Therapeutic Modalities Flashcards
1
Q
longboy tank
A
a tank that allows for long sitting with water up to mid thoracic level
2
Q
highboy tank
A
tank allows for water to be a chest height for large extremities; hips and knees to be submerged while flexed
3
Q
hubbard tank and contraindications
A
full body immersion
unstable blood pressure and incontinence
- should not exceed 100*
4
Q
how hot should a therapeutic pool be ?
A
79-97*
5
Q
what should be the temperature for acute inflammation of distal extremities ?
Exercise?
wound care/ spasticity?
Cardiopul compromise and burns?
A
inflammation: 32-79*
exercise: 79-92*
wound care/ spacitisy: 92-96* (low 90s)
Cardiopul compromise and burns: 96-98* (high 90s)
6
Q
how hot should water be for pn mgmt? chronic OA/RA and ROM ?
A
pn mgmt 99-104
chronic OA RA and ROM 104-110
7
Q
What requires the hottest and lowest water temps?
A
Acute inflammation in distal extremity = lowest
Chronic OA/RA and ROM = highest
8
Q
What are pool therapy advantages and considerations?
A
Advantages:
- decreased WB 2/2 buoyancy
- improved therapist handling
- better control over resistance
- decreased risk of falling
-therapist must remain with pt at all times to monitor vital signs and activity tolerance
9
Q
Who is pool therapy recommended for ?
A
- arthritis
- MSK injury
- neuro deficits
- SCI
- CVA
- MS
- selected CV dx
10
Q
Who is at an increased risk with hydrotherapy ?
A
hypotension ; increased risk for fainting
antihypertensive ie beta blockers
-Immersion of large body areas in warm or hot water can induce hypotension
11
Q
what temps should be used for contrast bath ?
A
hot: 104-106 for 3-4 mins (low 100s)
cold: 50-60 degrees 1 min
25- 30 mins in total
12
Q
what are the therapeutic effects of traction
A
decreased:
- disk protrusion
- pain
Increased:
- joint mobility
- relaxation
- soft tissue elasticity
- arterial, venous lymphatic flow
13
Q
what are indications for traction
A
Disc herniation joint hypomobility muscle guarding muscle spasm narrowing of the intravertebral foramen Nerve root impingement osteophyte formation subacute joint inflammation/ pain contracture of spinal ligaments and connective tissue
14
Q
what are contraindications for traction
A
Acute inflammation acute sprain or strain aortic aneurysm bone diseases cardiac/pulmonary problem movement contraindications or symptom exacerbation dislocation fracture Hiatal hernia radicular symptoms joint/bone infection Meningitis osteoporosis peripheralization of symptoms \+ Alar ligamentor vertebral artery test pregnancy advanced RA subluxation TMJ pain trauma without other med conditions ruled out tumors vascular condition vertebral joint instability
15
Q
what does traction in supine result in? L and C spine
A
greater separation of the posterior structures including facets and intervertebral foramen
- traction most often applied in supine
- Supine spinal stenosis 2/2 increased opening of intervertebral opening
16
Q
what does traction in extension result in ? L and C spine
A
greater separation of the anterior stxs
- positioned in extension
- separation of disk spaces
- application in prone allows application of modalities
- Prone: disk protrusions; disk can project anteriorly due to extension. Disk herniations most often occur and posterolateral direction
17
Q
what is the procedure for lumbar traction
A
select pt position
apply traction harness
select parameters: static or intermittent, Force, duration
18
Q
when is static traction indicated ? L spine
A
pt symptoms are slightly exaggerated by movement
19
Q
when is intermittent traction indicated L spine
A
- pt cant tolerate static traction
- joint mobilization
- calls for relax time (off) and hold times (on)
- F during relax period is about 50% of the hold F period
20
Q
what is the coefficient of friction and how is it calculated? what is it for a mattress ?
A
- constant friction force over 2 surfaces
- mattress on body = .5 (coefficient of friction)
- % of bodyweight below L3 (50%)x .5
- therefore 25% of the pts body weight is needed to overcome the force of friction on mattress
21
Q
how many lbs should be applied at the first session (recommended) for the L spine ? C- spine?
A
30 - lumbar
10 - cervical
22
Q
how much body weight should be used with traction for spasm, soft tissue or disk protrusion? L spine ? C-spine
A
lumbar: 25% of body weight
cervical: 7-10 % of BW or 11-15 lbs
23
Q
how much body weight should be used with traction for actual separation of vertebrae in L spine ? C-spine?
A
L: 50% of bw
C: 13-20% or bw or 20-30 lbs
24
Q
how long should traction be applied for disk related symptoms in L spine
A
10 - 30 mins
25
How would you target the upper, mid and lower cervical spine in traction
Upper: 0-5 flexion
Mid: 10-20 flexion
Lower: 25-35 flexion
26
when is intermittent traction indicated for cervical traction
- decrease pain
| - increase ROM
27
traction in the c-spine should not exceed how many lbs?
30
28
how long should tx be for traction in the c-spine for disk related symps? other conditions?
10 mins or less
| can extend up to 30 mins for other conditions
29
when should the therapist check in with the patient during traction for the initial tx?
first 5 mins
- check if symps worsen or peripheralize
- parameters should be modified or stopped if persistent
- pt should have bell or off switch
30
When is static compression indicated
- shape residual limbs
- control edema
- prevent abnormal scar formation
- decr. DVT
-
31
what bandage type offers the greatest resting pressure
long stretch bandage
60-70 mmhg
very little working pressure (P exerted with muscle contraction)
- often used in immobile patients
32
what bandage produces low pressure at rest and high working pressure
short stretch
- not effective in flaccid or inactive limbs
- mostly used in exercise
33
when are multilayered bandages used
venous stasis ulcers
| high resting P via use of several bandages
34
when is a semiridgid bandage used? what is an example?
- venous ulcer bandage that is applied wet and dries
- unna boot
- zinc oxide impregnated gauze
35
what mmhg is used to prevent DVT
16-18
36
what mmhg is used to prevent scar tissue
20-30
37
what mmgh is used for edema control
30-40
38
when is intermittent compression with a pneumatic device used
reduce chronic or post sx edema
39
what should the inflation Pressure be for intermittent compression with a pneumatic device used
- Should not exceed diastolic or systolic volume. Greater than systolic will restrict arterial bloodflow.
- arterial capillary P is 30 mmhg, P less than this will not have effect
- ***P should be btwn 30-80 ***
40
what are compression indications
```
Edema
hypertrophic scarring
lymphedema
new residual limb
risk for DVT
stasis ulcers
```
41
what are compression contraindications
```
Circulatory obstruction
DVT
heart failure
infected area
malignancy of area
unstable or acute fracture
pulmonary edema
```
42
What are indications for electrotherapy
```
Bell's palsy
decreased range of motion
facial neuropathy
fracture
idiopathic scoliosis
joint effusion
labor and delivery
muscle atrophy/spasm/weakness
open wound/ulcer
pain
stress incontinence
shoulder subluxation
```
43
What are contraindications for electrotherapy
```
Cardiac arrhythmia
cardiac pacemaker
over carotid sinus
patient with bladder stimulator
over pregnant uterus
malignancy
osteomyelitis
phlebitis
seizure
```
44
what is current, voltage, and resistance
current: the flow of charge from 1 end to the other via electrons
voltage: electrical difference from + and - end
resistance: opposition of flow of ions through it
R = V/C
45
what is direct current ? which modality uses it?
- constant flow of ions from anode(-) to cathode (+) for at least 1 sec
- polarity remains constant
- ionto
46
what is alternating current ?
- polarity changes from + and -
- change in current flow from one direction to another
- measured in Hz; frequency of cycles per second
- Alternating current is biphasic and can look asymmetrical or symmetrical and a sinusoidal wave
47
what is pulsatile current ? which modality uses it?
non-continous flow of AC or DC current
either: monophasic or biphasic
monophasic each wave is (+) or (-) produces polarity effect. Each phase will be either (+) or (-). Clarity effect allows current to flow through tissue.
- (1 phase in 1 pulse)
biphasic 1 (+) and 1 (-) phase in same pulse (2 phases 1 pulse). Phases will alternate "above and below line"
48
what should be done to the skin before electrode placement
clean with soap and water
| hair should be removed but not required
49
small electrodes
increased:
current density
impedance
Decreased: current flow
50
large electrodes
Decreased:
current density
impedance
increased: current flow
51
what is current density dependent of
size and distance apart from other electrode
- current is more concentrated under smaller E is 2 of unequal size are being used
- close in proximity, current is dense superfically
- far away in proximity, current is dense in deep tissue
52
what is monopolar technique
ionto and edema
| 1 active E is placed over target area (smaller), dispersive E is placed away from target area
53
what is bipolar technique
2 active E are placed on target area of = size
| used in msk weakness, nueromsk facilitation, spasm ROM
54
what is amplitude
magnitude of current
peak amp= max (+) or (-) point
peak amp must be big enough to pass nerve or muscle cell threshold
55
rise time
the time it takes to rise from 0 to peak amplituse
56
phase duration
amount of time it take for one phase of a pulse
biphasic: 2 phases in a pulse
monophasic: 1 phase in a pulse
(pulse duration = complete a cycle.)
57
frequncy
how many pulses are in 1 sec
| firing of fibers at faster rate, however same # of fibers are recruited
58
What are the parameters for NMES: amplitude, pulse duration and frequency, duty cycle tx time.
Amplitude: strong enough for contraction mindfull of strengthening or post sx
Pulse duration: high enough to overcome tissue capacitance
Frequency: prodice tetanic contraction
35-50
Ramp time: Based off 6-10 seconds on-time ramp should be 1 - 4 seconds
Duty cycle 6-10 secs on time, off time should b 5x longer
Time: 10-20 mins for 10-20 contractions at max
59
What is more comfortable for small muscles for pulse duration? large muscles?
small mus: short duration
| large mus: long pulse duration
60
what happens when pulse duration is shorted?
a greater amplitude is required to produce the same strength of contraction
61
When administering NMES, will high frequencies produce stronger contractions?
no, but will lead to more fatigue
62
conventional tens
provides pain relief by placing Es over painful area and stimulating a sensory but not motor response via short duration, low amplitude and high frequency.
- brief pain relief while machine is on
Used for ADLs
63
Acupuncture like tens
electrical pulses are delivered to generate muscle twitching for longer lasting pain relief via long duration, low freq, and moderate amplitude
64
breif intense tens
long duration high freq mod amplitude
| - minimize pain during therapeutic activity
65
noxious tens
delivered only for 30 micro secs-1 sec at high amplitude
| applied with probe
66
what principle of heat transfer does the body use to heat itself internally?
convection through blood circulation
| - other examples include whirlpool and fluidotherapy
67
what is conversion as a principle of heat transfer
heating when nonthermal energy is absorbed and converted to heat
- US and diathermy
68
therapeutic effects of cryotherapy
```
Decrease in:
BF to treatment area
decreased edema
local temperature
metabolic rate
nerve conduction velocity
tone
```
increased pain threshold
69
cryotherapy therapy indications
```
Abnormal tone
acute or chronic pain
acute or subacute inflammation
bursitis
muscle spasm
MSK trauma
trigger points
tendinitis /tenosynovitis
```
70
cryotherapy therapy contraindications
```
Cold intolerance
called Uticaria
cyroglobulinemia
infection
compromised area of circulation
area of regenerating peripheral nerves
parooxysmal cold hemoglobinuria
peripheral vascular disease
Reynards phenomenon
skin anesthesia
```
71
When is ice massage indicated
Small contoured area. Anti-inflammatory and stimulus to facilitate desired motor response with motor control impairment (Even though it decreases blood flow?)
72
Temperature should cooling packs be stored at
25*
73
How long should a cold pack be applied for? What is the depth of cold penetration
20 mins
30 mins for tissue spasticity
skin and subcutaneous tissues up to 2 cm in depth
74
how often should you check on a cold pack?
every 10 mins, replace after 20 mins
75
How long should a cold bath be used for at what temperature
15 to 20 minutes
| 55 to 64°
76
Indications for a cold bath
Effective for cooling distal extremities with circumferential contacts and home use. However requires extremity to remain in a gravity dependent position
77
Therapeutic effects of superficial thermotherapy
Decreased:
muscle spasm
tone
```
increased:
blood flow
capillary permeability
collagen extensibility
local temperature
metabolic rate
muscle elasticity
nerve conduction velocity
pain threshold
```
78
Indications for superficial thermal therapy
```
Decreased ROM
abnormal tone
mus gaurding/ spasm
trigger point
subacute or chronic pain or inflamation
```
79
Contra indications for superficial thermotherapy
```
acute trauma
arterial disease
bleeding /hemorrhage
compromised circulation
malignancy
PAD
thrombophlebitis
```
80
What temperature are hot packs stored at
158 - 167*
81
How many layers should be applied between the hot pack in skin
6-8
| commercial layers are equivalent to 2 to 3 towels
82
When is the max Superficial temperature reached with a hot pack when should skin checks begin. How long should treatment last
max temp reached: 6-8 min
check in 5 mins
15-20 mins tx time
83
what is the max tissue penetration with US
5 cm
84
what type of current does US use and what energy form does it use?
AC current
| Electric energy to acoustic energy is delivered at certain frequencies
85
what are the non thermal effects of US ?
increased cell permeability
increased intrcellualr Ca levels
tissue repair
promotion of normal cell fxn
86
what is unstable cavitation and when does it occur
rupture of bubbles that are formed with US
| Occurs with high intensity low frequency US
87
what does a low BNR indicate
high quality of crystal
| - less likely to experince hot spots and discomfort
88
what should BNR values range from
2:1 and 8:1
| commonly seen at 5:1 or 6:1
89
what does high BNR indicate
transducer will have to be moved at faster rate to avoid discomfort
90
what frequencies should be selected for superficial tissues in US
3mhz
91
what frequencies should be selected for deep tissues in US
1mhz
92
what does Frequency determine in US
depth
93
what is duty cylce
the total on time divided by the total on and off time to determine 100% continuous (thermal) or 20% pulsed (non-thermaal) US
94
how long should tx time be for US
with a size 2-3 times larger than the head, 5 mins
longer duration needed with lower Freq or intensity
if area is larger than 4x the effective radiating area ERA , dont use US
95
what is IFC?
-Used for pain relief, increased circulation, and muscle stimulation
2 biphasic currents that intersect and are amplified when both are in the same phase.
- very comfy for pts because deep amplitude goes in the muscles and only low amplitude is affects the skin
- can be delivered with bipolar, quadripolar and quadripolar with vector scan (offers the largest tx area)
96
Iontophoresis
Ions are delivered beyond skin barriers with direct current.
- ions are delivered based on:
1. ion concentration
2. pH and current density.
- Ions are repelled by the ion's charge from anode or cathode
97
Where are the indications for ultrasound
Non-thermal affects - acute and post acute conditions.
```
Calcium deposits
chronic inflammation
delayed soft tissue healing
dermal ulcer
joint contractures
muscle spasm trigger points
pain
plantar warts
scar tissue
tissue regeneration
```
98
What are the contraindications for ultrasound
use of thermal with acute and post acute conditions.
```
Active bleeding
Decreased temperature sensation/ circulation.
DVT
infection
malignancy
breast implants
carotid sinus or cervical ganglia
epiphyseal epiphyseal plates in children
eyes heart gentils
joint replacement
pelvic abdominal or lumbar in pregnant women
Pacemaker
thrombophlebitis
vascular insufficiency
```
99
Therapeutic effects for diathermy
```
Altered cell membrane function
increased:
collagen extensibility
metabolic rate
muscle elasticity
nerve conduction velocity
pain threshold
temperature
vasodilation
```
100
Diathermy indications
```
Bursitis
chronic inflammation or pelvic inflam. disease
decrease collagen extensibility
degenerative joint disease
increased metabolism (would you need this if metabolism is already increased tho?)
tissue healing
peripheral nerve regeneration pain
triggerpoints
muscle guarding/stiffness
```
101
Diathermy contraindications
```
ACute infection/inflammation
pacemaker
hemophilia
metal implants
intrauterine device
ishemic tissue
low back abdominal or pelvis of pregnant women
malignancy
moist wound dressing
hemorrhaging region
eyes, testes
pain and temperature sensor deficits
```
102
When would you use ultraviolet light
```
Acne
chronic ulcer/wound
osteomalacia
psoriasis
sinusitis
vitamin D deficiency
```
103
UV ilght contraindications
```
Active radiation area
diabetes
herpes Symplex
pellagra
photosensitive medication
skin cancer
systemic lupus erythematosus
tuberculosis
```
104
Iontophoresis indications
```
Pain
calcium deposits
fungal infection
hyperhidrosis
Inflammation
ischemia
keloids
muscle spasm
myositis ossifications
plantar warts
wounds
```
105
Iontophoresis contraindications
drug allergies and skin sensitivity reaction to specific ions
106
What's the dosage calculated with iontophoresis
Current amplitude and time are multiplied. Doses range from 40 to 80 mg
IxT=Dose
40mA dose= 4mA x10min
Lower amplitude with long duration less likely to cause skin irritation and burn
107
What should the polarity be set to for iontophoresis delivery
The same polarity as the Ion so it can be propelled (same charges repel)
108
how much space should be between the electrodes in iontophoresis
At least equivalent to the diameter of the active electrode
109
When are smaller and larger electrodes indicated for iontophoresis
Smaller electrodes: higher current density used for specific lesion.
Large electrodes: less well-defined defined
110
What is the current range for iontophoresis
1-4 mA
111
when does an acidic reaction occur with iontophoresis
Hydro chloric acid under the positive electrode anode
112
when does an alkaline reaction occur with iontophoresis
Sodium hydroxide under the negative electrode
113
How often should you check on a patient on iontophoresis and how can you decrease the risk of burns
```
Check every 3 to 5 minutes.
Burn risk decreased by:
- increase electrode size of cathode relative to anode
- decrease current density
- increase space between electrodes
```
114
Which ions used during iontophoresis are positive
Copper sulfate
Magnesium sulfate
lidocaine
zinc oxide
115
What is acetic acid used for?
Calcific deposits
| Myositis ossificans
116
What is calcium chloride used for with iontophoresis
Scar tissue keloids muscle spasms
117
What is Copper sulfate used for with iontophoresis
Fungal infection
118
What is dexamethasone used for with iontophoresis
Inflammation
119
What is Iodine used for with iontophoresis
Scars
| adhesive capsulitis
120
What is Lidocaine used for with iontophoresis
Analgesia
| inflammation
121
What is Magnesium sulfate used for with iontophoresis
Muscle spasms
| ischemia
122
What is Salicylates used for with iontophoresis
Muscle/joint pain plantar warts
123
What is Zinc oxide used for with iontophoresis
Healing
dermal ulcers
wounds
124
What is electromyography
Evaluation of motor units; the anterior horn cell and its axon axon neuromuscular junction and muscle fibers innervated by the unit
- Records the action potential's for a muscle fibers during voluntary and potentially spontaneous action potential's at rest
- Surface electrodes biofeedback used for larger muscles small or deep muscles require indwelling electrodes
125
During intramuscular MG what should a muscle at rest show? What Is an abnormal finding
Electrical silence, no electrical potentials
| Abnormal: spontaneous potential's during rest.
126
What would an EMG show during voluntary muscle contraction
- Action potential's begin to appear shape size frequency should be assessed.
- Increase of strength of contraction produces greater number of fibers
127
What is a fibrillation potential on EMG
Indicative of lower motor neuron disease
| a spontaneous abnormal potential
128
What is a Positive sharp wave on EMG
-Denervated muscle disorder at rest primary muscle disease such as muscular dystrophy
a spontaneous abnormal potential
129
What is a Fasciculation on EMG
- Irritation/degeneration of anterior horn, nerve root compression or muscle spasm
- a spontaneous abnormal potential
130
What is a Repetitive discharge on EMG
-Myopathy, lesion of anterior horn cell and peripheral nerve
| a spontaneous abnormal potential
131
What is a Polyphasic potential on EMG
Voluntary abnormal potential
| Myopathy muscle or peripheral nerve involvement
132
What can abnormal results on an EMG indicate
```
ALS
carpal tunnel syndrome
Duchenne muscular dystrophy
guillain barre syndrome
myasthenia gravis
peripheral neuropathy
polio
```
133
what Does biofeedback measure
Electrical activity *associated* with muscle contraction. Not muscle contraction
134
therapeutic effects of biofeedback
```
Pain reduction
muscular relaxation
neuromuscular control
improve strength
decreased muscle spasm
decreased accessory muscle use
```
135
What are the indications and contraindications for biofeedback
```
Indications:
bowel/urinary incontinence
cerebral palsy
hemiplegia
impaired motor control
muscle spasm/weakness pain
SCI
```
Contraindications:
muscle contraction is detrimental
skin irritation at electrode site
136
what are considerations for biofeedback used for muscle relaxation? Tx time? (+) sign?
high sensitivity setting used
-active E placed close to each other at first. As pt progresses, separate Es and increase sensivitiy
Tx time: 10-15
(+) sign: decrease in visual and audio
137
what are considerations for biofeedback used for muscle re-education ? Tx time? (+) sign?
low sensitivity setting used
- max mus contraction is perfomred, then machine is set to 66% of max contraction.
- isometric contraction held for 6-10 seconds
Tx time: 5- 10 min
(+) sign: increase in visual and audio
138
Massage therapeutic effects
```
Altered pain transmission
decreased anxiety and tension
decreased muscle atrophy, spasm
healing
improve circulation/lymphatic circulation
loosen adhesions
decreased edema
relaxation
removal of metabolic waste
stimulate reflective effects
```
139
massage indications
```
Adhesion
bursitis
decreased ROM
edema
intermittent claudication
lactic acid excess
migraine/headache
muscle spasm/cramping
pain
Reynards phenomenon
scar tissue
tendinitis
triggerpoints
```
140
massage contraindications
```
acute injury
arteriosclerosis
cancer
cellulitis
embolus
infection
thrombus
```
141
How do you recognize CPR and adult children and infants
all ages: no response
Adult : no breathing or 'no normal breathing'
child /infant: no breathing or only gasping
142
CPR sequence
Compression>airway >breathing
143
CPR compression rate
100-120
144
CPR compression depth
Adult : 1-2 inch
child : 1/3 chest depth ~2in
infant: 1/3 chest depth ~1.5 inch
145
CPR chest wall recoil depth
| how often should CPR providers rotate ?
allow complete recoil btwn compressions
| Health care providers rotate every 2 mins
146
CPR chest compression interruption
<10secs
147
What should a HCP perform to the airway in CPR if there is suspected trauma
jaw thrust
| otherwise the head tilt-chin lift should be used
148
compression to ventilation ratio (until airway is placed) for adult and child & infant
Adult 30:2 for 1 or 2 rescuers
Child/ infant: 30:2 for single rescuer or 15:2 for 2 rescuers
149
Rescuers untrained or not trained enough what sort of ventilation should be used
None compressions only
150
Ventilation for CPR with advanced airway. Who should perform this? Breaths are delivered per minute
- 1 breath every 6-8 secs (6-8 breaths/min)
- Asynchronous with chest compressions
- Take about one second for breath
- make sure Chest rises
151
When should an AED be attached? What should be done about interruptions? When resuming CPR what should you do after AED shock?
- AED should be attached as soon as possible.
- Minimize interruptions in chest compressions before and after shot
- resume CPR with compression immediately after shock
152
```
Pulmonary embolism:
Clinical presentation
Risk factors
Diagnosis
Treatment
```
Clinical presentation -Difficulty breathing chest pain that mimics hurt attack, rapid pulse, severe cases: circulatory instability and death
Risk factors-Immobility increase clotting factors in blood abnormal factors in vessel wall
Diagnosis-Seminary and geography, chest x-ray, lung scan, spiral CT scan
Treatment- Anticoagulant medication – heparin and warfarin
153
Hypovolemic shock:
Clinical presentation
Risk factors
Treatment
Clinical presentation -Anxiety, altered mental state, cool clammy skin ,rapid 30 pulse ,thirst, fatigue poor oxygenation
Risk factors-Severe trauma, burns
Treatment- Pain supine legs elevated 12 inches. Control bleeding attempt to restore blood volume with infusion and balanced salt solution
154
Autonomic dysreflexia
Clinical presentation
Risk factors
MGMT
Noxious stimuli such as: skin ulcers, UTI, bladder distention, and bowel impaction
Clinical presentation - Sweating above level of lesion, skin flushing above lesion, elevated blood pressure, blurred vision. Laying pt down is contraindicated due to exacerbation of blood pressure
Risk factors-SCI above T6
MGMT - Sit patient upright to lower elevated blood pressure. Remove tight clothing and stockings. Adjust Foley catheter
Treatment- Sit patient upright
155
What are other types of shock?
Cardiogenic shock: heart failure managed by oxygen therapy and cardiac medication.
Septic shock: overwhelming infection leading to vasodilation. MGMT by restoring intravascular volume and identify source of infection.
Anaphylactic shock: severe sometimes fatal re-allergic reaction causing vasodilation hypotension and capillary permeability. MGMT by removing allergen
