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Emergency treatment of anaphylactic reactions—–Guidelines for healthcare providersଝ
Jasmeet Soar ∗, Richard Pumphrey, Andrew Cant, Sue Clarke, Allison Corbett, Peter Dawson, Pamela Ewan, Bernard Fo¨ ex, David Gabbott, Matt Grifﬁths, Judith Hall, Nigel Harper, Fiona Jewkes, Ian Maconochie, Sarah Mitchell, Shuaib Nasser, Jerry Nolan, George Rylance, Aziz Sheikh, David Joseph Unsworth, David Warrell,
Working Group of the Resuscitation Council (UK)1
Received 5 February 2008; accepted 5 February 2008
Anaphylactic reactions; Treatment
Summary • The UK incidence of anaphylactic reactions is increasing. • Patients who have an anaphylactic reaction have life-threatening airway and, or breathing and, or circulation problems usually associated with skin or mucosal changes. • Patients having an anaphylactic reaction should be treated using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. • Anaphylactic reactions are not easy to study with randomised controlled trials. There are, however, systematic reviews of the available evidence and a wealth of clinical experience to help formulate guidelines. • The exact treatment will depend on the patient’s location, the equipment and drugs available, and the skills of those treating the anaphylactic reaction. • Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction. • Despite previous guidelines, there is still confusion about the indications, dose and route of adrenaline.
A Spanish translated version of the summary of this article appears as Appendix in the ﬁnal online version at doi:10.1016/j.resuscitation.2008.02.001. ∗ Corresponding author. Tel.: +44 117 323 5114. E-mail address: Jasmeet.email@example.com (J. Soar). 1 See Appendix A. 0300-9572/$ — see front matter © 2008 Resuscitation Council (UK). Published by Elsevier Ireland Ltd. doi:10.1016/j.resuscitation.2008.02.001
The document was accessed 15. • There is a need for further research about the diagnosis. There are no randomised controlled clinical trials in humans providing unequivocal evidence for the treatment of anaphylactic reactions.org. treatment and prevention of anaphylactic reactions. or breathing and. treatment. life-threatening. The ﬁnal guideline was made available on the Resuscitation Council UK website in January 2008. There is less emphasis on specifying treatments according to which speciﬁc groups of healthcare providers should give them. Drafts of this guideline were discussed by email.org. there is confusion about the diagnosis. Scope of this guideline This guideline is for healthcare providers who are expected to deal with an anaphylactic reaction during their usual clinical role (e. and that will be appropriate for most anaphylactic reactions. • All those who are suspected of having had an anaphylactic reaction should be referred to a specialist in allergy. The Association of Anaesthetists of Great Britain & Ireland and the British Society for Allergy and Clinical Immunology have published speciﬁc guidance for the treatment of anaphylactic reactions associated with anaesthesia (www. The group met in January and November 2007.bsaci. 2. Any differences will be highlighted. A greater focus on the treatments that a patient having an anaphylactic reaction should receive.uk). there is a wealth of experience and systematic reviews of the limited evidence that can be used as a resource. investigation and follow-up of patients who have an anaphylactic reaction. Introduction Purpose of this guideline The UK incidence of anaphylactic reactions is rising.432 times in this period. paramedics) working in the hospital or out-of-hospital setting. An updated consensus about the recognition and treatment of anaphylactic reactions.1 Despite previous guidelines. As the criteria for inclusion vary in different studies and countries.org). The co-chairs (appointed by the Executive Committee of the Resuscitation Council UK) identiﬁed the key issues based on review of the previous guidelines and a database of frequently asked questions. The review date for the guideline is January 2013 or earlier if necessary.aagbi. An American College of Allergy.6 This guideline gives: 1.000 persons per year and a lifetime prevalence of between 50 and 2000 episodes .5 The full version of this guideline and supplementary information is available on the Resuscitation Council UK website (www. Published by Elsevier Ireland Ltd. There is no universally agreed deﬁnition.g. We have therefore deliberately not developed guidelines for speciﬁc groups of healthcare provider. or circulation problems usually associated with skin and mucosal changes. There is considerable variation and overlap between the skills and knowledge of different healthcare providers who are expected to treat an anaphylactic reaction.resus. A draft guideline was made available for comment on the Resuscitation Council UK website between 25th September and 4th November 2007.7.uk). Nonetheless. The key treatment of a patient having an anaphylactic reaction in any setting is the same for children9 and adults.8 Epidemiology Anaphylaxis is not always recognised. generalised or systemic hypersensitivity reaction This is characterised by rapidly developing life-threatening airway and. Anaphylaxis Deﬁnition of anaphylaxis A precise deﬁnition of anaphylaxis is not important for the emergency treatment of an anaphylactic reaction.allergyinschools.2—4 This guideline replaces the previous guidance from the Resuscitation Council UK. Recommendations for treatment that are simple to learn and easy to implement. nurses.org and www.org.158 J. nurseries and similar settings (www.medicalconditionsatschool. • Intravenous adrenaline must only be used in certain specialist settings and only by those skilled and experienced in its use. Soar et al.. Asthma and Immunology working group found that the overall frequency of episodes of anaphylaxis using current data lies between 30 and 950 cases per 100. There is also speciﬁc guidance for managing medicines in schools. The European Academy of Allergology and Clinical Immunology Nomenclature Committee proposed the following broad deﬁnition10 : Anaphylaxis is a severe. Methods Organisations involved in the previous guideline nominated individuals for the Working Group. doctors. © 2008 Resuscitation Council (UK). The feedback was reviewed at the November working group meeting and the document updated. a picture has to be built up from different sources.uk and www. • Individuals who are at high risk of an anaphylactic reaction should carry an adrenaline autoinjector and receive training and support in its use. 3. so studies may underestimate the incidence.
5 gelatins.000 in 2005. death usually occurs very soon after contact with the trigger. Anaphylaxis can be triggered by any of a very broad range of triggers (Table 1). 1 hair dye. 11 mixed or unknown 5 milk.5 to 3. 1 vancomycin 19 suxamethonium.13 Taking speciﬁc causes of anaphylaxis where prevalence and severity data are available.6 admissions per 100. local anaesthetic. being estimated at approximately 1 in 12 per year. 7 vecuronium. . 1 hydatid 159 Food Food possible cause 13 17 Antibiotics 27 Anaesthetic drugs 39 Other drugs 24 Figure 1 Hospital admission rates for anaphylaxis.333 of the English population have experienced anaphylaxis at some point in their lives. acetazolamide. 2 chickpea.20 There are approximately 20 anaphylaxis deaths reported each year in the UK.0%. fatal food reactions cause respiratory arrest typically after 30—35 min. nectarine. Contrast media Other 11 3 NSAID. per 100. and relating this number to the population served.000 persons or 0. 2 protamine.int/classiﬁcations/icd/en/). 2 vitamin K. 1 snail 5 during meal. 2 crustacean. 3 ACEI. 6 atracurium.24 Figure 2 Time to cardiac arrest following exposure to triggering agent. 1 each . 2 brazil. 3 milk.000 between 1990 and 2004: an increase of 700% (Figure 1). or delay treatment with adrenaline. worldwide there are 1 million cases of venom anaphylaxis and 0. with a case fatality ratio of less than 1% reported in most populationbased studies.who. yeast.22. pethidine. but data indicate a dramatic increase in the rate of hospital admissions for anaphylaxis.etoposide. estimated that approximately 1 in 3500 patients had an episode of anaphylaxis during the study period 1993—1994. 1 hazel. but certain foods (nuts) and drugs (muscle relaxants. indicating a lifetime age-standardised prevalence of a recorded diagnosis of anaphylaxis of 75.15 Virtually any food or drug group can be implicated.11 More recent UK primary care data concur. 12 cephalosporin. nonsteroidal anti-inﬂammatory agents (NSAIDs) and aspirin) cause most reactions. identifying only the most severe cases. this increasing from 0. 1 each ﬁsh.5 per 100. The risk of individuals suffering recurrent anaphylactic reactions appears to be quite substantial. A retrospective study of Emergency department attendances. sherbet. streptokinase 9 iodinated.23 When anaphylaxis is fatal.24 .12 Calculations based on these data indicate that approximately 1 in 1.05—2. 2 amphotericin. diamorphine. The overall prognosis of anaphylaxis is good. 7 at induction 6 NSAID. 1 technetium. ACEI.17—19 Risk of death is increased in those with pre-existing asthma. 2 almond. 1 ciproﬂoxacin. grape. non-steroidal anti-inﬂammatory drug.21 There are very limited data on trends in anaphylaxis internationally. From a case-series. 2 ﬁsh. 3 nut. 14 unknown 10 peanut. 1990—2004.16 A signiﬁcant number of cases of anaphylaxis are idiopathic (non-IgE mediated). 1 banana. particularly if the asthma is poorly controlled or in those asthmatics who fail to use.4 million cases of nut anaphylaxis recorded up to age 44 years. England ICD—–International Classiﬁcation of Diseases (www. antibiotics. 1 ﬂuorescein 1 latex. and deaths caused by intravenous medication occur most commonly within 5 min. strawberry 11 penicillin. Angiotensin Converting Enzyme inhibitor. although this may be an underestimate. 6 walnut.14 Food is the commonest trigger in children and drugs the commonest in adults. Death never occurred more than 6 h after contact with the trigger (Figure 2).Emergency treatment of anaphylactic reactions—–Guidelines for healthcare providers Table 1 Suspected triggers for fatal anaphylactic reaction between 1992 and 200114 Stings Nuts 47 32 29 wasp. 4 bee. insect stings cause collapse from shock after 10—15 min.
Rarely. Patient becoming tired. e. however. • Most reactions occur over several minutes. Respiratory arrest. angioedema) The following supports the diagnosis • Exposure to a known allergen for the patient Remember • Skin or mucosal changes alone are not a sign of an anaphylactic reaction.g. Confusion caused by hypoxia. Breathing problems • • • • • • Shortness of breath—–increased respiratory rate. and loss of ﬂuid from the circulation. abdominal pain. or breathing and. throat and tongue swelling (pharyngeal/laryngeal oedema). There is a range of signs and symptoms.24 • The patient is usually anxious and can experience a ‘‘sense of impending doom’’.e. collapse.24 Anaphylaxis is likely when all of the following 3 criteria are met: • Sudden onset and rapid progression of symptoms • Life-threatening Airway and/or Breathing and/or Circulation problems • Skin and/or mucosal changes (ﬂushing. because the lifethreatening features are not present. a Circulation problem). There may be confusion. • Stridor—–this is a high-pitched inspiratory noise caused by upper airway obstruction. • There can also be gastrointestinal symptoms (e. often preceding cardiac arrest. or Circulation problems Patients can have either an A or B or C problem or any combination. agitation and loss of consciousness. angioedema. • Hoarse voice. • Skin or mucosal changes can be subtle or absent in up to 20% of reactions (some patients can have only a decrease in blood pressure.. vomiting. Cyanosis (appears blue)—–this is usually a late sign. An intravenous trigger will cause a more rapid onset of reaction than stings which. generalised urticaria. Disability problems) because of decreased brain perfusion. Confusion arises because some patients have systemic allergic reactions that are less severe. The reaction is usually unexpected. and rhinitis would not be described as an anaphylactic reaction. Soar et al.29 • Decreased conscious level or loss of consciousness. Life-threatening asthma with no features of anaphylaxis can be triggered by food allergy. The lack of any consistent clinical manifestation and a range of possible presentations cause diagnostic difﬁculty. or Breathing and.26 Life-threatening Airway and. For example. vasodilation and capillary leak. i.160 J. .14. Airway problems • Airway swelling.. urticaria. Guidelines for the treatment of an anaphylactic reaction must therefore take into account some inevitable diagnostic errors. Circulation problems (often referred to as anaphylactic shock) can be caused by direct myocardial depression. or circulation problems usually associated with skin and mucosal changes. • Anaphylaxis can cause myocardial ischaemia and electrocardiograph (ECG) changes even in individuals with normal coronary arteries.. certain combinations of signs make the diagnosis of an anaphylactic reaction more likely. none of which are entirely speciﬁc for an anaphylactic reaction.25 Patients have been given injections of adrenaline inappropriately for allergic reactions just involving the skin.28 Circulation problems • Signs of shock—–pale. • Low blood pressure (hypotension)—–feeling faint (dizziness). A single set of criteria will not identify all anaphylactic reactions. clammy. The patient has difﬁculty in breathing and swallowing and feels that the throat is closing up. in turn. tend to cause a more rapid onset than orally ingested triggers (Figure 2). or for vasovagal reactions or panic attacks. • The time of onset of an anaphylactic reaction depends on the type of trigger.27 Recognition of an anaphylactic reaction Anaphylactic reaction is the likely diagnosis if a patient who is exposed to a trigger (allergen) develops a sudden illness (usually within minutes) with rapidly developing lifethreatening airway and. • Increased pulse rate (tachycardia). incontinence). Breathing and Circulation problems also alter the patient’s neurological status (D. with an emphasis on the need for safety.g. Many patients with a genuine anaphylactic reaction are not given the correct treatment.30 • Cardiac arrest. reactions may be slower in onset. Sudden onset and rapid progression of symptoms • The patient will feel and look unwell.31 Airway. Patients with anaphylaxis can deteriorate if made to sit up or stand up. Wheeze. Bradycardia (a slow pulse) is usually a late feature.3 Diagnostic problems have arisen particularly in children.
They are usually itchy. Recognition that they are seriously unwell.33 3. an ambulance must be called early and the patient transported to an emergency department. Initial assessment and treatments based on an ABCDE approach. pallor. the clinical signs of critical illness are similar whatever the underlying process because they reﬂect failing respiratory. 2. Diagnostic difﬁculty may also occur with vasovagal attacks after immunisation procedures. Clinical staff should be familiar with the equipment and drugs they have available and should check them regularly. and swelling are useful distinguishing features. Patients with Airway and Breathing problems may prefer to sit up as this will make breathing easier. • There may be just skin. • Following an ABCDE approach will help with treating the differential diagnoses. Location—–Out of hospital. Use an ABCDE approach to recognise and treat an anaphylactic reaction.. or both skin and mucosal changes. 5. or mucosal changes These should be assessed as part of the Exposure when using the ABCDE approach. and neurological systems. Clinical staff who give parenteral medications should have initial training and regular updates in dealing with anaphylactic reactions. Lying ﬂat with or without leg elevation is helpful for patients with a low blood . cardiovascular. In general.e.Emergency treatment of anaphylactic reactions—–Guidelines for healthcare providers 161 Skin and. The speciﬁc treatment of an anaphylactic reaction depends on: 1. Reassuringly. An early call for help. i. Investigation and follow-up by an allergy specialist. The weals may be pale. red rash. wheeze. and are often surrounded by a red ﬂare. all those who treat anaphylaxis must have a systematic approach to the sick patient. • There may be erythema—–a patchy. • They are often the ﬁrst feature and present in over 80% of anaphylactic reactions. • Angioedema is similar to urticaria but involves swelling of deeper tissues. which can appear anywhere on the body. Non-life-threatening conditions (these usually respond to simple measures): • • • • Faint (vasovagal episode) Panic attack Breath-holding episode in child Idiopathic (non-allergic) urticaria or angioedema Patients having an anaphylactic reaction in any setting should expect the following as a minimum 1. The sense of impending doom and breathlessness leading to hyperventilation are symptoms that resemble anaphylaxis in some ways. All patients who have had an anaphylactic reaction should be monitored (e. breathing difﬁculties. by ambulance crew.. • There may be urticaria (also called hives. • Seek help early if there are any doubts about the diagnosis and treatment.) as soon as possible. several actions can be undertaken simultaneously. Treatment of an anaphylactic reaction As the diagnosis of anaphylaxis is not always obvious. • A low blood pressure (or normal in children) with a petechial or purpuric rash can be a sign of septic shock. 4. 3. or urticarial rash or swelling. and sometimes in the mouth and throat. weals or welts). Equipment and drugs available—–Resuscitation equipment and drugs to help with the rapid resuscitation of a patient with an anaphylactic reaction must be immediately available in all clinical settings. pink or red. If there are several rescuers. there may sometimes be ﬂushing or blotchy skin associated with anxiety adding to the diagnostic difﬁculty.32 • They can be subtle or dramatic. Differential diagnosis Life-threatening conditions: • Sometimes an anaphylactic reaction can present with symptoms and signs that are very similar to lifethreatening asthma—–this is commonest in children. most patients who have skin changes caused by allergy do not go on to develop an anaphylactic reaction. in the emergency department. but the absence of rash. ABCDE problems. Victims of previous anaphylaxis can be prone to panic attacks if they think they have been reexposed to the allergen that caused a previous problem. or generalised. tic episode. Adrenaline therapy if indicated. Treat life-threatening problems as you ﬁnd them. Number of responders—–The single responder must always ensure that help is coming. Fainting will usually respond to lying the patient down and raising the legs. Training and skills of rescuers—–All clinical staff should be able to call for help and initiate treatment in a patient with an anaphylactic reaction. 2. They can be different shapes and sizes. etc. While there is no hypotension. There can be confusion between an anaphylactic reaction and a panic attack. as is the slow pulse of a vasovagal attack compared with the rapid pulse of a severe anaphylac- Patient positioning All patients should be placed in a comfortable position. most commonly in the eyelids and lips. The basic principles of treatment are the same for all age groups. just mucosal.g. 4. The Health Protection Agency recommends that staff who give immunisations should have annual updates. Minimal monitoring includes pulse oximetry. nettle rash. non-invasive blood pressure and 3lead ECG. and may look like nettle stings.
38 Although there are no randomised controlled trials. i.3 mL) if child is small or prepubertal 300 g IM (0. Pregnant patients should lie on their left side to prevent caval compression. Stop any drug suspected of causing an anaphylactic reaction (e. Do not make patients sit or stand up if they feel faint—–this can cause cardiac arrest.g. This will help monitor the response to adrenaline.5 mL).5 mg IM (=500 g = 0. There are beta-2 adrenergic receptors on mast cells39 that inhibit activation. >6—12 years: >6 months—6 years: <6 months: Repeat the IM adrenaline dose if there is no improvement in the patient’s condition. Adrenaline must be readily available in clinical areas where an anaphylactic reaction could occur. attempts to make the patient vomit are not recommended. Many healthcare providers will have given IV adrenaline as part of resuscitating a patient in cardiac arrest. ECG.43 The subcutaneous or inhaled routes for adrenaline are not recommended for the treatment of an anaphylactic reaction because they are less effective than the IM route.37 Rescuers should ensure that help is on its way as early advanced life support (ALS) is essential.3 This section on IV adrenaline applies to those experienced in the use and titration of vasopressors in their normal clinical practice (e.. Adrenaline IM dose—–children The scientiﬁc basis for the recommended doses is weak.46 (The equivalent volume of 1:1000 adrenaline is shown in brackets. Further doses can be given at about 5-min intervals according to the patient’s response. Anaphylaxis algorithm The key steps for the treatment of an anaphylactic reaction are shown in the algorithm (Figure 3. The recommended doses are based on what is considered to be safe and practical to draw up and inject in an emergency. Adrenaline seems to work best when given early after the onset of the reaction41 but it is not without risk. blood pressure.42.40 and so early adrenaline attenuates the severity of IgE-mediated allergic reactions..35 After food-induced anaphylaxis.36.44. Cardiorespiratory arrest following an anaphylactic reaction Start cardiopulmonary resuscitation (CPR) immediately and follow current guidelines.15 mL) Remove the trigger if possible Removing the trigger of an anaphylactic reaction is not always possible. particularly when given intravenously. As an alpha-receptor agonist. anaesthetists. The IM route has several beneﬁts: • There is a greater margin of safety.15 mL) 150 g IM (0.) Drugs and their delivery Adrenaline (epinephrine) Adrenaline is the most important drug for the treatment of an anaphylactic reaction. adrenaline is a logical treatment31 and there is consistent anecdotal evidence supporting its use to ease breathing and circulation problems associated with anaphylaxis.5 mL of 1:1000) adrenaline. stop intravenous infusion of a gelatin solution or antibiotic). it reverses peripheral vasodilation and reduces oedema. • The IM route is easier to learn. Intravenous (IV) adrenaline (for specialist use only) The intramuscular route for adrenaline is the route of choice for most healthcare providers (see Section ‘Intramuscular (IM) adrenaline’). pulse oximetry). The intramuscular route for adrenaline is not recommended after cardiac arrest has occurred. Do not delay deﬁnitive treatment if removing the trigger is not feasible.42 The needle used for injection needs to be long enough to ensure that the adrenaline is injected into muscle. Intramuscular adrenaline The intramuscular route is the best for most individuals who have to give adrenaline to treat an anaphylactic reaction.29 Patients who are breathing and unconscious should be placed on their side (recovery position). same as adult dose 300 g (0.24 Adverse effects are extremely rare with correct doses injected intramuscularly (IM).162 pressure (Circulation problem). The best site for IM injection is the anterolateral aspect of the middle third of the thigh.) >12 years: 500 g IM (0.3 mL) 150 g IM (0. Its betareceptor activity dilates the bronchial airways. If these features are absent but there are other features of a systemic allergic reaction. Adrenaline should be given to all patients with lifethreatening features. and suppresses histamine and leukotriene release. Remove the stinger after a bee sting.e. This alone is insufﬁcient experience to use IV adrenaline for the treatment of an anaphylactic reaction. In patients with a . the patient needs careful observation and symptomatic treatment using the ABCDE approach.g. emergency physicians. Soar et al.34 J. Early removal is more important than the method of removal. • It does not require intravenous access. increases the force of myocardial contraction..45 Adrenaline IM dose—–adults 0. intensive care doctors). Use doses of adrenaline recommended in ALS guidelines.34. There is a much greater risk of causing harmful side effects by inappropriate dosage or misdiagnosis of anaphylaxis when using IV adrenaline. Monitor the patient as soon as possible (pulse.
.Emergency treatment of anaphylactic reactions—–Guidelines for healthcare providers 163 Figure 3 The anaphylaxis algorithm.
A dose of 50 g is 0. in patients taking tricyclic antidepressants. intravenous adrenaline can cause life-threatening hypertension.. The more appropriate dose for an auto-injector should be prescribed for individual patients by allergy specialists. Patients who are given IV adrenaline must be monitored—–continuous ECG and pulse oximetry and frequent non-invasive blood pressure measurements as a minimum. If intravenous access is delayed or impossible. Consider colloid infusion as a cause in a patient receiving a colloid at the time of onset of an anaphylactic reaction and stop the infusion. paediatric anaesthetists. tachycardia. The pre-ﬁlled 10 mL syringe of 1:10. titrate the dose according to effect. The dose of chlorphenamine depends on age (Figure 3). They may not help in reactions depending in part on other mediators but they have the virtue of safety.48. which is the smallest dose that can be given accurately. start with a safe dose and give further doses if a greater response is needed. The dose recommendations for adrenaline in this guideline are intended for healthcare providers treating an anaphylactic reaction. it is important to monitor the response. and myocardial ischaemia. the previous recommendation was to give half the dose). Healthcare professionals should be familiar with the use of the most commonly available auto-injector devices. arrhythmias.3 mg.. the intra-osseous route can be used for ﬂuids or drugs when resuscitating children or adults. A child may respond to a dose as small as 1 g/kg.g. The IV route is recommended only in specialist paediatric settings by those familiar with its use (e. In clinical practice. infuse intravenous ﬂuids immediately. healthcare providers should use it. but only by healthcare workers who are accustomed to do so. There is no evidence to support the use of colloids over crystalloids in this setting. If there is intravenous access. Patients who require repeated IM doses of adrenaline may beneﬁt from IV adrenaline. There is no evidence on which to base a dose recommendation—–the dose is titrated according to response.50 Do not delay the administration of IM adrenaline attempting intra-osseous access.49 Hartmann’s solution or 0. Do not give the undiluted 1:1000 adrenaline concentration IV. J. If an adrenaline auto-injector is the only available adrenaline preparation when treating anaphylaxis. but there are logical reasons for them. there . Adrenaline in special populations Previous guidelines recommended adrenaline dose adjustments in certain circumstances (e. use the IM route for adrenaline. The evidence to support their use is weak. There will also be vasodilation. A large volume of ﬂuid may be needed. start an IV adrenaline infusion.47 Use local guidelines for the preparation and infusion of adrenaline. Antihistamines (after initial resuscitation) Antihistamines are a second line treatment for an anaphylactic reaction. they are unlikely to be life-saving in a true anaphylactic reaction.. are only two doses of adrenaline auto-injector commonly available: 0. If the patient’s trachea is intubated. Used alone. ventilate the lungs with high concentration oxygen using a self-inﬂating bag. ranitidine..5 mL. Adrenaline IV bolus dose—–children IM adrenaline is the preferred route for children having an anaphylactic reaction.51 Antihistamines (H1 -antihistamine) may help counter histamine-mediated vasodilation and bronchoconstriction. cimetidine) for the initial treatment of an anaphylactic reaction. give the highest concentration of oxygen possible using a mask with an oxygen reservoir. There is large inter-individual variability in the response to adrenaline.000 adrenaline contains 100 g/mL. It is essential that these patients receive expert help early. If repeated adrenaline doses are needed. Give a rapid IV ﬂuid challenge (20 mL/kg in a child or 500—1000 mL in an adult) and monitor the response.5 The Working Group considered it unhelpful to have caveats such as this in the setting of an acute anaphylactic reaction. Inject chlorphenamine slowly intravenously or intramuscularly. Soar et al.15 and 0. There is little evidence to support the routine use of an H2 -antihistamine (e. At the time of writing. If the patient requires repeated IV bolus doses of adrenaline.9% saline are suitable ﬂuids for initial resuscitation. For specialist use only Ensure patient is monitored Adrenaline IV bolus dose—–adult Titrate IV adrenaline using 50 g boluses according to response. If IV access is not available or not achieved rapidly.164 spontaneous circulation. Oxygen (give as soon as available) Initially.g. This requires very careful dilution and checking to prevent dose errors. give further doses as necessary. i.52 Adrenaline auto-injectors Auto-injectors are often given to patients at risk of anaphylaxis for their own use. paediatric intensivists) and if the patient is monitored and IV access is already available.g. Adrenaline infusion An infusion of adrenaline with the rate titrated according to response in the presence of continued haemodynamic monitoring is an effective way of giving adrenaline during anaphylaxis. Ensure high ﬂow oxygen (usually greater than 10 L min−1 ) to prevent collapse of the reservoir during inspiration. Fluids (give as soon as available) Large volumes of ﬂuid may leak from the patient’s circulation during an anaphylactic reaction. start an adrenaline infusion. paediatric emergency physicians.e.
61 Some patients develop severe bradycardia after an anaphylactic reaction. .63 Investigations Undertake the usual investigations appropriate for a medical emergency. Remember that intravenous magnesium is a vasodilator and can cause hot ﬂushes and make hypotension worse.62 The half-life of tryptase is short (approximately 2 h).. metaraminol and glucagon) when initial resuscitation with adrenaline and ﬂuids has not been successful. follow the British Thoracic Society—–SIGN asthma guidelines (www. (2) Second sample at 1—2 h after the start of symptoms. There are animal studies and case reports describing the use of other vasopressors and inotropes (noradrenaline. though sub-optimal. Tryptase levels are useful in the follow-up of suspected anaphylactic reactions. In hospital patients with asthma.54 There is little evidence on which to base the optimum dose of hydrocortisone in anaphylaxis. intensive care units) where there is experience in their use. arterial blood gases. Other drugs Bronchodilators The presenting symptoms and signs of a severe anaphylactic reaction and life-threatening asthma can be the same. As well as the drugs listed above. etc. information.g.org. mast cell degranulation leads to markedly increased blood tryptase concentrations (Figure 4). Some laboratories ask for a plasma sample—–either plasma or serum samples can be tested. (4) Optimally. but 5 mL (adults) is better.britthoracic. 12-lead ECG. not in the initial recognition and treatment: measuring tryptase levels must not delay initial resuscitation.47 Figure 4 Suggested time course for the appearance of tryptase in serum or plasma during systemic anaphylaxis. vasopressin. The dose of hydrocortisone for adults and children depends on age (Figure 3).62 Reproduced and adapted with permission from Elsevier.uk). (1) Use a serum or clotted blood sample. It is important that this time is accurately recorded. If the patient has asthma-like features alone. e. Consider IV atropine to treat this. ipratropium (inhaled). Tryptase concentrations in the blood may not increase signiﬁcantly until 30 min or more after the onset of symptoms. so timing of any blood samples is very important. (5) Tryptase is very stable (50% of tryptase is still detectable after 4 days at room temperature62 ). chest X-ray.56—60 Only use these drugs in specialist settings (e. early corticosteroid treatment is beneﬁcial in adults and children. In anaphylaxis. (6) Consult your local laboratory if you have any queries.36. before dispatch to a reference laboratory. Cardiac drugs Adrenaline remains the ﬁrst line vasopressor for the treatment of anaphylactic reactions. higher doses of hydrocortisone do not seem to be better than smaller doses.53. store the serum from spun samples frozen (−20 ◦ C) in the local laboratory. This provides baseline tryptase levels—–some individuals have an elevated baseline level. (3) Third sample either at 24 h or in convalescence (for example in a follow-up allergy clinic). aminophyline (IV) or magnesium (IV). (b) Ideally: Three timed samples: (1) Initial sample as soon as feasible after resuscitation has started—–do not delay resuscitation to take sample.Emergency treatment of anaphylactic reactions—–Guidelines for healthcare providers 165 Steroids (after initial resuscitation) Corticosteroids may help prevent or shorten protracted reactions. (a) Minimum: one sample at 1—2 h after the start of symptoms. Sample requirements Mast cell tryptase The speciﬁc test to help conﬁrm a diagnosis of an anaphylactic reaction is measurement of mast cell tryptase. Serial samples have better speciﬁcity and sensitivity than a single measurement in the conﬁrmation of anaphylaxis. and concentrations may be back to normal within 6—8 h. Sample timing The time of onset of the anaphylactic reaction is the time when symptoms were ﬁrst noticed. (2) Record the timing of each sample accurately on the sample bottle and request form. In asthma.g. Tryptase is the major protein component of mast cell secretory granules. (3) As little as 0. Glucagon can be useful to treat an anaphylactic reaction in a patient taking a beta-blocker.55 Inject hydrocortisone slowly by the intravenously or intramuscularly.5 mL of sample can be enough (children). so even samples stored at room temperature over a weekend can give useful. urea and electrolytes.. and peak 1—2 h after onset. consider further bronchodilator therapy with salbutamol (inhaled or IV).
There is a list of specialist clinics in the UK on the British Society for Allergy and Clinical Immunology (BSACI) website (www. so that they can summon help quickly and prepare to use their emergency medication. Conﬂict of interest Dr Jasmeet Soar (Co-Chair). Patients with a good response to initial treatment should be warned of the possibility of an early recurrence of symptoms and in some circumstances should be kept under observation for up to 24 h. including the timings of mast cell tryptase samples.g.64 They should then be reviewed by a senior clinician and a decision made about the need for further treatment or a longer period of observation. it is useful for the allergy clinic to have a description of the reaction with circumstances and timings to help identify potential triggers. Although there are no randomised clinical trials.72 All those at risk of an anaphylactic reaction should consider wearing some device. other healthcare professional or the Anaphylaxis Campaign. and all the names that can be used to describe it. to triggers such as venom stings and food-induced reactions (unless easy to avoid). • Considered for antihistamines and oral steroids therapy for up to 3 days.bsaci. friends. a list of treatments. general practitioner. so that they will know what to do in an emergency. Patients and those close to them (e.69 Individuals provided with an auto-injector on discharge from hospital must be given instructions and training and have appropriate follow-up including contact with the patient’s general practitioner. unless it is difﬁcult to avoid the drug.64. e. Southmead Hospital.70 Patients must always seek urgent medical assistance when experiencing anaphylaxis and after using an adrenaline auto-injector. • Patients with a previous history of biphasic reactions. • Patients in areas where access to emergency care is difﬁcult. they need to know what products are likely to contain it. If the allergen is a food.. Soar et al. it is not clear whether all the patients actually had an anaphylactic reaction and whether the initial treatment was appropriate. and thereby reduce the risk of future reactions and prepare the patient to manage future episodes themselves. Patients at risk are usually advised to carry their adrenaline auto-injector with them at all times. an airway. Information about managing severe allergies can be obtained from their allergy specialist. including contact with the patient’s general practitioner.g. Patients need to be able to recognise the early symptoms of anaphylaxis. Where possible they also need to know how to avoid situations that could expose them to the allergen.66 There is no reliable way of predicting who will have a biphasic reaction. Although studies quote an incidence of 1—20%.. carers) should receive training in using the auto-injector and should practise regularly using a suitable training device.7. family.e. emergency department records. • Given clear instructions to return to hospital if symptoms return. all patients should be assessed by an allergy specialist and have a treatment plan based on their individual risk. The exact incidence of biphasic reactions is unknown. or for anyone at continued high risk of reaction. An auto-injector is not usually necessary for patients who have suffered drug-induced anaphylaxis.71 there is evidence that individualised action plans for self-management should decrease the risk of recurrence. Consultant in Anaesthetics & Intensive Care Medicine. and the results of any investigations already completed. Medic Alert). An auto-injector is an appropriate treatment for patients at increased risk of an idiopathic anaphylactic reaction. It is therefore important that decisions about discharge are made for each patient by an experienced clinician.org). observation charts. anaesthetic charts). • Reactions in individuals with severe asthma or with a severe asthmatic component> • Reactions with the possibility of continuing absorption of allergen. This is helpful for treatment of urticaria67 and may decrease the chance of further reaction. • Have a plan for follow-up. that provides information about their history of anaphylactic reaction.g. Record keeping To help conﬁrm the diagnosis of anaphylaxis and identify the most likely trigger. copies of relevant patient records (e. • Patients presenting in the evening or at night. Discharge and follow-up Discharge from hospital Patients who have had a suspected anaphylactic reaction (i.. When to prescribe an adrenaline auto-injector Emergency departments should liaise with a specialist allergy service to devise a local guideline for which patients should be given an adrenaline auto-injector on discharge. or those who may not be able to respond to any deterioration.g.65 This caution is particularly applicable to: • Severe reactions with slow onset caused by idiopathic anaphylaxis..68 • Considered for an adrenaline auto-injector (see below). or given a replacement. such as a bracelet (e..166 J. Before discharge from hospital all patients must be: • Reviewed by a senior clinician. ambulance charts. Specialist referral All patients presenting with anaphylaxis should be referred to an allergy clinic to identify the cause. Patient education Patients need to know the allergen responsible and how to avoid it. Ideally. breathing or circulation (ABC) problem) should be treated and then observed for at least 6 h in a clinical area with facilities for treating life-threatening ABC problems. North .
Royal College of Physicians. Heath Park. Dr Nigel Harper. Professional Nursing Development. Peter Dawson. George Rylance. Dept of Imaging. Cambridge University NHS Foundation Trust. no conﬂict of interest. no conﬂict of interest. Gloucestershire Royal Hospital. Manchester M13 9WL. References 1. consulting work for NHS Pathways. Anaphylaxis Campaign. Royal College of Nursing. Praed St. Royal College of Nursing. Royal College of Radiologists. Consultant in Allergy and Asthma. 2006. Dr Shuaib Nasser. Dept of Anaesthetics and Intensive Care Medicine. no conﬂict of interest. . Jose R. 3. no conﬂict of interest. Co-chair Working Group. Manchester Royal Inﬁrmary. Allison Corbett. Dr Pamela Ewan. Dr Bernard Fo¨ ex. Royal College of Paediatrics and Child Health. Richard Pumphrey. Gompels MM. 91 Waterloo Road. Vice Chair Resuscitation Council (UK). Capital Tower. Postgrad Med J 2002. Sarah Mitchell. Has a son with anaphylaxis. no conﬂict of interest. Bristol BS10 5NB. 6. Clinical Lead. Royal College of Pathologists. Bath BA1 3NG. no conﬂict of interest. Allergy 2007. Newcastle upon Tyne. Headington. Johnston SL. Johnston SL. List of Working Group of the Resuscitation Council (UK) Jasmeet Soar. Dr David Gabbott. Ambulance Service Association. Cambridge University NHS Foundation Trust. Sue Clarke. no conﬂict of interest. Great Western Road. A review of services for allergy. BMJ 2003. Central Manchester & Manchester Children’s Hospitals. Clesham GJ. British National Formulary.41(2):93—9. Cambridge CB2 0QQ. Melbourn. no conﬂict of interest. Royal College of General Practitioners. Co-chair Working Group. Newcastle General Hospital. London. Euston Rd NW1 2BU. Children’s Emergency Medicine. 20 Cavendish Sq. Pamela Ewan. Royal United Hospital. Ward 23. no conﬂict of interest. Reader. Dr Richard Pumphrey (Co-Chair). Consultant in Allergy. Unsworth J. Sheikh A.62(8):827—9. Judith Hall. Mary’s Hospital NHS Trust. Executive Committee Member Resuscitation Council (UK). Consultant Anaesthetist. Nigel Harper. Department of Health.Chair Resuscitation Council (UK). Sarah Mitchell. London SE1 7JN. David Gabbott. Combe Park. Royal Pharmaceutical Society of GB. Oxford OX3 9DU. Gompels MM. no conﬂict of interest. Matt Grifﬁths. David Joseph Unsworth. Gloucester GL1 3NN. Royal Victoria Inﬁrmary. Queen Victoria Rd. Gompels LL. Manchester M13 9WL. St. Newcastle upon Tyne. 35 Orchard Rd. Jerry Nolan . no conﬂict of interest. Andrew Cant. Postgrad Med J 2007. Consultant. no conﬂict of interest. Simons FE. Herts SG8 6HH. The epidemiology. SE1 8RT.326(7389):589—90. Professor Matt Grifﬁths. 7th Floor. Community Health Clinic. 5. London. Resuscitation 1999. Manchester Royal Inﬁrmary. demand for. Bethune C. no conﬂict of interest. Project Team of The Resuscitation Council (UK). Royston. Evidence-based management of anaphylaxis.Emergency treatment of anaphylactic reactions—–Guidelines for healthcare providers Bristol NHS Trust. Sue Clarke. Joint Royal College Ambulance Liaison Committee Ian Maconochie. and provision of treatment and effectiveness of clinical interventions. Association of Anaesthetists of Great Britain & Ireland. British Society for Allergy and Clinical Immunology. Consultant Paediatrician. Professor Aziz Sheikh. David Warrell. John Radcliffe Hospital. Oxford Road. British Society for Allergy and Clinical Immunology. Emergency medical treatment of anaphylactic reactions. Consultant in Anaesthesia and Critical Care. 1 Lambeth High St. Bristol BS10 5NB. Hills Road. Professor of Primary Care Research & Development. Consultant in Emergency Medicine and Intensive Care. no conﬂict of interest. Proposed use of adrenaline (epinephrine) in anaphylaxis and related conditions: a study of senior house ofﬁcers starting accident and emergency posts. Department of Health E. 2. Allison Corbett. Dr George Rylance. Manchester M13 9WL. General Practice section Division of Community Health Sciences The University of Edinburgh 20 West Richmond Street Edinburgh EH8 9DX.78(921):416—8. Dr Jerry Nolan. North Bristol NHS Trust. Executive Committee Member Resuscitation Council (UK). no conﬂict of interest. College of Emergency Medicine. British National Formulary. London W1G 0RN. Cambridge CB2 0QQ. Professor Peter Dawson. And. Resuscitation Council UK. Southmead Hospital. Anaesthetic Reaction Clinic. Appendix A. Westgate Rd. Royal College of Anaesthetists. UCL Hospitals. 4. no conﬂict of interest. no conﬂict of interest. W2 1NY. Adrenaline given outside the context of life threatening allergic reactions.83(983):610—1. Royal College of Pathologists. NE1 4LP. Dr Judith Hall. Clinical Director of Imaging. Resuscitation Council UK. Fiona Jewkes. Joint National Prescribing and Medicines Adviser. Aziz Sheikh. Director Resuscitation Council UK. Royal College of Paediatrics and Child Health. Survey of the use of epinephrine (adrenaline) for anaphylaxis by junior hospital doctors. Shuaib Nasser. Professor Andrew Cant. 167 Dr David Joseph Unsworth. Hills Road. Consultant in Anaesthetics & Intensive Care Medicine. Director. NE4 6BE. General Practitioner. Cardiff CF14 4XN. Consultant in Paediatric Immunology. Cardiff University. Dr Ian Maconochie. Dr Fiona Jewkes. Honorary Consultant in Clinical Immunology. Professor David Warrell. no conﬂict of interest. no conﬂict of interest. Paddington. Consultant Immunologist. Bernard Fo¨ ex.
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