Resuscitation (2008) 77, 157—169

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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: (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

• Intravenous adrenaline must only be used in certain specialist settings and only by those skilled and experienced in its • There is a need for further research about the diagnosis. A draft guideline was made available for comment on the Resuscitation Council UK website between 25th September and 4th November 2007.000 persons per year and a lifetime prevalence of between 50 and 2000 episodes . 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. nurseries and similar settings (www. and that will be appropriate for most anaphylactic reactions. Any differences will be highlighted. 3. paramedics) working in the hospital or out-of-hospital setting.1 Despite previous guidelines. Drafts of this guideline were discussed by An updated consensus about the recognition and treatment of anaphylactic reactions. a picture has to be built up from different sources. Published by Elsevier Ireland Ltd. investigation and follow-up of patients who have an anaphylactic reaction. A greater focus on the treatments that a patient having an anaphylactic reaction should and www. © 2008 Resuscitation Council (UK). 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 final guideline was made available on the Resuscitation Council UK website in January 2008. Nonetheless. Soar et al.allergyinschools. As the criteria for inclusion vary in different studies and countries. There is less emphasis on specifying treatments according to which specific groups of healthcare providers should give them. or circulation problems usually associated with skin and mucosal changes. The key treatment of a patient having an anaphylactic reaction in any setting is the same for children9 and adults. We have therefore deliberately not developed guidelines for specific groups of healthcare provider. • Individuals who are at high risk of an anaphylactic reaction should carry an adrenaline autoinjector and receive training and support in its use.6 This guideline gives: 1. The document was accessed 15.5 The full version of this guideline and supplementary information is available on the Resuscitation Council UK website (www. There is also specific guidance for managing medicines in schools.158 J. so studies may underestimate the incidence. treatment and prevention of anaphylactic reactions.aagbi. The review date for the guideline is January 2013 or earlier if necessary. 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. There is no universally agreed definition. There are no randomised controlled clinical trials in humans providing unequivocal evidence for the treatment of anaphylactic reactions.432 times in this period. • All those who are suspected of having had an anaphylactic reaction should be referred to a specialist in allergy.8 Epidemiology Anaphylaxis is not always recognised. Anaphylaxis Definition of anaphylaxis A precise definition of anaphylaxis is not important for the emergency treatment of an anaphylactic reaction.2—4 This guideline replaces the previous guidance from the Resuscitation Council UK. There is considerable variation and overlap between the skills and knowledge of different healthcare providers who are expected to treat an anaphylactic reaction. The group met in January and November 2007.. The European Academy of Allergology and Clinical Immunology Nomenclature Committee proposed the following broad definition10 : Anaphylaxis is a severe. Recommendations for treatment that are simple to learn and easy to implement.resus. nurses. doctors.g. Methods Organisations involved in the previous guideline nominated individuals for the Working Group. The feedback was reviewed at the November working group meeting and the document updated. there is confusion about the An American College of and www. there is a wealth of experience and systematic reviews of the limited evidence that can be used as a resource. Introduction Purpose of this guideline The UK incidence of anaphylactic reactions is rising.bsaci. generalised or systemic hypersensitivity reaction This is characterised by rapidly developing life-threatening airway and. Asthma and Immunology working group found that the overall frequency of episodes of anaphylaxis using current data lies between 30 and 950 cases per treatment. life-threatening. or breathing and.

15 Virtually any food or drug group can be implicated.16 A significant number of cases of anaphylaxis are idiopathic (non-IgE mediated). The risk of individuals suffering recurrent anaphylactic reactions appears to be quite substantial.17—19 Risk of death is increased in those with pre-existing asthma. identifying only the most severe cases. non-steroidal anti-inflammatory drug. ACEI.13 Taking specific causes of anaphylaxis where prevalence and severity data are available. 2 amphotericin. 1 each .23 When anaphylaxis is fatal. acetazolamide. although this may be an underestimate. yeast. 7 vecuronium.4 million cases of nut anaphylaxis recorded up to age 44 years. 4 14 unknown 10 peanut. 1 hydatid 159 Food Food possible cause 13 17 Antibiotics 27 Anaesthetic drugs 39 Other drugs 24 Figure 1 Hospital admission rates for anaphylaxis. and relating this number to the population served. pethidine. 1 each fish. 6 atracurium. per 100.333 of the English population have experienced anaphylaxis at some point in their lives. 2 fish.21 There are very limited data on trends in anaphylaxis internationally.5 per 100.24 Figure 2 Time to cardiac arrest following exposure to triggering agent.000 between 1990 and 2004: an increase of 700% (Figure 1). 2 brazil.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. this increasing from 0.who. 7 at induction 6 NSAID. 12 cephalosporin. death usually occurs very soon after contact with the trigger. but certain foods (nuts) and drugs (muscle relaxants.12 Calculations based on these data indicate that approximately 1 in 1. streptokinase 9 iodinated. estimated that approximately 1 in 3500 patients had an episode of anaphylaxis during the study period 1993—1994. 1990—2004. England ICD—–International Classification of Diseases (www. Death never occurred more than 6 h after contact with the trigger (Figure 2). insect stings cause collapse from shock after 10—15 min. or delay treatment with adrenaline. indicating a lifetime age-standardised prevalence of a recorded diagnosis of anaphylaxis of 75. 1 snail 5 during meal. diamorphine.05—2.6 admissions per 100. strawberry 11 penicillin. 3 ACEI. 11 mixed or unknown 5 milk. antibiotics. nectarine. 1 technetium. Anaphylaxis can be triggered by any of a very broad range of triggers (Table 1). sherbet. 3 nut. From a case-series. with a case fatality ratio of less than 1% reported in most populationbased studies. worldwide there are 1 million cases of venom anaphylaxis and 0. 1 fluorescein 1 latex.22. 2 vitamin K. 2 almond. A retrospective study of Emergency department attendances. 5 gelatins.5 to 3. but data indicate a dramatic increase in the rate of hospital admissions for anaphylaxis. local anaesthetic. 2 crustacean. particularly if the asthma is poorly controlled or in those asthmatics who fail to use. 3 milk. 1 ciprofloxacin. nonsteroidal anti-inflammatory agents (NSAIDs) and aspirin) cause most reactions.11 More recent UK primary care data concur.24 . Angiotensin Converting Enzyme inhibitor. Contrast media Other 11 3 NSAID.000 in 2005. and deaths caused by intravenous medication occur most commonly within 5 min. .0%. 6 walnut.000 persons or 0. The overall prognosis of anaphylaxis is good. 1 vancomycin 19 suxamethonium. 1 hair dye. 1 banana. 1 hazel.20 There are approximately 20 anaphylaxis deaths reported each year in the UK. fatal food reactions cause respiratory arrest typically after 30—35 min. 2 protamine.14 Food is the commonest trigger in children and drugs the commonest in adults. 2 chickpea. grape. being estimated at approximately 1 in 12 per year.etoposide.

and loss of fluid from the circulation. collapse.29 • Decreased conscious level or loss of consciousness. reactions may be slower in onset. vomiting.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. clammy.31 Airway. Patients with anaphylaxis can deteriorate if made to sit up or stand up. For example. or breathing and. i..160 J. Guidelines for the treatment of an anaphylactic reaction must therefore take into account some inevitable diagnostic errors. Many patients with a genuine anaphylactic reaction are not given the correct treatment. The reaction is usually unexpected.3 Diagnostic problems have arisen particularly in children.g. tend to cause a more rapid onset than orally ingested triggers (Figure 2). An intravenous trigger will cause a more rapid onset of reaction than stings which. Sudden onset and rapid progression of symptoms • The patient will feel and look unwell.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. • Anaphylaxis can cause myocardial ischaemia and electrocardiograph (ECG) changes even in individuals with normal coronary arteries. incontinence).25 Patients have been given injections of adrenaline inappropriately for allergic reactions just involving the skin. abdominal pain. Confusion arises because some patients have systemic allergic reactions that are less severe. or circulation problems usually associated with skin and mucosal changes. Disability problems) because of decreased brain perfusion. none of which are entirely specific for an anaphylactic reaction. Patient becoming tired. • Increased pulse rate (tachycardia). Life-threatening asthma with no features of anaphylaxis can be triggered by food allergy. 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. Confusion caused by hypoxia. or Circulation problems Patients can have either an A or B or C problem or any combination. There is a range of signs and symptoms. Breathing problems • • • • • • Shortness of breath—–increased respiratory rate. a Circulation problem). • Stridor—–this is a high-pitched inspiratory noise caused by upper airway obstruction. or for vasovagal reactions or panic attacks. vasodilation and capillary leak. throat and tongue swelling (pharyngeal/laryngeal oedema). and rhinitis would not be described as an anaphylactic reaction. • Most reactions occur over several minutes. agitation and loss of consciousness.. A single set of criteria will not identify all anaphylactic reactions. urticaria.14. Respiratory arrest. often preceding cardiac arrest. There may be confusion.24 • The patient is usually anxious and can experience a ‘‘sense of impending doom’’. Breathing and Circulation problems also alter the patient’s neurological status (D. Soar et al.e. The patient has difficulty in breathing and swallowing and feels that the throat is closing up. with an emphasis on the need for safety. Wheeze. generalised urticaria. however. angioedema. in turn. .30 • Cardiac arrest. • There can also be gastrointestinal symptoms (e. e.26 Life-threatening Airway and.28 Circulation problems • Signs of shock—–pale. Airway problems • Airway swelling. • Low blood pressure (hypotension)—–feeling faint (dizziness). Cyanosis (appears blue)—–this is usually a late sign. • 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. Bradycardia (a slow pulse) is usually a late feature. because the lifethreatening features are not present. • The time of onset of an anaphylactic reaction depends on the type of trigger. • Hoarse voice. or Breathing and.g.. Rarely. Circulation problems (often referred to as anaphylactic shock) can be caused by direct myocardial depression. certain combinations of signs make the diagnosis of an anaphylactic reaction more likely. The lack of any consistent clinical manifestation and a range of possible presentations cause diagnostic difficulty.

The Health Protection Agency recommends that staff who give immunisations should have annual updates. by ambulance crew. and neurological systems. most patients who have skin changes caused by allergy do not go on to develop an anaphylactic reaction. 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. Fainting will usually respond to lying the patient down and raising the legs. and sometimes in the mouth and throat. • There may be just skin. • Seek help early if there are any doubts about the diagnosis and treatment. The basic principles of treatment are the same for all age groups.) as soon as possible. Diagnostic difficulty may also occur with vasovagal attacks after immunisation procedures. or mucosal changes These should be assessed as part of the Exposure when using the ABCDE approach. 4. Adrenaline therapy if indicated. Treat life-threatening problems as you find them. red rash. or urticarial rash or swelling. breathing difficulties. Treatment of an anaphylactic reaction As the diagnosis of anaphylaxis is not always obvious. There can be confusion between an anaphylactic reaction and a panic attack.. 4. most commonly in the eyelids and lips. tic episode. The sense of impending doom and breathlessness leading to hyperventilation are symptoms that resemble anaphylaxis in some ways. pallor. While there is no hypotension. Patients with Airway and Breathing problems may prefer to sit up as this will make breathing easier. non-invasive blood pressure and 3lead ECG. Clinical staff should be familiar with the equipment and drugs they have available and should check them regularly. Initial assessment and treatments based on an ABCDE approach. They can be different shapes and sizes.. ABCDE problems. 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. All patients who have had an anaphylactic reaction should be monitored (e. • They are often the first feature and present in over 80% of anaphylactic reactions. 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.e. but the absence of rash. in the emergency department.Emergency treatment of anaphylactic reactions—–Guidelines for healthcare providers 161 Skin and. Investigation and follow-up by an allergy specialist.33 3. all those who treat anaphylaxis must have a systematic approach to the sick patient. the clinical signs of critical illness are similar whatever the underlying process because they reflect failing respiratory. • Following an ABCDE approach will help with treating the differential diagnoses. 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. which can appear anywhere on the body. Lying flat with or without leg elevation is helpful for patients with a low blood . Clinical staff who give parenteral medications should have initial training and regular updates in dealing with anaphylactic reactions. an ambulance must be called early and the patient transported to an emergency department. 2. Use an ABCDE approach to recognise and treat an anaphylactic reaction. 3. The weals may be pale. there may sometimes be flushing or blotchy skin associated with anxiety adding to the diagnostic difficulty. Minimal monitoring includes pulse oximetry. If there are several rescuers. 5. Location—–Out of hospital.32 • They can be subtle or dramatic. etc. In general. Number of responders—–The single responder must always ensure that help is coming. just mucosal. The specific treatment of an anaphylactic reaction depends on: 1. An early call for help. i. • Angioedema is similar to urticaria but involves swelling of deeper tissues. several actions can be undertaken simultaneously. • There may be urticaria (also called hives. • A low blood pressure (or normal in children) with a petechial or purpuric rash can be a sign of septic shock. wheeze. pink or red. Reassuringly. and are often surrounded by a red flare. 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. 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. They are usually itchy. or generalised. Recognition that they are seriously unwell. nettle rash. or both skin and mucosal changes. • There may be erythema—–a patchy. 2.g. weals or welts). cardiovascular. and swelling are useful distinguishing features. and may look like nettle stings.

44. Early removal is more important than the method of removal. In patients with a . Adrenaline should be given to all patients with lifethreatening features. intensive care doctors).38 Although there are no randomised controlled trials. Further doses can be given at about 5-min intervals according to the patient’s response.40 and so early adrenaline attenuates the severity of IgE-mediated allergic reactions. Intramuscular adrenaline The intramuscular route is the best for most individuals who have to give adrenaline to treat an anaphylactic reaction.15 mL) Remove the trigger if possible Removing the trigger of an anaphylactic reaction is not always possible.. Pregnant patients should lie on their left side to prevent caval compression. Many healthcare providers will have given IV adrenaline as part of resuscitating a patient in cardiac arrest.36. emergency physicians. Its betareceptor activity dilates the bronchial airways. Anaphylaxis algorithm The key steps for the treatment of an anaphylactic reaction are shown in the algorithm (Figure 3. pulse oximetry).42. The best site for IM injection is the anterolateral aspect of the middle third of the thigh.162 pressure (Circulation problem). particularly when given intravenously. • It does not require intravenous access. Do not make patients sit or stand up if they feel faint—–this can cause cardiac arrest. adrenaline is a logical treatment31 and there is consistent anecdotal evidence supporting its use to ease breathing and circulation problems associated with anaphylaxis.35 After food-induced anaphylaxis. Use doses of adrenaline recommended in ALS guidelines. Do not delay definitive treatment if removing the trigger is not feasible..5 mL). increases the force of myocardial contraction.5 mg IM (=500 ␮g = 0.15 mL) 150 ␮g IM (0.34. Stop any drug suspected of causing an anaphylactic reaction (e. This alone is insufficient experience to use IV adrenaline for the treatment of an anaphylactic reaction.3 mL) if child is small or prepubertal 300 ␮g IM (0. 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’).29 Patients who are breathing and unconscious should be placed on their side (recovery position).3 mL) 150 ␮g IM (0. anaesthetists.5 mL of 1:1000) adrenaline. As an alpha-receptor agonist. blood pressure. • The IM route is easier to learn. attempts to make the patient vomit are not recommended.42 The needle used for injection needs to be long enough to ensure that the adrenaline is injected into muscle. and suppresses histamine and leukotriene release. Soar et al.37 Rescuers should ensure that help is on its way as early advanced life support (ALS) is essential. it reverses peripheral vasodilation and reduces oedema. Adrenaline IM dose—–children The scientific basis for the recommended doses is weak. The IM route has several benefits: • There is a greater margin of safety.g. Adrenaline must be readily available in clinical areas where an anaphylactic reaction could occur.34 J.. the patient needs careful observation and symptomatic treatment using the ABCDE approach. >6—12 years: >6 months—6 years: <6 months: Repeat the IM adrenaline dose if there is no improvement in the patient’s condition. Cardiorespiratory arrest following an anaphylactic reaction Start cardiopulmonary resuscitation (CPR) immediately and follow current guidelines. stop intravenous infusion of a gelatin solution or antibiotic).45 Adrenaline IM dose—–adults 0. If these features are absent but there are other features of a systemic allergic reaction.e.g. Monitor the patient as soon as possible (pulse. The intramuscular route for adrenaline is not recommended after cardiac arrest has occurred.) >12 years: 500 ␮g IM (0.3 This section on IV adrenaline applies to those experienced in the use and titration of vasopressors in their normal clinical practice (e. Remove the stinger after a bee sting.) Drugs and their delivery Adrenaline (epinephrine) Adrenaline is the most important drug for the treatment of an anaphylactic reaction.46 (The equivalent volume of 1:1000 adrenaline is shown in brackets. This will help monitor the response to adrenaline. same as adult dose 300 ␮g (0. There is a much greater risk of causing harmful side effects by inappropriate dosage or misdiagnosis of anaphylaxis when using IV adrenaline. Adrenaline seems to work best when given early after the onset of the reaction41 but it is not without risk.24 Adverse effects are extremely rare with correct doses injected intramuscularly (IM). ECG. There are beta-2 adrenergic receptors on mast cells39 that inhibit activation. i.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. The recommended doses are based on what is considered to be safe and practical to draw up and inject in an emergency.

.Emergency treatment of anaphylactic reactions—–Guidelines for healthcare providers 163 Figure 3 The anaphylaxis algorithm.

g. There is large inter-individual variability in the response to adrenaline. Patients who require repeated IM doses of adrenaline may benefit from IV adrenaline.51 Antihistamines (H1 -antihistamine) may help counter histamine-mediated vasodilation and bronchoconstriction. 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. In clinical practice. The dose of chlorphenamine depends on age (Figure 3). Soar et al. If repeated adrenaline doses are needed. They may not help in reactions depending in part on other mediators but they have the virtue of safety. At the time of writing. it is important to monitor the response. There is little evidence to support the routine use of an H2 -antihistamine (e. infuse intravenous fluids immediately.g.9% saline are suitable fluids for initial resuscitation. There is no evidence on which to base a dose recommendation—–the dose is titrated according to response. This requires very careful dilution and checking to prevent dose errors.15 and 0. they are unlikely to be life-saving in a true anaphylactic reaction. there . start with a safe dose and give further doses if a greater response is needed.g. If the patient’s trachea is intubated. The IV route is recommended only in specialist paediatric settings by those familiar with its use (e. Fluids (give as soon as available) Large volumes of fluid may leak from the patient’s circulation during an anaphylactic reaction. paediatric emergency physicians. healthcare providers should use it.47 Use local guidelines for the preparation and infusion of adrenaline.164 spontaneous circulation. Do not give the undiluted 1:1000 adrenaline concentration IV. give the highest concentration of oxygen possible using a mask with an oxygen reservoir. Healthcare professionals should be familiar with the use of the most commonly available auto-injector devices. If intravenous access is delayed or impossible.5 The Working Group considered it unhelpful to have caveats such as this in the setting of an acute anaphylactic reaction. Antihistamines (after initial resuscitation) Antihistamines are a second line treatment for an anaphylactic reaction. J. cimetidine) for the initial treatment of an anaphylactic reaction. Adrenaline IV bolus dose—–children IM adrenaline is the preferred route for children having an anaphylactic reaction.52 Adrenaline auto-injectors Auto-injectors are often given to patients at risk of anaphylaxis for their own use. A dose of 50 ␮g is 0. the previous recommendation was to give half the dose). the intra-osseous route can be used for fluids or drugs when resuscitating children or adults. but only by healthcare workers who are accustomed to do so. If an adrenaline auto-injector is the only available adrenaline preparation when treating anaphylaxis. For specialist use only Ensure patient is monitored Adrenaline IV bolus dose—–adult Titrate IV adrenaline using 50 ␮g boluses according to response. Adrenaline in special populations Previous guidelines recommended adrenaline dose adjustments in certain circumstances (e. Inject chlorphenamine slowly intravenously or intramuscularly. paediatric intensivists) and if the patient is monitored and IV access is already available. If there is intravenous access. but there are logical reasons for them. start an adrenaline infusion. which is the smallest dose that can be given accurately. and myocardial ischaemia. tachycardia. A large volume of fluid may be needed. start an IV adrenaline infusion. The dose recommendations for adrenaline in this guideline are intended for healthcare providers treating an anaphylactic reaction. If the patient requires repeated IV bolus doses of adrenaline. If IV access is not available or not achieved rapidly. There is no evidence to support the use of colloids over crystalloids in this setting.3 mg. paediatric anaesthetists. ranitidine. ventilate the lungs with high concentration oxygen using a self-inflating bag. intravenous adrenaline can cause life-threatening hypertension. Used alone.e. in patients taking tricyclic antidepressants. A child may respond to a dose as small as 1 ␮g/kg.. use the IM route for adrenaline.50 Do not delay the administration of IM adrenaline attempting intra-osseous access. 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.5 mL. are only two doses of adrenaline auto-injector commonly available: 0. titrate the dose according to effect.49 Hartmann’s solution or 0.48.. give further doses as necessary.. It is essential that these patients receive expert help early.. The evidence to support their use is weak. Ensure high flow oxygen (usually greater than 10 L min−1 ) to prevent collapse of the reservoir during inspiration.000 adrenaline contains 100 ␮g/mL. The more appropriate dose for an auto-injector should be prescribed for individual patients by allergy specialists. The pre-filled 10 mL syringe of 1:10. arrhythmias. i. There will also be vasodilation. Give a rapid IV fluid challenge (20 mL/kg in a child or 500—1000 mL in an adult) and monitor the response. Oxygen (give as soon as available) Initially. 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 the patient has asthma-like features alone. This provides baseline tryptase levels—–some individuals have an elevated baseline level.63 Investigations Undertake the usual investigations appropriate for a medical emergency.56—60 Only use these drugs in specialist settings (e. arterial blood gases.. (3) As little as 0. Sample timing The time of onset of the anaphylactic reaction is the time when symptoms were first noticed. It is important that this time is accurately recorded. before dispatch to a reference laboratory. early corticosteroid treatment is beneficial in adults and children. etc. .47 Figure 4 Suggested time course for the appearance of tryptase in serum or plasma during systemic anaphylaxis.g. (6) Consult your local laboratory if you have any queries.61 Some patients develop severe bradycardia after an anaphylactic aminophyline (IV) or magnesium (IV). Glucagon can be useful to treat an anaphylactic reaction in a patient taking a beta-blocker. In asthma. ipratropium (inhaled). so even samples stored at room temperature over a weekend can give useful.. and concentrations may be back to normal within 6—8 h.62 Reproduced and adapted with permission from Elsevier. Cardiac drugs Adrenaline remains the first line vasopressor for the treatment of anaphylactic reactions. Remember that intravenous magnesium is a vasodilator and can cause hot flushes and make hypotension worse. In anaphylaxis. Consider IV atropine to treat this. Serial samples have better specificity and sensitivity than a single measurement in the confirmation of anaphylaxis.Emergency treatment of anaphylactic reactions—–Guidelines for healthcare providers 165 Steroids (after initial resuscitation) Corticosteroids may help prevent or shorten protracted reactions. follow the British Thoracic Society—–SIGN asthma guidelines (www. (2) Second sample at 1—2 h after the start of symptoms. information. (2) Record the timing of each sample accurately on the sample bottle and request form. (b) Ideally: Three timed samples: (1) Initial sample as soon as feasible after resuscitation has started—–do not delay resuscitation to take sample. Sample requirements Mast cell tryptase The specific test to help confirm a diagnosis of an anaphylactic reaction is measurement of mast cell tryptase. higher doses of hydrocortisone do not seem to be better than smaller doses. Tryptase concentrations in the blood may not increase significantly until 30 min or more after the onset of symptoms. though sub-optimal. 12-lead ECG. metaraminol and glucagon) when initial resuscitation with adrenaline and fluids has not been successful. The dose of hydrocortisone for adults and children depends on age (Figure 3). (5) Tryptase is very stable (50% of tryptase is still detectable after 4 days at room temperature62 ). Tryptase is the major protein component of mast cell secretory granules. (4) Optimally.5 mL of sample can be enough (children). so timing of any blood samples is very important.53. and peak 1—2 h after onset. In hospital patients with asthma. (a) Minimum: one sample at 1—2 h after the start of e. Other drugs Bronchodilators The presenting symptoms and signs of a severe anaphylactic reaction and life-threatening asthma can be the same.36. not in the initial recognition and treatment: measuring tryptase levels must not delay initial resuscitation. (1) Use a serum or clotted blood sample. store the serum from spun samples frozen (−20 ◦ C) in the local laboratory.54 There is little evidence on which to base the optimum dose of hydrocortisone in anaphylaxis. mast cell degranulation leads to markedly increased blood tryptase concentrations (Figure 4). (3) Third sample either at 24 h or in convalescence (for example in a follow-up allergy clinic). urea and electrolytes. vasopressin. As well as the drugs listed above. but 5 mL (adults) is better. intensive care units) where there is experience in their use.62 The half-life of tryptase is short (approximately 2 h). consider further bronchodilator therapy with salbutamol (inhaled or IV).britthoracic. There are animal studies and case reports describing the use of other vasopressors and inotropes (noradrenaline. Some laboratories ask for a plasma sample—–either plasma or serum samples can be tested. Tryptase levels are useful in the follow-up of suspected anaphylactic reactions. chest X-ray.55 Inject hydrocortisone slowly by the intravenously or intramuscularly.

Medic Alert).g. Before discharge from hospital all patients must be: • Reviewed by a senior clinician.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. they need to know what products are likely to contain it. 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. unless it is difficult to avoid the drug. to triggers such as venom stings and food-induced reactions (unless easy to avoid).e.72 All those at risk of an anaphylactic reaction should consider wearing some device. This is helpful for treatment of urticaria67 and may decrease the chance of further reaction.. If the allergen is a food. general practitioner.g. including the timings of mast cell tryptase samples. Consultant in Anaesthetics & Intensive Care Medicine.70 Patients must always seek urgent medical assistance when experiencing anaphylaxis and after using an adrenaline auto-injector. Record keeping To help confirm the diagnosis of anaphylaxis and identify the most likely trigger. so that they can summon help quickly and prepare to use their emergency medication. all patients should be assessed by an allergy specialist and have a treatment plan based on their individual risk. and all the names that can be used to describe it. • Patients presenting in the evening or at night. • Given clear instructions to return to hospital if symptoms return. Specialist referral All patients presenting with anaphylaxis should be referred to an allergy clinic to identify the cause. Discharge and follow-up Discharge from hospital Patients who have had a suspected anaphylactic reaction (i. There is a list of specialist clinics in the UK on the British Society for Allergy and Clinical Immunology (BSACI) website (www. North . observation charts. • Reactions in individuals with severe asthma or with a severe asthmatic component> • Reactions with the possibility of continuing absorption of allergen. other healthcare professional or the Anaphylaxis Campaign.68 • Considered for an adrenaline auto-injector (see below). Information about managing severe allergies can be obtained from their allergy specialist. Ideally. Patients and those close to them (e. • Have a plan for follow-up.71 there is evidence that individualised action plans for self-management should decrease the risk of recurrence..bsaci.7. It is therefore important that decisions about discharge are made for each patient by an experienced clinician.65 This caution is particularly applicable to: • Severe reactions with slow onset caused by idiopathic anaphylaxis. carers) should receive training in using the auto-injector and should practise regularly using a suitable training device. or those who may not be able to respond to any deterioration..64. emergency department records. Where possible they also need to know how to avoid situations that could expose them to the allergen. copies of relevant patient records (e. 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. Conflict of interest Dr Jasmeet Soar (Co-Chair). including contact with the patient’s general practitioner. Patient education Patients need to know the allergen responsible and how to avoid it. The exact incidence of biphasic reactions is unknown. Patients need to be able to recognise the early symptoms of anaphylaxis.166 J. An auto-injector is not usually necessary for patients who have suffered drug-induced anaphylaxis. e. family. and the results of any investigations already completed. Patients at risk are usually advised to carry their adrenaline auto-injector with them at all times. • Considered for antihistamines and oral steroids therapy for up to 3 days. ambulance charts. 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..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. • Patients in areas where access to emergency care is difficult. Soar et al. it is not clear whether all the patients actually had an anaphylactic reaction and whether the initial treatment was appropriate. an airway. anaesthetic charts).g. An auto-injector is an appropriate treatment for patients at increased risk of an idiopathic anaphylactic reaction. or given a replacement. or for anyone at continued high risk of reaction. a list of treatments. 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.66 There is no reliable way of predicting who will have a biphasic reaction. so that they will know what to do in an emergency. that provides information about their history of anaphylactic reaction. Although studies quote an incidence of 1—20%. • Patients with a previous history of biphasic reactions. Southmead Hospital. such as a bracelet (e. and thereby reduce the risk of future reactions and prepare the patient to manage future episodes themselves.g.

Bethune C. Cardiff University. British Society for Allergy and Clinical Immunology. Herts SG8 6HH. Sarah Mitchell. Allison Corbett. Community Health Clinic. Professor Peter Dawson. London. Royal College of Paediatrics and Child Health. Cambridge University NHS Foundation Trust. UCL Hospitals. Consultant in Anaesthetics & Intensive Care Medicine. Bath BA1 3NG. Simons FE. Newcastle upon Tyne. 20 Cavendish Sq. Ward 23. Clinical Lead. Jerry Nolan . Emergency medical treatment of anaphylactic reactions. Dr Shuaib Nasser. 2. Westgate Rd. Consultant in Allergy. Consultant in Paediatric Immunology. John Radcliffe Hospital. Has a son with anaphylaxis. no conflict of interest.62(8):827—9. Sue Clarke. Dr Fiona Jewkes. Anaesthetic Reaction Clinic. David Warrell. 1 Lambeth High St. 7th Floor. Fiona Jewkes. Manchester M13 9WL. Dept of Anaesthetics and Intensive Care Medicine. Aziz Sheikh. And. Peter Dawson. London SE1 7JN. Professor of Primary Care Research & Development. Consultant in Emergency Medicine and Intensive Care. Newcastle upon Tyne. Melbourn. 6. Royal College of Physicians. Matt Griffiths. Dr Richard Pumphrey (Co-Chair). Dr Judith Hall. Consultant Anaesthetist. Gompels LL. Royal College of General Practitioners. Association of Anaesthetists of Great Britain & Ireland. General Practice section Division of Community Health Sciences The University of Edinburgh 20 West Richmond Street Edinburgh EH8 9DX. Dr Ian Maconochie. 91 Waterloo Road. Gloucestershire Royal Hospital. Great Western Road. Royal College of Radiologists. Royal College of Nursing. Heath Park. Vice Chair Resuscitation Council (UK). Central Manchester & Manchester Children’s Hospitals. Consultant Paediatrician. Southmead Hospital. Co-chair Working Group. W2 1NY. SE1 8RT. Paddington. Resuscitation Council UK. Ambulance Service Association. no conflict of interest. 4. Resuscitation Council UK.Chair Resuscitation Council (UK). demand for. Executive Committee Member Resuscitation Council (UK). Consultant Immunologist. Johnston SL. Manchester Royal Infirmary. Department of Health E. Joint National Prescribing and Medicines Adviser. NE1 4LP. David Gabbott. Professor Aziz Sheikh. Dr Jerry Nolan. Oxford OX3 9DU. no conflict of interest. David Joseph Unsworth. British Society for Allergy and Clinical Immunology. Royal College of Paediatrics and Child Health. North Bristol NHS Trust. London W1G 0RN. Cardiff CF14 4XN. Director Resuscitation Council UK. 3. Gloucester GL1 3NN. no conflict of interest. Dr Nigel Harper. Capital Tower. Allergy 2007. Professional Nursing Development. Sue Clarke. Euston Rd NW1 2BU. Royal Pharmaceutical Society of GB. Royal United Hospital. Manchester Royal Infirmary. no conflict of interest.Emergency treatment of anaphylactic reactions—–Guidelines for healthcare providers Bristol NHS Trust. Reader. British National Formulary. British National Formulary. Joint Royal College Ambulance Liaison Committee Ian Maconochie. no conflict of interest. Bernard Fo¨ ex. Pamela Ewan. St. no conflict of interest. Royston. London. Sarah Mitchell.41(2):93—9. no conflict of interest. Allison Corbett. no conflict of interest. Gompels MM. Honorary Consultant in Clinical Immunology. no conflict of interest. 2006. Children’s Emergency Medicine. Manchester M13 9WL. Dr Pamela Ewan. Professor Andrew Cant. References 1. consulting work for NHS Pathways. Richard Pumphrey. no conflict of interest. Director. Dr David Gabbott. and provision of treatment and effectiveness of clinical interventions. Consultant in Anaesthesia and Critical Care. Royal College of Nursing.83(983):610—1. Newcastle General Hospital. Shuaib Nasser. Executive Committee Member Resuscitation Council (UK). . General Practitioner. George Rylance. Professor David Warrell. Royal Victoria Infirmary. Judith Hall. Professor Matt Griffiths.326(7389):589—90. The epidemiology. Appendix A. no conflict of interest. Bristol BS10 5NB.78(921):416—8. NE4 6BE. Adrenaline given outside the context of life threatening allergic reactions. Combe Park. Anaphylaxis Campaign. Clinical Director of Imaging. no conflict of interest. Unsworth J. A review of services for allergy. Project Team of The Resuscitation Council (UK). 5. Proposed use of adrenaline (epinephrine) in anaphylaxis and related conditions: a study of senior house officers starting accident and emergency posts. Praed St. no conflict of interest. Johnston SL. Sheikh A. Cambridge University NHS Foundation Trust. BMJ 2003. no conflict of interest. List of Working Group of the Resuscitation Council (UK) Jasmeet Soar. Cambridge CB2 0QQ. Gompels MM. Hills Road. Consultant in Allergy and Asthma. Postgrad Med J 2002. Survey of the use of epinephrine (adrenaline) for anaphylaxis by junior hospital doctors. no conflict of interest. Oxford Road. Dr Bernard Fo¨ ex. Queen Victoria Rd. College of Emergency Medicine. Postgrad Med J 2007. Nigel Harper. no conflict of interest. Hills Road. Mary’s Hospital NHS Trust. 167 Dr David Joseph Unsworth. Evidence-based management of anaphylaxis. Clesham GJ. Co-chair Working Group. Resuscitation 1999. Royal College of Anaesthetists. no conflict of interest. Department of Health. Manchester M13 9WL. Jose R. 35 Orchard Rd. Dr George Rylance. Dept of Imaging. Bristol BS10 5NB. Headington. Andrew Cant. no conflict of interest. Consultant. Cambridge CB2 0QQ. Royal College of Pathologists. Royal College of Pathologists.

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