containing histamine. This causes the degranulation of the latter with the release of a biologically active substance. In addition to histamine, with an anaphylastic shock, a large number of kinines, prostaglandins, heparin are thrown into the blood.

Third - Pathophysiological - Stage It is the realization of the substances formed in the second stage. There is an echo of fabrics, itching at the place of contact with the allergen. The most severe condition is associated with laryngospasm and bronchospasm, the edema of the larynx and hypotension. A sharp decline in pressure causes tachycardia, tachota and is the result of hypovolemia, which has developed during inadequate vasodilation. In this case, there is a decrease in the volume of circulating blood in the peripheral organs - it is deposited in the brain, heart, lungs.

Clinical symptoms

Since in the pathogenesis of anaphylactic shock, as well as any other shock, there is a collaptic state, the symptoms are primarily the drop in blood pressure and the stupkey of consciousness.

With anaphylactic shock, there is a sharpweight edema and spasm of the respiratory tract, which leads to asphyxia. In addition, the above symptoms may occur against the background of general manifestations of allergies: abdominal pain, skin rashes with itching.

Treatment

The patient with an anaphylactic shock should be delivered to the separation of intensive therapy. Shock relief goes in two stages. The primary assistance stage begins with the fact that the patient is placed on a solid surface, lifting his legs.

The next urgent stage in anaphylactic shock is to prevent the admission of allergen. If an allergic reaction has developed on an insect bite or an injection of a medicinal product, you should impose a harness above the injection site. Harness weakens each quarter of an hour for 3 minutes. The place of deployment of allergen can be infiltrated with a solution of adrenaline (0.3 ml of 0.1% solution is injected). However, some experts believe that subcutaneous or intramuscular administration of adrenaline does not have such a significant effect as its intravenous infusion and recommend to adhere to exactly such a method for administering the drug during anaphylactic shock. Adrenaline injections can be repeated twice with a break of 20 minutes. Adrenaline can be administered with a dropper (0.1% solution of 1 ml in 250 ml of 5% glucose solution).

An important point of emergency therapy of anaphylactic shock is to establish the passability of the respiratory tract, which is achieved by the intubation of the trachea and the translation of the patient to artificial ventilation of the lungs. In some cases, it is not possible to remove the larynx edema and produce intubation, so they resort to tracheostomy.

The collapse formed during anaphylactic shock requires the replenishment of the circulating fluid volume, which is carried out by intravenous administration of colloid and crystalloid solutions.

The protocols for maintaining patients with anaphylactic shock include the use of vasopressar drugs: dopamine, norepinephrine. The first is applied at a dose of 15 μg / kg / min in 250 ml of 5% glucose solution. Noreproined is used in the form of 1 ml of a 0.2% solution, diluted in 250 ml of 5% glucose solution.

At the first stage of assistance, resuscitation activities can be carried out (indirect heart massage, defibrillation).

After eliminating threatening life, states are proceeded to further treatment of anaphylactic shock. First prescribe antihistamine drugs: DIMEDROL (solution of 1% -1 ml or tablet 0.05 3 times a day), phenkarol (tablets of 0.05 3 times a day), suprastin (1 ml of 2% solution or tablets of 0.025 3 times a day), Pipolfen (1 ml of 2.5% solution 3 times a day).

With heavy forms of anaphylactic shock, glucocorticoids are justified. Preparations of this group stabilize obese cells, which are synthesized and emitted to the Histamine Bloodstock - the main mediator of the allergic reaction. But it should be remembered that the effect of glucocorticoid applications occurs no earlier than 6-12 hours, so that their use is required when the attachment of anaphylactic shock. However, in each case, it is difficult to predict the duration of the pathological condition, so many authors recommend introducing glucocorticoids at any stage of medical care. From the group of glucocorticoid preparations, prednisone is used in a dose of 240 mg intravenously or intramuscularly.

Bronchospasm can be removed by the use of euphilline (10 ml of 2.4% of the solution is divorced by 10 ml of saline).

With a long non-coming hypotension, acidosis may develop. Its prophylaxis is carried out by intravenous infusion of 150 ml-200 ml of 4% sodium bicarbonate solution.

Monitoring patients undergoing anaphylactic shock

Patients who transferred anaphylactic shock should remain in hospital at least 10 days. After extracting the patient put on the dispensary accounting at the allergist. An allergic passport is started at each patient, which indicates the intolerance to those or other medical preparations. When allergic in insect bites, hyposensestability is possible.

Comments

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