F
oo
d
poisoning
Hea
lth pro
b
l
e
ms
F
oo
d
poisoning is
a c
on
d
ition of
d
ig
e
stiv
e d
isor
de
rs
ca
us
ed b
y
c
onsuming foo
d
or w
a
t
e
r
c
ont
a
min
a
t
ed
with th
e
su
b
st
a
n
ce
p
a
thog
e
ns
a
n
d
/
or
c
h
e
mi
ca
ls
,
for
e
x
a
mpl
e N
orovirus
,
Sa
lmon
e
ll
a
,
C
lostri
d
ium
p
e
rfring
e
ns
,
Ca
mpylo
bac
t
e
r
,
a
n
d S
t
a
phylo
c
o
cc
us
a
ur
e
us
.
H
istory
Re
sults
(
S
u
b
j
ec
tiv
e
)
C
ompl
a
int
1
.
Ac
ut
e d
i
a
rrh
ea
.
F
oo
d
poisoning usu
a
lly l
a
sts l
e
ss th
a
n
2
w
ee
ks
.
B
loo
d
or mu
c
us in th
e
stool
;
in
d
i
ca
t
e
s inv
a
sion of th
e
int
e
stin
a
l or
c
oloni
c
mu
c
os
a
.
2
.
Abd
omin
a
l p
a
in
.
3
.
Abd
omin
a
l mus
c
l
e c
r
a
mping p
a
in
;
in
d
i
ca
ting un
de
rlying loss of
e
l
ec
trolyt
e
s
,
a
s in s
e
v
e
r
e c
hol
e
r
a
.
4
.
B
lo
a
ting
.
R
isk
Fac
tors
1
.
H
istory of
ea
ting
/
d
rinking in unhygi
e
ni
c
pl
ace
s
2
.
C
onsuming un
de
r
c
ook
ed
m
ea
t
/
poultry
ca
n
be
susp
ec
t
ed
Sa
lmon
e
ll
a
spp
,
Ca
mpylo
bac
t
e
r spp
,
S
hig
a
toxin
E c
oli
,
a
n
d C
lostri
d
ium
p
e
rfring
e
ns
.
3
.
C
onsumption of r
a
w s
ea
foo
d
m
a
y
be
susp
ec
t
ed
for
N
orw
a
lk
-
lik
e
virus
,
V
i
b
rio spp
,
or h
e
p
a
titis
A
.
S
impl
e P
hysi
ca
l
a
n
d S
upporting
E
x
a
min
a
tion
Re
sults
(
Ob
j
ec
tiv
e
)
Pa
thognomoni
c P
hysi
ca
l
E
x
a
min
a
tion
T
h
e
physi
ca
l
e
x
a
min
a
tion shoul
d
fo
c
us on
a
ss
e
ssing th
e
s
e
v
e
rity of
de
hy
d
r
a
tion
.
1
.
D
i
a
rrh
ea
,
de
hy
d
r
a
tion
,
with signs of f
a
lling
b
loo
d
pr
e
ssur
e
,
r
a
pi
d
puls
e
,
d
ry mouth
,
dec
r
ea
s
ed
sw
ea
ting
,
a
n
d dec
r
ea
s
ed
urin
e
output
.
2
.
Abd
omin
a
l t
e
n
de
rn
e
ss
,
in
c
r
ea
s
ed
or w
ea
k
e
n
ed b
ow
e
l soun
d
s
.
S
upporting inv
e
stig
a
tion
1
.
Pe
rform
a
mi
c
ros
c
opi
c e
x
a
min
a
tion of th
e
f
ece
s for worm
e
ggs
a
n
d
p
a
r
a
sit
e
.
2
.
G
r
a
m
,
K
o
c
h
a
n
d L
o
e
ffl
e
r
'
s m
e
thyl
e
n
e b
lu
e
st
a
ins to h
e
lp
D
iff
e
r
e
nti
a
t
e
inv
a
siv
e d
is
ea
s
e
from non
-
inv
a
siv
e d
is
ea
s
e
.
D
i
a
gnosti
c E
nfor
ce
m
e
nt
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
D
i
a
gnosis
T
h
e d
i
a
gnosis is m
ade ba
s
ed
on
a
n
a
mn
e
sis
,
physi
ca
l
e
x
a
min
a
tion
a
n
d
supporting
pro
ced
ur
e
s
.
D
iff
e
r
e
nti
a
l
D
i
a
gnosis
1
.
I
ntol
e
r
a
n
ce
2
.
S
p
ec
ifi
c d
i
a
rrh
ea
su
c
h
a
s
d
ys
e
nt
e
ry
,
c
hol
e
r
a a
n
d
oth
e
rs
.
C
ompli
ca
tions
Se
v
e
r
e de
hy
d
r
a
tion
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
Ma
n
a
g
e
m
e
nt
1
.
Beca
us
e
most
ca
s
e
s of
ac
ut
e
g
a
stro
e
nt
e
ritis
a
r
e
s
e
lf
-
limiting
,
sp
ec
i
a
l tr
ea
tm
e
nt is not r
e
quir
ed
.
F
rom s
e
v
e
r
a
l stu
d
i
e
s it w
a
s foun
d
th
a
t only
10
%
of
ca
s
e
s r
e
quir
e a
nti
b
ioti
c
th
e
r
a
py
.
T
h
e
m
a
in go
a
l
is
ade
qu
a
t
e
r
e
hy
d
r
a
tion
a
n
d e
l
ec
trolyt
e
suppl
e
m
e
nts
.
T
his
ca
n
be ac
hi
e
v
ed
b
y
ad
minist
e
ring or
a
l r
e
hy
d
r
a
tion flui
d
s
(
ORS
)
or intr
a
v
e
nous solutions
(
e
.
g
.,
isotoni
c
so
d
ium
c
hlori
de
solution
,
Lac
t
a
t
ed R
ing
e
r
'
s solution
).
Re
hy
d
r
a
t
e
or
a
l
ad
ministr
a
tion is
ac
hi
e
v
ed b
y
ad
minist
e
ring flui
d
s
c
ont
a
ining so
d
ium
a
n
d
glu
c
os
e
.
Ab
sor
be
nt
d
rugs
(
e
g
,
k
a
op
ec
t
a
t
e
,
a
luminum hy
d
roxi
de
)
h
e
lps to
c
omp
ac
t th
e
stool giv
e
n if th
e d
i
a
rrh
ea d
o
e
s not stop imm
ed
i
a
t
e
ly
.
D
iph
e
noxyl
a
t
e
with
a
tropin
e
(
L
omotil
)
is
a
v
a
il
ab
l
e
in t
ab
l
e
ts
(
2
.
5
mg
d
iph
e
noxyl
a
t
e
)
a
n
d
liqui
d
(
2
.
5
mg
d
iph
e
noxyl
a
t
e
/
5
m
L
).
I
niti
a
l
d
os
e
for
ad
ults
a
r
e
2
t
ab
l
e
ts
4
tim
e
s
a da
y
(
20
mg
/
d
),
us
ed
only
if th
e d
i
a
rrh
ea
is m
a
ssiv
e
.
2
.
I
f symptoms p
e
rsist
a
ft
e
r
3
-
4
da
ys
,
th
e
sp
ec
ifi
c e
tiology must
be de
t
e
rmin
ed
b
y p
e
rforming
a
stool
c
ultur
e
.
F
or this r
ea
son
,
it must
be
r
e
f
e
rr
ed
imm
ed
i
a
t
e
ly
.
3
.
L
if
e
styl
e
mo
d
ifi
ca
tions
a
n
d ed
u
ca
tion to m
a
int
a
in p
e
rson
a
l hygi
e
n
e
.
C
ouns
e
ling
a
n
d Ed
u
ca
tion
Ed
u
ca
t
e
f
a
mili
e
s to h
e
lp m
a
int
a
in f
a
mily
a
n
d
p
a
ti
e
nt hygi
e
n
e
.
Re
f
e
r
e
n
ce C
rit
e
ri
a
1
.
S
ymptoms of poisoning
d
o not stop
a
ft
e
r
3
da
ys of
ade
qu
a
t
e
tr
ea
tm
e
nt
.
2
.
T
h
e
p
a
ti
e
nt
e
xp
e
ri
e
n
ce
s wors
e
ning
.
Re
f
e
rr
ed
to s
ec
on
da
ry h
ea
lth s
e
rvi
ce
s with
a
sp
ec
i
a
list in int
e
rn
a
l m
ed
i
c
in
e
or p
ed
i
a
tri
c
sp
ec
i
a
list
.
E
quipm
e
nt
1
.
Re
hy
d
r
a
tion flui
d
(
0
.
9
%
NaC
l
,
RL
,
ORS
)
2
.
I
nfusion s
e
t
3
.
A
nti
b
ioti
c
s if n
ece
ss
a
ry
P
rognosis
T
h
e
g
e
n
e
r
a
l prognosis if th
e
p
a
ti
e
nt
d
o
e
s not
e
xp
e
ri
e
n
ce c
ompli
ca
tions is goo
d
.
F
oo
d A
ll
e
rgi
e
s
Hea
lth pro
b
l
e
ms
F
oo
d ca
n
ca
us
e a
v
a
ri
e
ty of symptoms r
e
sulting from r
eac
tions
immunity to foo
d a
ll
e
rg
e
ns
.
T
his r
eac
tion
ca
n
be ca
us
ed b
y
a
ll
e
rgi
c
or non
-
a
ll
e
rgi
c
r
eac
tions
.
F
oo
d a
ll
e
rgi
c
r
eac
tions o
cc
ur wh
e
n th
e
r
e a
r
e a
ll
e
rg
e
ns
F
oo
d
p
e
n
e
tr
a
t
e
s th
e
g
a
stro int
e
stin
a
l
ba
rri
e
r whi
c
h trigg
e
rs
a
n
I
g
E
r
eac
tion
.
S
ymptom
ca
n
a
pp
ea
r within
a
f
e
w minut
e
s to
a
f
e
w hours
,
ca
n
be
limit
ed
to
on
e
or s
e
v
e
r
a
l org
a
ns
,
skin
,
r
e
spir
a
tory
a
n
d d
ig
e
stiv
e
tr
ac
t
,
lo
ca
l
a
n
d
syst
e
mi
c
.
F
oo
d a
ll
e
rg
e
ns th
a
t oft
e
n
ca
us
e a
ll
e
rgi
e
s in
c
hil
d
r
e
n
a
r
e
milk
,
e
ggs
,
p
ea
nuts
,
soy
a
,
wh
ea
t
a
n
d
s
ea
fish
.
Mea
nwhil
e
,
oft
e
n
ca
us
e
s
a
ll
e
rgi
e
s in
ad
ults
a
r
e
p
ea
nuts
,
s
ea
fish
,
shrimp
,
c
r
ab
,
c
l
a
ms
a
n
d e
ggs
.
F
oo
d a
ll
e
rgi
e
s
d
o not l
a
st
a
lif
e
tim
e
,
e
sp
ec
i
a
lly in
c
hil
d
r
e
n
.
S
ymptom
ca
n
d
is
a
pp
ea
r
,
b
ut
ca
n r
ec
ur in
ce
rt
a
in
c
ir
c
umst
a
n
ce
s su
c
h
a
s vir
a
l inf
ec
tions
,
un
ba
l
a
n
ced
nutrition or g
a
stroint
e
stin
a
l mus
c
l
e
injury
.
H
istory
Re
sults
(
S
u
b
j
ec
tiv
e
)
C
ompl
a
int
1
.
O
n th
e
skin
:
ec
z
e
m
a a
n
d
urti
ca
ri
a
.
2
.
I
n th
e
r
e
spir
a
tory tr
ac
t
:
rhinitis
a
n
d a
sthm
a
.
3
.
C
ompl
a
ints in th
e d
ig
e
stiv
e
tr
ac
t
:
non
-
sp
ec
ifi
c
g
a
stroint
e
stin
a
l symptoms
a
n
d
r
a
ng
e
from
ede
m
a
,
pruritus of th
e
lips
,
c
h
ee
k mu
c
os
a
,
ph
a
ryng
ea
l mu
c
os
a
,
vomiting
,
c
r
a
mps
,
d
ist
e
nsion
,
a
n
d d
i
a
rrh
ea
.
4
.
C
hroni
c d
i
a
rrh
ea a
n
d
m
a
l
ab
sorption o
cc
ur
d
u
e
to
de
l
a
y
ed
hyp
e
rs
e
nsitivity r
eac
tions
non
I
g
-
E
-
m
ed
i
a
t
ed a
s in foo
d
prot
e
in
e
nt
e
rop
a
thy
a
n
d d
is
ea
s
e
ce
li
ac
5
.
H
yp
e
rs
e
nsitivity to
c
ow
'
s milk in
bab
i
e
s
ca
us
e
s o
cc
ult
b
l
eed
ing or
fr
a
nk
c
olitis
.
R
isk
Fac
tors
T
h
e
r
e
is
a
history of
a
ll
e
rgi
e
s in th
e
f
a
mily
S
impl
e P
hysi
ca
l
a
n
d S
upporting
E
x
a
min
a
tion
Re
sults
(
Ob
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
P
hysi
ca
l
e
x
a
min
a
tion of th
e
skin
a
n
d
mu
c
os
a a
n
d
lungs
.
S
upporting inv
e
stig
a
tion
:-
D
i
a
gnosti
c E
nfor
ce
m
e
nt
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
D
i
a
gnosis
T
h
e d
i
a
gnosis is m
ade ba
s
ed
on th
e
history
a
n
d
physi
ca
l
e
x
a
min
a
tion
D
iff
e
r
e
nti
a
l
D
i
a
gnosis
F
oo
d
intoxi
ca
tion
C
ompli
ca
tions
Se
v
e
r
e a
ll
e
rgi
c
r
eac
tion
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
Ma
n
a
g
e
m
e
nt
Me
ntos
a Med
i
ca
H
istory of s
e
v
e
r
e a
ll
e
rgi
c
r
eac
tions or
a
n
a
phyl
a
xis
:
1
.
A
voi
d ca
us
a
tiv
e
foo
d
s
2
.
D
o not p
e
rform skin t
e
sts or foo
d
provo
ca
tion t
e
sts
F
ollow up pl
a
n
1
.
Pa
ti
e
nt
ed
u
ca
tion for p
a
ti
e
nt
d
i
e
t
c
ompli
a
n
ce
2
.
A
voi
d
foo
d
s th
a
t
a
r
e a
ll
e
rg
e
ns int
e
ntion
a
lly or not
int
e
ntion
a
lly
(
n
eed
s
c
onsult
a
tion with
a
nutritionist
)
3
.
Pa
y
a
tt
e
ntion to foo
d
l
abe
ls
4
.
B
r
ea
stf
eed
ing
a bab
y until
6
months of
a
g
e
h
a
s
a
prot
ec
tiv
e e
ff
ec
t on
foo
d a
ll
e
rgi
e
s
Re
f
e
r
e
n
ce C
rit
e
ri
a
Pa
ti
e
nts
a
r
e
r
e
f
e
rr
ed
for skin t
e
sts
,
provo
ca
tion
a
n
d e
limin
a
tion t
e
sts
foo
d
,
a
n
a
n
a
phyl
ac
ti
c
r
eac
tion o
cc
urs
.
E
quipm
e
nt
: -
P
rognosis
Ge
n
e
r
a
lly th
e
prognosis is
d
u
b
i
a ad b
on
a
m if m
ed
i
ca
tion is
acc
omp
a
ni
ed
with lif
e
styl
e c
h
a
ng
e
s
.
S
ho
c
k
Hea
lth pro
b
l
e
ms
S
ho
c
k is on
e
of th
e e
m
e
rg
e
n
c
y syn
d
rom
e
s
r
e
quir
e
s int
e
nsiv
e a
n
d a
ggr
e
ssiv
e
tr
ea
tm
e
nt
.
S
ho
c
k is
a
syn
d
rom
e
multif
ac
tori
a
l l
ead
ing to lo
ca
l or syst
e
mi
c
tissu
e
hypop
e
rfusion
a
n
d
r
e
sulting in
ce
llul
a
r hypoxi
a a
n
d
multipl
e
org
a
n
d
ysfun
c
tion
.
Pe
rfusion f
a
ilur
e
tissu
e a
n
d
in
ade
qu
a
t
e
syst
e
mi
c de
liv
e
ry of nutri
e
nts
a
n
d
oxyg
e
n
ab
l
e
to m
ee
t th
e
m
e
t
ab
oli
c
n
eed
s of
ce
lls
.
T
h
e c
h
a
r
ac
t
e
risti
c
s of this
c
on
d
ition
a
r
e
:
1
)
de
p
e
n
de
n
ce
on oxyg
e
n supply
,
2
)
l
ac
k of oxyg
e
n
,
3
)
tissu
e ac
i
d
osis
r
e
sulting in
a
n
ae
ro
b
i
c
m
e
t
ab
olism
a
n
d e
n
d
ing in fun
c
tion
a
l f
a
ilur
e
vit
a
l org
a
ns
a
n
d dea
th
.
S
ho
c
k is
c
l
a
ssifi
ed ba
s
ed
on
e
tiology
,
ca
us
e a
n
d
p
a
tt
e
rn
c
h
a
r
ac
t
e
risti
c
s
T
h
e
r
e
sulting h
e
mo
d
yn
a
mi
c
s
a
r
e
:
1
.
H
ypovol
e
mi
c
sho
c
k
,
n
a
m
e
ly f
a
ilur
e
of p
e
rfusion
a
n
d
oxyg
e
n supply
ca
us
ed
b
y loss of
c
ir
c
ul
a
ting intr
a
v
a
s
c
ul
a
r volum
e
of
>
20
-
25
%
a
s
a
s
a
r
e
sult of
ac
ut
e b
l
eed
ing
,
de
hy
d
r
a
tion
,
loss of flui
d
in th
e
sp
ace
thir
d
or s
ec
on
da
ry r
e
sult of
d
il
a
t
a
tion of
a
rt
e
ri
e
s
a
n
d
v
e
ins
.
2
.
Ca
r
d
iog
e
ni
c
sho
c
k
,
n
a
m
e
ly f
a
ilur
e
of p
e
rfusion
a
n
d
oxyg
e
n supply
ca
us
ed
b
y prim
a
ry
da
m
a
g
e
to th
e
fun
c
tion or pumping
ca
p
ac
ity of th
e
h
ea
rt
suffi
c
i
e
nt minut
e
h
ea
rt volum
e
,
a
sso
c
i
a
t
ed
with
d
isruption
pr
e
lo
ad
,
a
ft
e
rlo
ad
,
c
ontr
ac
tility
,
h
ea
rt r
a
t
e
or rhythm
.
T
h
e
most
c
ommon
ca
us
e
s
a
r
e ac
ut
e
myo
ca
r
d
i
a
l inf
a
r
c
tion
,
d
rug poisoning
,
inf
ec
tion
/
infl
a
mm
a
tion
,
m
ec
h
a
ni
ca
l
d
isor
de
rs
.
3
.
D
istri
b
utiv
e
sho
c
k
,
n
a
m
e
ly f
a
ilur
e
of p
e
rfusion
a
n
d
oxyg
e
n supply
ca
us
ed
b
y
dec
r
ea
s
ed
v
a
s
c
ul
a
r ton
e
r
e
sulting in
a
rt
e
ri
a
l v
a
so
d
il
a
tion
,
acc
umul
a
tion of v
e
ins
a
n
d
r
ed
istri
b
ution of
b
loo
d
flow
.
Ca
us
e
of
c
on
d
ition
th
e
s
e a
r
e
prim
a
rily th
e
v
a
so
ac
tiv
e c
ompon
e
nts of
a
n
a
phyl
ac
ti
c
sho
c
k
;
bac
t
e
ri
a a
n
d
its toxin in s
e
pti
c
sho
c
k
a
s
a
m
ed
i
a
tor of
SIRS
;
loss of ton
e
v
a
s
c
ul
a
r
d
is
ea
s
e
in n
e
urog
e
ni
c
sho
c
k
.
Ob
stru
c
tiv
e S
ho
c
k is
a
r
e
l
a
t
ed
f
a
ilur
e
of p
e
rfusion
a
n
d
oxyg
e
n supply
with
d
isruption of th
e b
loo
d
r
e
turn m
ec
h
a
nism
d
u
e
to
in
c
r
ea
s
ed
intr
a
thor
ac
i
c
pr
e
ssur
e
or imp
a
ir
ed a
rt
e
ri
a
l outflow
h
ea
rt
(
pulmon
a
ry
e
m
b
olism
,
a
ir
e
m
b
olism
,
a
orti
c d
iss
ec
tion
,
hyp
e
rt
e
nsion
pulmon
a
ry
,
p
e
ri
ca
r
d
i
a
l t
a
mpon
ade
,
c
onstri
c
tiv
e
p
e
ri
ca
r
d
itis
)
or
b
oth
d
u
e
to m
ec
h
a
ni
ca
l o
b
stru
c
tion
.
5
.
E
n
d
o
c
rin
e
sho
c
k
,
ca
us
ed b
y hypothyroi
d
ism
,
hyp
e
rthyroi
d
ism with
ca
r
d
i
ac c
oll
a
ps
e a
n
d ad
r
e
n
a
l insuffi
c
i
e
n
c
y
.
T
r
ea
tm
e
nt is with
be
n
e
fits
ca
r
d
iov
a
s
c
ul
a
r
d
is
ea
s
e
whil
e
tr
ea
ting th
e ca
us
e
.
Ad
r
e
n
a
l insuffi
c
i
e
n
c
y
m
a
y
be a c
ontri
b
utor to sho
c
k in
c
riti
ca
lly ill p
a
ti
e
nts
.
Pa
ti
e
nts who
unr
e
sponsiv
e
to tr
ea
tm
e
nt shoul
d be
t
e
st
ed
for
ad
r
e
n
a
l insuffi
c
i
e
n
c
y
.
H
istory
Re
sults
(
S
u
b
j
ec
tiv
e
)
C
ompl
a
int
Pa
ti
e
nts
c
om
e
in w
ea
k or un
c
ons
c
ious
.
C
lini
ca
l symptoms
a
lso
de
p
e
n
d
on th
e e
tiology of th
e ca
us
e
,
whi
c
h oft
e
n o
cc
urs
pulmon
a
ry throm
b
o
e
m
b
olism
,
ca
r
d
i
ac
t
a
mpon
ade
,
a
rt
e
riov
e
ntri
c
ul
a
r o
b
stru
c
tion
,
t
e
nsion
pn
e
umothor
a
x
.
T
o i
de
ntify th
e ca
us
e
,
it is n
ece
ss
a
ry to
a
sk
ab
out pr
ed
isposing f
ac
tors su
c
h
a
s
:
d
u
e
to myo
ca
r
d
i
a
l inf
a
r
c
tion
,
in
c
lu
d
ing
:
a
g
e
,
d
i
abe
t
e
s m
e
llitus
,
history of
a
ngin
a
,
c
ong
e
stiv
e
h
ea
rt f
a
ilur
e
,
a
nt
e
rior inf
a
r
c
tion
.
Ea
rly signs of
ac
ut
e ca
r
d
i
ac
is
c
h
e
mi
a a
r
e
:
c
h
e
st p
a
in
,
shortn
e
ss of
b
r
ea
th
,
d
i
a
phor
e
sis
,
a
nxi
e
ty
a
n
d
f
ea
r
,
n
a
us
ea a
n
d
vomiting
a
n
d c
ir
c
ul
a
tory
d
isor
de
rs furth
e
r
ca
us
e
v
a
rious
d
ysfun
c
tions
e
n
d
org
a
n
.
H
istory of tr
a
um
a
for sho
c
k
d
u
e
to
b
l
eed
ing or n
e
urog
e
ni
c
sho
c
k
in
ce
rvi
ca
l tr
a
um
a
or high thor
ac
i
c
spin
a
l
c
or
d
injury
.
Fe
v
e
r
a
n
d
history
inf
ec
tion to s
e
pti
c
sho
c
k
.
C
lini
ca
l symptoms th
a
t
a
ris
e a
ft
e
r
c
ont
ac
t with
a
ntig
e
n in
a
n
a
phyl
ac
ti
c
sho
c
k
.
Ob
stru
c
tiv
e
sho
c
k
,
looks
a
lmost th
e
s
a
m
e a
s
ca
r
d
iog
e
ni
c
sho
c
k
a
n
d
hypovol
e
mi
c
.
R
isk
Fac
tors
:-
S
impl
e P
hysi
ca
l
a
n
d S
upporting
E
x
a
min
a
tion
Re
sults
(
Ob
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
Ge
n
e
r
a
l
c
on
d
ition
:
1
.
H
ypot
e
nsion
a
n
d
n
a
rrowing of puls
a
til
e
pr
e
ssur
e
(
a
r
e
signs of
d
is
a
pp
ea
r
a
n
ce
h
ea
vy flui
d
s
a
n
d
sho
c
k
).
2
.
H
yp
e
rth
e
rmi
a
,
normoth
e
rmi
a
,
or hypoth
e
rmi
a ca
n o
cc
ur in sho
c
k
.
H
ypoth
e
rmi
a
is
a
sign of s
e
v
e
r
e
hypovol
e
mi
a a
n
d
s
e
pti
c
sho
c
k
.
3
.
Hea
rt r
a
t
e
in
c
r
ea
s
e
s
,
r
e
spir
a
tory r
a
t
e
in
c
r
ea
s
e
s
,
c
ons
c
iousn
e
ss
dec
r
ea
s
e
s
.
4
.
U
rin
e
pro
d
u
c
tion
dec
r
ea
s
e
s
.
U
rin
e
pro
d
u
c
tion is
a
n
ea
rly in
d
i
ca
tor of hypovol
e
mi
a
a
n
d
r
e
n
a
l r
e
spons
e
to sho
c
k
.
5
.
T
h
e c
lini
ca
l pi
c
tur
e
of
ca
r
d
iog
e
ni
c
sho
c
k
a
pp
ea
rs th
e
s
a
m
e a
s th
e c
lini
ca
l symptoms of
sho
c
k
hypovol
e
mi
c
,
c
oupl
ed
with
d
ysrhythmi
a
s
,
h
ea
rt murmurs
,
g
a
llops
.
T
h
e c
lini
ca
l symptoms of s
e
pti
c
sho
c
k
ca
nnot
be
s
e
p
a
r
a
t
ed
from th
e
s
e
psis its
e
lf
in th
e
form of syst
e
mi
c
infl
a
mm
a
tory r
eac
tion syn
d
rom
e
(
SIRS
)
of whi
c
h th
e
r
e a
r
e
two
symptoms or mor
e
:
a
.
Te
mp
e
r
a
tur
e
>
380
C
or
<
360
C
.
b
.
Hea
rt r
a
t
e
>
90
x
/
min
.
c
.
Re
spir
a
tory fr
e
qu
e
n
c
y
>
20
x
/
min or
PaCO
2
<
4
.
3
k
Pa
.
d
.
Le
uko
c
yt
e
s
>
12
,
000
ce
lls
/
mm or
<
4000
ce
lls
/
mm or
>
10
%
imm
a
tur
e
form
.
7
.
C
lini
ca
l
e
ff
ec
ts of
a
n
a
phyl
ac
ti
c
sho
c
k on th
e
r
e
spir
a
tory syst
e
m
a
n
d
syst
e
ms
c
ir
c
ul
a
tion
,
n
a
m
e
ly
:
H
ypoph
a
ryng
ea
l
a
n
d
l
a
ryng
ea
l
ede
m
a
o
cc
urs
,
c
onstri
c
tion of th
e b
ron
c
hi
a
n
d b
ron
c
hiol
e
s
,
acc
omp
a
ni
ed b
y hyp
e
rs
ec
r
e
tion of mu
c
us
,
whi
c
h
a
ll th
e
s
e c
on
d
itions
ca
us
e
sp
a
sms
a
n
d ac
ut
e a
irw
a
y o
b
stru
c
tion
.
8
.
Ne
urog
e
ni
c
sho
c
k is
c
h
a
r
ac
t
e
riz
ed b
y hypot
e
nsion
acc
omp
a
ni
ed b
y
b
r
ad
y
ca
r
d
i
a
.
D
istur
ba
n
ce
n
e
urologi
ca
l
:
fl
acc
i
d
p
a
r
a
lysis
,
lost lim
b
r
e
fl
e
x
e
s
a
n
d
pri
a
pism
.
9
.
Ob
stru
c
tiv
e
sho
c
k
,
looks
a
lmost th
e
s
a
m
e a
s
ca
r
d
iog
e
ni
c
sho
c
k
a
n
d
hypovol
e
mi
c
.
C
lini
ca
l symptoms
a
lso
de
p
e
n
d
on th
e e
tiology of th
e ca
us
e
,
whi
c
h
F
r
e
qu
e
nt o
cc
urr
e
n
ce
s
a
r
e
pulmon
a
ry throm
b
o
e
m
b
olism
,
ca
r
d
i
ac
t
a
mpon
ade
,
o
b
stru
c
tion
a
rt
e
riov
e
ntri
c
ul
a
r
,
t
e
nsion pn
e
umothor
a
x
.
T
h
e
s
e
symptoms will
c
ontinu
e a
s
signs of
ac
ut
e c
or pulmon
a
l
e a
n
d
right h
ea
rt f
a
ilur
e
:
v
e
nous puls
a
tion
jugul
a
r
,
g
a
llop
,
pulmon
a
ry murmur
,
a
rrhythmi
a
.
C
h
a
r
ac
t
e
risti
c
s of
c
lini
ca
l m
a
nif
e
st
a
tions
ca
r
d
i
ac
t
a
mpon
ade
:
d
ist
a
nt h
ea
rt soun
d
s
,
pulsus
a
lt
e
m
a
ns
,
JVP d
uring
inspir
a
tion
.
Mea
nwhil
e
,
pulmon
a
ry
e
m
b
olism
:
ca
r
d
i
ac d
ysrhythmi
a
,
h
ea
rt f
a
ilur
e
c
ong
e
stion
.
S
upporting inv
e
stig
a
tion
1
.
P
uls
e
oxim
e
try
2
.
ECG
D
i
a
gnosti
c E
nfor
ce
m
e
nt
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
D
i
a
gnosis
T
h
e d
i
a
gnosis is m
ade ba
s
ed
on history
,
physi
ca
l
e
x
a
min
a
tion
,
a
n
d
support
.
D
iff
e
r
e
nti
a
l
D
i
a
gnosis
:-
C
ompli
ca
tions
B
r
a
in
da
m
a
g
e
,
c
om
a
,
dea
th
.
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
Ma
n
a
g
e
m
e
nt
1
.
Ra
pi
d
r
ec
ognition
a
n
d
r
e
stor
a
tion of p
e
rfusion is k
e
y
pr
e
v
e
ntion of multipl
e
org
a
n
d
ysfun
c
tion
a
n
d dea
th
.
2
.
I
n
a
ll forms of sho
c
k
,
a
irw
a
y
a
n
d
r
e
spir
a
tory m
a
n
a
g
e
m
e
nt for
e
nsur
e
th
e
p
a
ti
e
nt
'
s oxyg
e
n
a
tion is goo
d
,
th
e
n r
e
stor
e
qui
c
kly with infusion
flui
d
.
T
h
e
first
c
hoi
ce
is
c
ryst
a
lloi
d
(
R
ing
e
r l
ac
t
a
t
e
/
R
ing
e
r
ace
t
a
t
e
)
follow
ed b
y
b
loo
d
in h
e
morrh
a
gi
c
sho
c
k
.
H
ypovol
e
mi
c c
on
d
itions
a
r
e
tr
ea
t
ed
with flui
d
s
c
olloi
d
s or
c
ryst
a
lloi
d
s whil
e
improving th
e c
on
d
ition of
ac
i
d
osis
.
4
.
T
r
ea
tm
e
nt of pr
e
vious sho
c
k is pr
eceded b
y
e
st
ab
lishing
a d
i
a
gnosis
e
tiology
.
Ea
rly
d
i
a
gnosis of th
e e
tiology of sho
c
k is
e
ss
e
nti
a
l
,
th
e
n th
e
r
a
py
Ne
xt
de
p
e
n
d
s on th
e e
tiology
.
5
.
I
nv
a
siv
e
pro
ced
ur
e
s su
c
h
a
s
e
n
d
otr
ac
h
ea
l intu
ba
tion
a
n
d c
ri
c
othyroi
d
otomy or
T
r
ac
h
e
otomy
ca
n
be
p
e
rform
ed
only for lif
e
s
a
ving
b
y
a d
o
c
tor
c
omp
e
t
e
nt
.
H
ypovol
e
mi
c S
ho
c
k
:
1
.
Ra
pi
d
infusion of
c
ryst
a
lloi
d
s for intr
a
v
a
s
c
ul
a
r volum
e e
xp
a
nsion vi
a ca
nnul
a
l
a
rg
e
v
e
ins
(
ca
n
be
in mor
e
th
a
n on
e
pl
ace
)
or through th
e ce
ntr
a
l v
e
in
.
2
.
I
n
ca
s
e
of
b
l
eed
ing
,
3
-
4
tim
e
s th
e a
mount of
b
l
eed
ing
ca
n
be
giv
e
n
.
A
ft
e
r giving
3
lit
e
rs follow
ed b
y
a b
loo
d
tr
a
nsfusion
.
B
y
C
on
c
omit
a
nt sour
ce
of
b
l
eed
ing must
be c
ontroll
ed
.
3
.
Re
sus
c
it
a
tion is not
c
ompl
e
t
e
until s
e
rum l
ac
t
a
t
e
r
e
turns to norm
a
l
.
T
h
e
p
a
ti
e
nt is in
sho
c
k
Se
v
e
r
e
hypovol
e
mi
a
with flui
d
r
e
sus
c
it
a
tion will r
e
sult in
acc
umul
a
tion
flui
d
in th
e
thir
d ca
vity
.
4
.
Va
so
c
onstri
c
tion is r
a
r
e
ly n
ece
ss
a
ry in pur
e
hypovol
e
mi
c
sho
c
k
.
Ob
stru
c
tiv
e S
ho
c
k
:
1
.
T
h
e ca
us
e
of o
b
stru
c
tiv
e
sho
c
k must
be
i
de
ntifi
ed a
n
d
promptly
e
limin
a
t
ed
.
2
.
Pe
ri
ca
r
d
io
ce
nt
e
sis or p
e
ri
ca
r
d
iotomy for
ca
r
d
i
ac
t
a
mpon
ade
.
3
.
Dec
ompr
e
ss th
e
n
eed
l
e
or thor
ac
ostomy tu
be
or
b
oth in t
e
nsion
pn
e
umothor
a
x
.
4
.
Ve
ntil
a
tory
a
n
d ca
r
d
i
ac
support
,
possi
b
ly throm
b
olysis
,
a
n
d
possi
b
ly
I
nt
e
rv
e
ntion
a
l r
ad
iology pro
ced
ur
e
s for pulmon
a
ry
e
m
b
olism
.
5
.
Abd
omin
a
l
c
omp
a
rtm
e
nt syn
d
rom
e
is tr
ea
t
ed
with l
a
p
a
rotomy
dec
ompr
e
ssiv
e
.
Ca
r
d
iog
e
ni
c S
ho
c
k
:
1
.
O
ptimiz
e
pr
e
-
lo
ad
with flui
d
infusion
.
2
.
O
ptimiz
e
h
ea
rt
c
ontr
ac
tility with inotrop
e
s
a
s n
eeded
,
ba
l
a
n
ce
th
e
h
ea
rt
'
s oxyg
e
n n
eed
s
.
P
lus
,
it
ca
n
be
worn
d
o
b
ut
a
min
e
or oth
e
r v
a
so
ac
tiv
e d
rugs
.
3
.
Ad
just post
-
lo
ad
to m
a
ximiz
e CO
.
Ca
n
be
us
ed
v
a
so
c
onstri
c
tor if th
e
p
a
ti
e
nt is hypot
e
nsiv
e
with low
SVR
.
T
h
e
p
a
ti
e
nt is in sho
c
k
ca
r
d
iog
e
ni
c
p
a
ti
e
nts m
a
y r
e
quir
e
v
a
so
d
il
a
tion to r
ed
u
ce SVR
,
r
e
sist
a
n
ce
to
b
loo
d
flow from
a
w
ea
k h
ea
rt
.
P
ossi
b
l
e
m
ed
i
ca
tion
us
ed a
r
e
nitroprussi
de a
n
d
nitrogly
ce
rin
.
4
.
G
iv
e d
iur
e
ti
c
s if th
e
h
ea
rt
dec
omp
e
ns
a
t
e
s
.
5
.
I
t is r
ec
omm
e
n
ded
th
a
t
PAC be
inst
a
ll
ed
to gui
de
th
e
r
a
py
.
6
.
U
n
de
rlying h
ea
rt
d
is
ea
s
e
must
be
i
de
ntifi
ed a
n
d
tr
ea
t
ed
.
D
istri
b
utiv
e S
ho
c
k
:
1
.
I
n
SIRS a
n
d
s
e
psis
,
if sho
c
k o
cc
urs it is
d
u
e
to toxins or m
ed
i
a
tors
ca
us
e
s v
a
so
d
il
a
tion
.
T
r
ea
tm
e
nt
c
onsists of imm
ed
i
a
t
e
flui
d
r
e
sus
c
it
a
tion
a
n
d
A
ft
e
r th
e
flui
d c
on
d
ition is
c
orr
ec
t
ed
,
v
a
sopr
e
ssors
ca
n
be
giv
e
n
ac
hi
e
v
e
optim
a
l
MAP
.
I
t oft
e
n h
a
pp
e
ns th
a
t v
a
sopr
e
ssors
a
r
e
st
a
rt
ed be
for
e
pr
e
-
ade
qu
a
t
e
lo
ad
is
ac
hi
e
v
ed
.
T
issu
e
p
e
rfusion
a
n
d ce
ll oxyg
e
n
a
tion will not
optim
a
l unl
e
ss th
e
r
e
is pr
e
-
lo
ad
improv
e
m
e
nt
.
2
.
D
rugs th
a
t
ca
n
be
us
ed a
r
e d
op
a
min
e
,
nor
e
pin
e
phrin
e a
n
d
v
a
sopr
e
ssin
.
3
.
I
nst
a
ll
a
tion of
PAC
is r
ec
omm
e
n
ded
.
4
.
Ca
us
a
l tr
ea
tm
e
nt of s
e
psis
.
Ne
urog
e
ni
c S
ho
c
k
:
1
.
A
ft
e
r s
ec
uring th
e a
irw
a
y
a
n
d
flui
d
r
e
sus
c
it
a
tion
,
us
e
I
n
c
r
ea
s
e
s v
a
s
c
ul
a
r ton
e a
n
d
pr
e
v
e
nts
b
r
ad
y
ca
r
d
i
a
e
pin
e
phrin
e
.
2
.
E
pin
e
phrin
e
is us
e
ful for in
c
r
ea
sing v
a
s
c
ul
a
r ton
e b
ut will m
a
k
e
it wors
e
b
r
ad
y
ca
r
d
i
a
,
so
d
op
a
min
e a
n
d e
ph
ed
rin
e ca
n
be added
.
A
g
e
nt
a
ntimus
ca
rini
ca
tropin
a
n
d
gly
c
opyrrol
a
t
e ca
n
a
lso
be
tr
ea
t
ed
b
r
ad
y
ca
r
d
i
a
.
3
.
De
finitiv
e
th
e
r
a
py is st
ab
iliz
a
tion of th
e a
ff
ec
t
ed
spin
a
l
c
or
d
.
F
ollow up pl
a
n
L
ook for th
e ca
us
e
of sho
c
k
a
n
d
r
ec
or
d
it in th
e
m
ed
i
ca
l r
ec
or
d a
s w
e
ll
N
otify th
e
p
a
ti
e
nt
a
n
d
f
a
mily for furth
e
r
ac
tion
r
e
quir
ed
.
C
ouns
e
ling
a
n
d Ed
u
ca
tion
T
h
e
f
a
mily n
eed
s to
be
inform
ed ab
out th
e
worst possi
b
l
e
out
c
om
e
o
cc
ur in p
a
ti
e
nts
a
n
d
pr
e
v
e
nt th
e
o
cc
urr
e
n
ce
of simil
a
r
c
on
d
itions
.
Re
f
e
r
e
n
ce C
rit
e
ri
a
A
ft
e
r th
e
p
a
ti
e
nt
'
s
e
m
e
rg
e
n
c
y is h
a
n
d
l
ed
,
th
e
p
a
ti
e
nt is r
e
f
e
rr
ed
to h
ea
lth s
e
rvi
ce
s
s
ec
on
da
ry
.
E
quipm
e
nt
1
.
I
nfusion s
e
t
2
.
O
xyg
e
n
3
.
NaC
l
0
.
9
%
4
.
F
l
a
shlight
5
.
ECG
P
rognosis
T
h
e
prognosis of sho
c
k
de
p
e
n
d
s gr
ea
tly on th
e
sp
eed
of
d
i
a
gnosis
a
n
d
m
a
n
a
g
e
m
e
nt so th
a
t in g
e
n
e
r
a
l it is
d
u
b
i
a ad b
on
a
m
.
A
n
a
phyl
ac
ti
c Reac
tion
Hea
lth pro
b
l
e
ms
A
n
a
phyl
a
xis is
a
g
e
n
e
r
a
liz
ed
or syst
e
mi
c
hyp
e
rs
e
nsitivity r
eac
tion
f
a
st
-
p
aced
,
s
e
rious
a
n
d
thr
ea
t
e
ning
.
I
f th
e
r
eac
tion is gr
ea
t
e
nough
ca
n
ca
us
e
sho
c
k known
a
s
a
n
a
phyl
ac
ti
c
sho
c
k
.
S
ho
c
k
A
n
a
phyl
a
xis r
e
quir
e
s qui
c
k
a
n
d a
ppropri
a
t
e
h
e
lp
.
F
or th
a
t it is n
ece
ss
a
ry
knowl
ed
g
e a
n
d
skills in m
a
n
a
ging
a
n
a
phyl
ac
ti
c
sho
c
k
.
T
h
e
in
c
i
de
n
ce
of
a
n
a
phyl
ac
ti
c
sho
c
k is
40
–
60
%
d
u
e
to ins
ec
t
b
it
e
s
,
20
–
40
%
d
u
e
to r
ad
iogr
a
phi
c c
ontr
a
st
a
g
e
nts
,
a
n
d
10
–
20
%
d
u
e
to
ad
ministr
a
tion of p
e
ni
c
illin
d
rugs
.
Da
t
a
acc
ur
a
t
e
in th
e
in
c
i
de
n
ce a
n
d
pr
e
v
a
l
e
n
ce
of
a
n
a
phyl
ac
ti
c
sho
c
k is still
v
e
ry l
e
ss
.
Fa
t
a
l
a
n
a
phyl
a
xis
acc
ounts for only
ab
out
4
dea
ths out of
10
million p
e
opl
e
p
e
r y
ea
r
.
M
ost
ca
s
e
s
a
r
e
s
e
rious
a
n
a
phyl
a
xis
is
a
r
e
sult of
ad
ministr
a
tion of
a
nti
b
ioti
c
s su
c
h
a
s p
e
ni
c
illin
a
n
d
r
ad
iologi
ca
l su
b
st
a
n
ce
s
.
Pe
ni
c
illin is th
e ca
us
e
of
dea
th in
100
out of
500
dea
ths
d
u
e
to r
eac
tions
a
n
a
phyl
a
xis
.
H
istory
Re
sults
(
S
u
b
j
ec
tiv
e
)
C
ompl
a
int
T
h
e c
lini
ca
l pi
c
tur
e
or symptoms of
a
n
a
n
a
phyl
ac
ti
c
r
eac
tion v
a
ry in gr
ada
tion
acc
or
d
ing to th
e
s
e
v
e
rity of th
e a
ntig
e
n
-
a
nti
b
o
d
y r
eac
tion or th
e
l
e
v
e
l of s
e
nsitivity
a
p
e
rson
,
b
ut
a
t
a
s
e
v
e
r
e
l
e
v
e
l th
e
r
e a
r
e
symptoms of
a
n
a
phyl
ac
ti
c
sho
c
k
P
romin
e
nt
a
r
e c
ir
c
ul
a
tory
d
isor
de
rs
a
n
d
r
e
spir
a
tory
d
isor
de
rs
.
B
oth
d
isor
de
rs
T
h
e
s
e ca
n o
cc
ur simult
a
n
e
ously or in
a
v
e
ry
c
hronologi
ca
l s
e
qu
e
n
ce
v
a
ri
e
s from
a
f
e
w s
ec
on
d
s to s
e
v
e
r
a
l hours
.
Ba
si
ca
lly mor
e
T
h
e
qui
c
k
e
r th
e
r
eac
tion o
cc
urs
,
th
e
mor
e
s
e
rious th
e
p
a
ti
e
nt
'
s
c
on
d
ition is
.
Re
spir
a
tory symptoms
ca
n
be
gin in th
e
form of sn
ee
zing
,
stuffy nos
e
or just
c
oughing
whi
c
h is th
e
n imm
ed
i
a
t
e
ly follow
ed b
y shortn
e
ss of
b
r
ea
th
.
S
kin symptoms
a
r
e
th
e
most
c
ommon
c
lini
ca
l symptoms foun
d
in
a
n
a
phyl
ac
ti
c
r
eac
tion
.
A
lthough th
e
s
e
symptoms
a
r
e
not f
a
t
a
l
,
th
e
y
a
r
e
s
e
rious
I
t is import
a
nt to p
a
y
a
tt
e
ntion
beca
us
e
this m
a
y
be a
pro
d
rom
a
l symptom
for th
e e
m
e
rg
e
n
ce
of mor
e
s
e
v
e
r
e
symptoms in th
e
form of
b
r
ea
thing pro
b
l
e
ms
a
n
d
d
istur
ba
n
ce
s
c
ir
c
ul
a
tion
.
T
h
e
r
e
for
e
,
e
v
e
ry skin symptom is it
c
hy
,
r
edd
ish skin
must
be a
l
e
rt for th
e
possi
b
ility of mor
e
s
e
v
e
r
e
symptoms
.
Ma
nif
e
st
a
tions of g
a
stroint
e
stin
a
l
d
isor
de
rs in
c
lu
de
stom
ac
h
c
r
a
mps
,
n
a
us
ea
,
vomiting
to
d
i
a
rrh
ea
whi
c
h
ca
n
a
lso
be a
pro
d
rom
a
l symptom for its ons
e
t
symptoms of r
e
spir
a
tory
a
n
d c
ir
c
ul
a
tion
d
isor
de
rs
.
R
isk
Fac
tors
:
A
ll
e
rgy
H
istory
S
impl
e P
hysi
ca
l
a
n
d S
upporting
E
x
a
min
a
tion
Re
sults
(
Ob
j
ec
tiv
e
)
P
hysi
ca
l
e
x
a
min
a
tion
T
h
e
p
a
ti
e
nt
a
pp
ea
rs short of
b
r
ea
th
,
in
c
r
ea
s
ed
r
e
spir
a
tory fr
e
qu
e
n
c
y
,
c
y
a
nosis
d
u
e
to
ede
m
a
l
a
rynx
a
n
d b
ron
c
hosp
a
sm
.
H
ypot
e
nsion is
a
promin
e
nt symptom in
a
n
a
phyl
ac
ti
c
sho
c
k
.
T
h
e
r
e
is t
ac
hy
ca
r
d
i
a
,
p
e
rior
b
it
a
l
ede
m
a
,
w
a
t
e
ry
e
y
e
s
,
hyp
e
r
e
mi
a
c
onjun
c
tiv
a
.
P
ro
d
rom
a
l signs on th
e
skin in
c
lu
de
urti
ca
ri
a a
n
d e
ryth
e
m
a
.
D
i
a
gnosti
c E
nfor
ce
m
e
nt
(
A
ss
e
ssm
e
nt
)
C
lini
ca
l
D
i
a
gnosis
T
o h
e
lp
e
st
ab
lish
a d
i
a
gnosis
,
th
e W
orl
d A
ll
e
rgy
O
rg
a
niz
a
tion
h
a
v
e e
st
ab
lish
ed
s
e
v
e
r
a
l
c
rit
e
ri
a b
y whi
c
h
a
n
a
phyl
ac
ti
c
r
eac
tions
a
r
e e
xpr
e
ss
ed
strongly
m
a
y
be
if
:
1
.
Ac
ut
e
ons
e
t of symptoms
(
minut
e
s to hours
)
involving
skin
,
mu
c
os
a
l tissu
e
,
or
b
oth
(
e
g
,
g
e
n
e
r
a
liz
ed
urti
ca
ri
a
,
pruritus with r
ed
n
e
ss
,
sw
e
lling of th
e
lips
/
tongu
e
/
uvul
a
)
a
n
d
a
t l
ea
st on
e
of th
e
following signs
:
a
.
Re
spir
a
tory
d
isor
de
rs
(
e
g
:
shortn
e
ss of
b
r
ea
th
,
wh
ee
zing
d
u
e
to
b
ron
c
hosp
a
sm
,
stri
d
or
,
dec
r
ea
s
ed
p
ea
k
e
xpir
a
tory flow
/
APE
,
hypox
e
mi
a
).
b
.
Dec
r
ea
s
ed b
loo
d
pr
e
ssur
e
or r
e
l
a
t
ed
symptoms
t
a
rg
e
t org
a
n f
a
ilur
e
(
e
.
g
.
hypotoni
a
,
v
a
s
c
ul
a
r
c
oll
a
ps
e
,
syn
c
op
e
,
in
c
ontin
e
n
ce
).
2
.
O
r
,
two or mor
e
of th
e
following signs
a
pp
ea
r imm
ed
i
a
t
e
ly
(
a
f
e
w minut
e
s
up to s
e
v
e
r
a
l hours
)
a
ft
e
r
e
xposur
e
to
a
possi
b
l
e a
ll
e
rg
e
n
(
lik
e
ly
a
ll
e
rg
e
ns
),
n
a
m
e
ly
:
a
.
I
nvolv
e
m
e
nt of mu
c
os
a
l tissu
e a
n
d
skin
b
.
Re
spir
a
tory
d
isor
de
rs
c
.
Dec
r
ea
s
ed b
loo
d
pr
e
ssur
e
or r
e
l
a
t
ed
symptoms
t
a
rg
e
t org
a
n f
a
ilur
e
d
.
Pe
rsist
e
nt g
a
stroint
e
stin
a
l symptoms
(
e
.
g
.
abd
omin
a
l
c
r
a
mping p
a
in
,
vomit
)
3
.
O
r
,
a dec
r
ea
s
e
in
b
loo
d
pr
e
ssur
e
imm
ed
i
a
t
e
ly
(
minut
e
s or hours
)
a
ft
e
r
e
xpos
ed
to known
a
ll
e
rg
e
ns
,
acc
or
d
ing to th
e c
rit
e
ri
a
following
:
a
.
I
nf
a
nts
a
n
d c
hil
d
r
e
n
:
L
ow systoli
c b
loo
d
pr
e
ssur
e
(
for
a
g
e
)
or
th
e
r
e
w
a
s
a dec
r
ea
s
e
of
>
30
%
of th
e
origin
a
l systoli
c b
loo
d
pr
e
ssur
e
.
b
.
Ad
ult
:
S
ystoli
c b
loo
d
pr
e
ssur
e
<
90
mm
H
g or o
cc
urs
r
ed
u
c
tion of
>
30
%
of origin
a
l systoli
c b
loo
d
pr
e
ssur
e
.
D
iff
e
r
e
nti
a
l
D
i
a
gnosis
1
.
S
om
e d
isor
de
rs r
e
s
e
m
b
l
e a
n
a
phyl
a
xis
a
.
Ac
ut
e a
sthm
a a
tt
ac
k
b
.
S
yn
c
op
e
c
.
A
nxi
e
ty
d
isor
de
rs
/
p
a
ni
c a
tt
ac
ks
d
.
Ge
n
e
r
a
liz
ed ac
ut
e
urti
ca
ri
a
e
.
F
or
e
ign
b
o
d
y
a
spir
a
tion
f
.
Ac
ut
e ca
r
d
iov
a
s
c
ul
a
r
d
isor
de
rs
(
myo
ca
r
d
i
a
l inf
a
r
c
tion
,
pulmon
a
ry
e
m
b
olism
)
g
.
Ac
ut
e
n
e
urologi
ca
l
d
isor
de
rs
(
s
e
izur
e
s
,
strok
e
)
2
.
F
lush syn
d
rom
e
a
.
Pe
rim
e
nop
a
us
e
b
.
Ca
r
c
inoi
d
syn
d
rom
e
c
.
A
utonomi
c e
pil
e
psy
d
.
Med
ull
a
ry thyroi
d ca
r
c
inom
a
3
.
P
ost
-
pr
a
n
d
i
a
l syn
d
rom
e
a
.
Sc
om
b
roi
d
osis
,
n
a
m
e
ly hist
a
min
e
poisoning from fish
,
for
e
x
a
mpl
e
tun
a
,
stor
ed a
t high t
e
mp
e
r
a
tur
e
.
b
.
P
oll
e
n foo
d a
ll
e
rgy syn
d
rom
e
,
g
e
n
e
r
a
lly fruit or v
e
g
e
t
ab
l
e
s
c
ont
a
ins pl
a
nt prot
e
ins th
a
t h
a
v
e c
ross
-
r
eac
t
ed
with
a
ir
b
orn
e a
ll
e
rg
e
ns
c
.
M
onoso
d
ium glut
a
m
a
t
e
or
C
hin
e
s
e
r
e
st
a
ur
a
nt syn
d
rom
e
d
.
S
ulfit
e
s
e
.
F
oo
d
poisoning
4
.
O
th
e
r typ
e
s of sho
c
k
a
.
H
ypovol
e
mi
c
b
.
Ca
r
d
iog
e
ni
c
c
.
D
istri
b
utiv
e
d
.
Se
pti
c
5
.
N
on
-
org
a
ni
c d
isor
de
rs
a
.
V
o
ca
l
c
or
d d
ysfun
c
tion
b
.
hyp
e
rv
e
ntil
a
tion
c
.
P
sy
c
hosom
a
ti
c e
piso
de
6
.
I
n
c
r
ea
s
e
in
e
n
d
og
e
nous hist
a
min
e
a
.
Ma
sto
c
ytosis
/
c
lon
a
l m
a
st
ce
ll
d
isor
de
r
b
.
Ba
sophili
c
l
e
uk
e
mi
a
7
.
O
th
e
rs
a
.
N
on
-
a
ll
e
rgi
c a
ngio
ede
m
a
,
for
e
x
a
mpl
e
:
h
e
r
ed
it
a
ry
a
ngio
ede
m
a
typ
e I
,
II
,
or
III
,
ACE
-
inhi
b
itor
a
sso
c
i
a
t
ed a
ngio
ede
m
a
)
b
.
S
yst
e
mi
c ca
pill
a
ry l
ea
k syn
d
rom
e
c
.
Red
m
a
n syn
d
rom
e d
u
e
to v
a
n
c
omy
c
in
d
.
Pa
r
ad
oxi
ca
l r
e
spons
e
in ph
e
o
c
hromo
c
ytom
a
C
ompli
ca
tions
1
.
C
omm
a
2
.
Dea
th
C
ompr
e
h
e
nsiv
e Ma
n
a
g
e
m
e
nt
(
P
l
a
n
)
Ma
n
a
g
e
m
e
nt
1
.
T
r
e
n
de
l
e
n
b
urg position or lying
d
own with
b
oth l
e
gs r
a
is
ed
(
support
ed b
y
a c
h
a
ir
)
will h
e
lp in
c
r
ea
s
e
v
e
nous r
e
turn
so
b
loo
d
pr
e
ssur
e a
lso in
c
r
ea
s
e
s
.
2
.
O
xyg
e
n
ad
ministr
a
tion of
3
–
5
lit
e
rs
/
minut
e
must
be ca
rri
ed
out
,
in
ce
rt
a
in
c
ir
c
umst
a
n
ce
s
v
e
ry
e
xtr
e
m
e
tr
ac
h
e
ostomy or
c
ri
c
othyroi
dec
tomy is n
ece
ss
a
ry
c
onsi
de
r
ed
.
3
.
I
nst
a
ll
a
tion of
a
n infusion
,
pl
a
sm
a e
xp
a
n
de
r flui
d
(
De
xtr
a
n
)
is
a
n option
T
h
e
m
a
in
a
im is to fill th
e
intr
a
v
a
s
c
ul
a
r volum
e a
s qui
c
kly
a
s possi
b
l
e
.
I
f liqui
d
I
f th
e
s
e a
r
e
not
a
v
a
il
ab
l
e
,
R
ing
e
r
'
s
Lac
t
a
t
e
or physiologi
ca
l
NaC
l
ca
n
be
us
ed
a
s
a
r
e
pl
ace
m
e
nt flui
d
.
G
iving intr
a
v
e
nous flui
d
s is
be
st
m
a
int
a
in
ed
until
b
loo
d
pr
e
ssur
e
r
e
turns to optim
a
l
a
n
d
st
ab
l
e
.
4
.
Ad
r
e
n
a
lin
e
0
.
3
–
0
.
5
ml of
1
:
1000
solution is giv
e
n intr
a
mus
c
ul
a
rly
whi
c
h
ca
n
be
r
e
p
ea
t
ed
5
–
10
minut
e
s
.
Re
p
ea
t
d
os
e
s
a
r
e
g
e
n
e
r
a
lly n
ece
ss
a
ry
,
c
onsi
de
ring th
a
t th
e d
ur
a
tion of
ac
tion for
ad
r
e
n
a
lin
e
is quit
e
short
.
I
f th
e
r
e
spons
e
is giv
e
n
intr
a
mus
c
ul
a
rly is l
e
ss
e
ff
ec
tiv
e
,
ca
n
be
giv
e
n intr
a
v
e
nously
a
ft
e
r
0
.
1
–
0
.
2
ml of
ad
r
e
n
a
lin
e
is
d
issolv
ed
in
a
10
ml syring
e
with
NaC
l
physiologi
ca
l
,
giv
e
n slowly
.
S
u
bc
ut
a
n
e
ous
ad
ministr
a
tion
,
pr
e
f
e
r
ab
ly
a
voi
ded
in
a
n
a
phyl
ac
ti
c
sho
c
k
beca
us
e
th
e e
ff
ec
t is slow if possi
b
l
e
T
h
e
r
e
is no v
a
so
c
onstri
c
tion
e
ff
ec
t on th
e
skin
,
so th
e
r
e
is no
d
rug
ab
sorption
h
a
pp
e
n
.
5
.
A
minophyllin
e
,
ca
n
be
giv
e
n with gr
ea
t
ca
r
e
if th
e
r
e
is
b
ron
c
hosp
a
sm
h
a
s not
d
is
a
pp
ea
r
ed
with
ad
ministr
a
tion of
ad
r
e
n
a
lin
e
.
250
mg
a
minophyllin
e
w
a
s
ad
minist
e
r
ed
slowly ov
e
r
10
minut
e
s intr
a
v
e
nously
.
Ca
n
be c
ontinu
ed
with
a
noth
e
r
250
mg
vi
a
infusion
d
rips if
dee
m
ed
n
ece
ss
a
ry
.
6
.
A
ntihist
a
min
e
s
a
n
d c
orti
c
ost
e
roi
d
s
a
r
e
th
e
s
ec
on
d c
hoi
ce a
ft
e
r
ad
r
e
n
a
lin
e
.
B
oth
d
rugs
a
r
e
l
e
ss us
e
ful in th
e
st
a
g
e
of
a
n
a
phyl
ac
ti
c
sho
c
k
,
ca
n
be
giv
e
n
a
ft
e
r
c
lini
ca
l symptoms
be
gin to improv
e
to pr
e
v
e
nt
F
urth
e
r
c
ompli
ca
tions in
c
lu
de
s
e
rum si
c
kn
e
ss or prolong
ed e
ff
ec
ts
.
T
h
e a
ntihist
a
min
e c
ommonly us
ed
is
d
iph
e
nhy
d
r
a
min
e HC
l
5
–
20
mg
IV
a
n
d
for th
e c
orti
c
ost
e
roi
d
group
,
de
x
a
m
e
th
a
son
e
5
–
10
ca
n
be
us
ed
mg
IV
or hy
d
ro
c
ortison
e
100
–
250
mg
IV
.
7
.
Ca
r
d
io
P
ulmon
a
ry
Re
sus
c
it
a
tion
(
RKP
),
if
ca
r
d
i
ac a
rr
e
st o
cc
urs
(
ca
r
d
i
ac a
rr
e
st
)
th
e
n imm
ed
i
a
t
e ca
r
d
iopulmon
a
ry r
e
sus
c
it
a
tion pro
ced
ur
e
s
a
r
e
r
e
quir
ed
ca
rri
ed
out in
acc
or
da
n
ce
with th
e ABC
philosophy
a
n
d
so on
.
Re
m
e
m
be
r
T
h
e
possi
b
ility of
ca
r
d
i
ac a
rr
e
st in
a
n
a
n
a
phyl
ac
ti
c
sho
c
k is
a
lw
a
ys
I
f th
e
r
e
is
,
th
e
n n
a
tur
a
lly
a d
o
c
tor is
a
v
a
il
ab
l
e
in
e
v
e
ry pr
ac
ti
ce
room
A
p
a
rt from
e
m
e
rg
e
n
c
y m
ed
i
c
in
e
s
,
infusion
de
vi
ce
s
a
n
d
flui
d
s
a
r
e a
lso
de
vi
ce
s
r
e
sus
c
it
a
tion
(
Re
sus
c
it
a
tion kit
)
to f
ac
ilit
a
t
e
imm
ed
i
a
t
e ac
tion
.
8
.
A
lgorithm for
Ma
n
a
g
e
m
e
nt of
A
n
a
phyl
ac
ti
c Reac
tions
(
See A
pp
e
n
d
ix
1
)
F
ollow up pl
a
n
L
ook for th
e ca
us
e
of th
e a
n
a
phyl
ac
ti
c
r
eac
tion
a
n
d
r
ec
or
d
it in th
e
m
ed
i
ca
l r
ec
or
d a
s w
e
ll
N
otify th
e
p
a
ti
e
nt
a
n
d
f
a
mily
.
C
ouns
e
ling
a
n
d Ed
u
ca
tion
Fa
mili
e
s n
eed
to
be
inform
ed ab
out
a
ny form of inj
ec
tion
e
sp
ec
i
a
lly
d
rugs th
a
t h
a
v
e bee
n r
e
port
ed
to
be a
ntig
e
ni
c
(
s
e
rum
,
p
e
ni
c
illin
,
lo
ca
l
a
n
e
sth
e
si
a
,
e
t
c
.)
must
a
lw
a
ys
be a
l
e
rt for th
e
o
cc
urr
e
n
ce
of
a
n
a
phyl
ac
ti
c
r
eac
tions
.
Pa
ti
e
nts who
a
r
e c
l
a
ssifi
ed a
s high risk
(
with
a
history of
a
sthm
a
,
rhinitis
,
ec
z
e
m
a
,
or
oth
e
r
a
ll
e
rgi
c d
is
ea
s
e
s
)
n
eed
to
be
mor
e ca
r
e
ful
.
D
on
'
t try
inj
ec
t th
e
s
a
m
e d
rug if you h
a
v
e
pr
e
viously h
ad a
history of
a
ll
e
rgi
e
s
how
e
v
e
r sm
a
ll
.
I
t is
be
tt
e
r to r
e
pl
ace
it with
a
noth
e
r mor
e
suit
ab
l
e
pr
e
p
a
r
a
tion
s
a
f
e
.
Re
f
e
r
e
n
ce C
rit
e
ri
a
T
h
e
p
a
ti
e
nt
'
s
e
m
e
rg
e
n
c
y is h
a
n
d
l
ed
,
if th
e
tr
ea
tm
e
nt is
ca
rri
ed
out
I
f th
e
r
e
is no improv
e
m
e
nt
,
th
e
p
a
ti
e
nt is r
e
f
e
rr
ed
to s
ec
on
da
ry s
e
rvi
ce
s
.
E
quipm
e
nt
1
.
I
nfusion s
e
t
2
.
O
xyg
e
n
3
.
Ad
r
e
n
a
lin
e a
mpoul
e
,
a
minophyllin
e a
mpoul
e
,
d
iph
e
nhy
d
r
a
min
e
vi
a
l
,
de
x
a
m
e
th
a
son
e
a
mpoul
e
4
.
NaC
l
0
.
9
%
P
rognosis
T
h
e
prognosis of
a
n
a
phyl
ac
ti
c
sho
c
k
de
p
e
n
d
s gr
ea
tly on th
e
sp
eed
of
d
i
a
gnosis
a
n
d
m
a
n
a
g
e
m
e
nt is th
e
r
e
for
e
g
e
n
e
r
a
lly
d
u
b
i
a ad b
on
a
m
.
