Anaphylaxis: The Right Clinical Information, Right Where It's Needed

Anaphylaxis
The right clinical information, right where it's needed
Last updated: Oct 27, 2017

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 5
Classification 5
Prevention 7
Primary prevention 7
Secondary prevention 7
Diagnosis 8
Case history 8
Step-by-step diagnostic approach 8
Risk factors 10
History & examination factors 11
Diagnostic tests 14
Differential diagnosis 15
Diagnostic criteria 18
Treatment 20
Step-by-step treatment approach 20
Treatment details overview 25
Treatment options 26
Emerging 40
Follow up 42
Recommendations 42
Complications 42
Prognosis 43
Guidelines 44
Diagnostic guidelines 44
Treatment guidelines 45
Online resources 48
Evidence scores 49
References 50
Disclaimer 58
Summary
◊ Sudden onset of respiratory or cardiovascular compromise, usually with a history of allergen

exposure in sensitised individuals.
◊ Skin rash, wheezing and inspiratory stridor, hypotension, anxiety, nausea, and vomiting are the
cardinal signs and symptoms.
◊ The diagnosis is clinical. Allergy testing is helpful only for secondary prophylaxis.
◊ Securing the airway and initiating prompt treatment with epinephrine (adrenaline) may save lives.
◊ Comorbidities (e.g., CAD and COPD) may pose a treatment challenge and warrant expert
consultation
Anaphylaxis Basics
Definition
Anaphylaxis is an acute, severe, life-threatening allergic reaction in pre-sensitised individuals, leading to
a systemic response caused by the release of immune and inflammatory mediators from basophils and
BASICS
mast cells. At least 2 organ systems are involved, such as the skin, the upper and lower airways, and the
cardiovascular, neurological, and GI systems, in this order of priority or in combination. Allergy to medicines,
food, immunotherapy, or insect stings is the most frequent cause. Similar symptoms caused by non-
immunological mechanisms are termed anaphylactoid reactions.[1] [2] [3]
Epidemiology
Anaphylaxis is under-reported and until recently has lacked a useful clinical definition and consensus
criteria.[2] [3] [5] [6] Due to this deficiency, precise data collection on incidence and prevalence poses a
challenge. The prevalence is estimated between 1% and 17% of the total population in the US, where
0.002% of the population may die from an anaphylactic reaction.[7] Others describe a lifetime prevalence of
between 0.05% and 2%, citing recent studies in North America, Europe, and Australia.[8] These estimates
vary widely, due to varying populations, different methods of identification, and a plethora of classifications.
Incidence and prevalence differ for specific allergens. In adults, drug- and vaccine-induced reactions with
penicillin and NSAIDs are seen most commonly. The incidence of food allergic reactions that are coded as
anaphylaxis is highest in young children.[9] In children, food allergy is most prevalent in the industrialised
world and the emerging economies of southeast Asia, possibly due to an increased exposure to processed
food. Food allergy affects both sexes equally.[10] There are reports of slightly higher rates of anaphylaxis to
food in males in Hong Kong[11] and in females in Australia.[12]
Aetiology
Exposure to allergen in pre-sensitised individuals is the cause of immune-mediated anaphylaxis. Common
allergens include drugs, foods, and insect stings, but exercise with or without presence of an allergen may
also trigger the condition. Sometimes, a co-factor (such as NSAIDs, alcohol, another food) is required to
provoke food-associated and exercise-induced anaphylaxis.[13]
Approximately one third to one half of reactions are triggered by food. Ingestion, food aerosols (e.g., peanut
particles produced during processing, airborne proteins associated with preparation of shellfish or egg
powder used in bakeries) as well as handling of the culprit food (e.g., peanuts, tree nuts, egg, milk, and fish)
may trigger severe reactions.[14] Food-associated, exercise-induced anaphylaxis occurs 2 to 4 hours after
exercise in predisposed patients ingesting the responsible allergen.[15] Insect stings with the ubiquitous
Hymenoptera (wasps and bees) are commonplace globally, while ant stings and spider bites are limited to
their geographical prevalence.[16]
Drug- and immunotherapy-induced anaphylactic reactions are frequent both in the hospital setting and
outside. For adults, antibiotics, especially penicillin, have been found to be the most common offender.[17]
Omalizumab administration is associated with an anaphylaxis reporting rate of 0.09%.[18]
The risk of anaphylaxis after vaccine administration is low. A review of the Vaccine Safety Datalink estimated
the risk of anaphylaxis after vaccination to be 0.65 per million to 1.53 per million doses. Intradermal testing
with the vaccine is recommended prior to vaccination if the patient is at risk for anaphylactic reactions.[19]
[20] Specific recommendations have been made for the special case of influenza vaccine in egg-allergic
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Oct 27, 2017.
BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on
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Anaphylaxis Basics
children;[21] however, the risk of an allergic reaction has been found to be low and guidelines have since
been updated.[22] [23]
Anaphylaxis during anaesthesia in adults is most often due to reactions to neuromuscular-blocking agents,
BASICS
next to reactions to intravenous (IV) anaesthetics, opioid analgesics, non-steroidal anti-inflammatory drugs
(NSAIDs), local anaesthetics, colloids, and latex.[24] In children anaphylactic reactions during anaesthesia
are more often due to latex, which makes a latex-free environment crucial.[25]
Idiopathic anaphylaxis used to be the major diagnosis in anaphylactic cases presenting to allergists or
immunologists.[26] However, due to more sophisticated and precise testing, the true underlying causes are
detected more often and idiopathic anaphylaxis is diagnosed less frequently.
Pathophysiology
The clinical symptoms derive from pro-inflammatory and vasoactive mediators and cytokines released by
massive degranulation or release from basophils and mast cells. Classically, this cascade is initiated by an
IgE-mediated hypersensitivity reaction.
Allergens are introduced into the body by various routes: ingestion, inhalation, parenteral, or skin contact. On
first exposure, a susceptible person forms IgE antibodies specific to the antigen presented. IgE antibodies
attach to high-affinity Fc receptors on basophils and mast cells.
On subsequent exposure, binding of antigen to the IgE antibodies leads to bridging and triggers the
degranulation of mast cells. Histamine, prostaglandin D2, leukotrienes, platelet-activating factor, tryptase,
nitric oxide, and eosinophil and neutrophil chemotactic factors have diverse effects on target organs and lead
to the clinical manifestations of anaphylaxis. These manifestations include increased vascular permeability,
vasodilation, and myocardial dysfunction, leading to hypotension and cardiovascular collapse, as up to 50%
of intravascular volume can shift to the extravascular compartment in minutes. Altered smooth muscle tone
results in bronchospasm and asthma in the respiratory tract, and may also lead to uterine cramps. Activation
of the autonomic nervous system causes tachycardia, anxiety, and mucus hypersecretion. Increased
platelet aggregation and subsequent recruitment of more immune cells complete the picture of the systemic
inflammatory response.
NSAIDs may also trigger cell activation by altering arachidonic acid metabolism. Activation of complement,
the complement peptides (anaphylatoxins) such as C3a and C5a, and their direct action on mast cells
and basophils may lead to mediator release, producing symptoms indistinguishable from the classic IgE-
mediated reaction.[27]
Classification
Classification of immediate-type, life-threatening allergic or
pseudoallergic reactions (CHEST)[4]
I. IgE antibody-mediated systemic anaphylaxis
• food
• medicines
• venom
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Oct 27, 2017.
5
Anaphylaxis Basics
• allergen immunotherapy
• blood products (including plasma and antibodies [intravenous immunoglobulin])
• monoclonal antibodies (e.g., omalizumab).
II. IgE-mediated, local, life-threatening laryngeal obstruction.
BASICS
III. Immunological but not IgE-mediated anaphylaxis
• mediated by anaphylatoxins C3a and C5a

• monoclonal antibodies against lymphocyte receptors
• other new biological products.
IV. Munchausen's anaphylaxis: real or simulated factitious anaphylaxis
• IgE-mediated, due to purposeful self-exposure to an allergen

• simulated: purposeful approximation of the vocal cords resulting in laryngeal stridor
• prevarication anaphylaxis: patient reports signs and symptoms of anaphylaxis on repeated occasions;
based on history, idiopathic anaphylaxis is suspected; however, never any documented signs and
symptoms by physicians.
V. Anaphylactoid: clinically indistinguishable from anaphylaxis, but not IgE-mediated; seen in response to
opiates, NSAIDs, and radiocontrast agents
• radiographical contrast medium (mechanism uncertain)

• pharmacological.
VI. Idiopathic anaphylaxis: the cause cannot be identified
• generalised frequent: >6 episodes per year, or ≥2 episodes within a 2-month period
• generalised infrequent: less often than generalised frequent
• angio-oedema (potentially life-threatening) frequent: >6 episodes per year or ≥2 episodes within a 2-
month period
• angio-oedema (potentially life-threatening) infrequent: less often than angio-oedema frequent.
Allergic Diseases Resource Center classification [World Allergy

Organization Allergic Diseases Resource Center: anaphylaxis]
1. Anaphylaxis: immunological, particularly IgE-mediated reactions
2. Non-allergic anaphylaxis: clinically identical to anaphylaxis; however, not immunologically mediated.
Anaphylaxis Prevention
Primary prevention
Prevention of allergy formation focuses on reduction of allergen exposure in susceptible individuals: in
particular, during immunologically vulnerable periods early in life. This includes abstinence from certain
foods for young children and breastfeeding mothers, even though there is weak supporting evidence.
In some south Asian countries, certain food allergies are emerging, due to shifting eating habits toward
processed food. For example, allergies are on the rise in China since consumption changed from fresh to
high-temperature-treated peanuts. Effective intervention seems idealistic in this area at the moment.
Precautions against exposure to insect stings includes closed footwear and thick socks when outside.
Windows should be closed when driving and when at home (insect protection windows are recommended
for the home). Drinking or eating outdoors requires special care, as honeybees seek all fluids, especially
in hot weather, and wasps seek the sugar in drinks. These recommendations are crucial for individuals
with known allergies and individuals at high risk, such as children from allergic families or atopic children.
Avoiding exposure to insect stings (e.g., bees, wasps, and ants) is recommended for the general population,
as individuals might not be aware of their allergy.
PREVENTION
Medical personnel and high-risk patient groups (e.g., patients with spina bifida) can be protected from
developing latex allergy by avoidance of latex-containing materials and catheters.[25]
Secondary prevention
Prevention of subsequent allergic reactions starts with clear identification of the causative allergen and
allergen avoidance. Patient and carer awareness and education is crucial.[105]
For food allergies, awareness includes careful attention to food labelling, caution with take-away and
restaurant foods, and an allergen-free environment. Many industrial countries mandate the precise labelling
of all foods. Restaurants will often specify special additives and ingredients. This is helpful as even traces of
an allergen may be sufficient to trigger a full-blown allergic attack.
Latex-free precautions are necessary in surgical or dental procedures in latex-allergic patients.[106] Medicine
allergies require a medical record alert and a MedicAlert-type bracelet or necklace. Possible cross-reactivity
has to be considered as well.
Prevention of insect stings is crucial in allergic individuals. Venom immunotherapy is recommended for
patients who have experienced severe systemic reactions to insect stings and have specific IgE to venom
allergens.[107]
A prescription of two epinephrine (adrenaline) auto-injectors must be given to all patients after any episode
of anaphylaxis.[6] [72] The patient or carer should carry both of them at all times and be familiar with their
use.[64] For children at risk of anaphylaxis, the epinephrine (adrenaline) auto-injectors should be prescribed
in conjunction with a personalised written emergency plan.[64] [73] [American Academy of Pediatrics: allergy
and anaphylaxis emergency plan]
7
Anaphylaxis Diagnosis
Case history
Case history #1
A 14-year-old girl presents in severe respiratory distress to the emergency department. Her past medical
history includes asthma and a peanut and tree nut allergy. Shortly after ingestion of a biscuit in the school
cafeteria, she began complaining about flushing, pruritus, and diaphoresis followed by throat tightness,
wheezing, and dyspnoea. The school nurse called an ambulance. No medications were administered and
the patient did not have an epinephrine (adrenaline) auto-injector prescribed by her allergist. Her physical
examination reveals audible wheezing and laryngeal oedema and an oxygen saturation of 92%.
Case history #2
A 65-year-old man reports being stung while working in his garden. He removed the sting and found the
dying bee. In the past he tolerated insect stings on several occasions without reaction. On this occasion,
within minutes, he experienced flushing, sweating, and a brief loss of consciousness. Too confused to call
for help, he was found 10 minutes later by his wife. On arrival of an ambulance he was rousable, without
respiratory distress or rash. Systolic BP was 75 mmHg and pulse rate was 55 bpm.
Other presentations
A patient may follow a biphasic time course, or the presentation may be atypical and limited to a single
organ system (e.g., only laryngeal oedema or GI symptoms after shellfish ingestion). Biphasic reactions
describe the recurrence of symptoms after resolution of the initial episode and can occur up to 78 hours
after the event, with the majority occurring at 8 to 10 hours. The severity of symptoms is highly variable,
with about one third more severe, one third severe, and one third less severe. Anaphylaxis may also
occur with no previously known exposure to the allergen, particularly in older adults or in children (e.g.,
peanut allergy in toddlers exposed only through breast milk). Simple hypotension after drug administration
may represent the beginning of severe anaphylaxis (e.g., radioiodine allergy or secondary to some
DIAGNOSIS
neuromuscular blockers).
Step-by-step diagnostic approach

A life-threatening, rapid hypersensitivity reaction, requiring immediate medical attention, anaphylaxis is
characterised by rapidly progressive upper airway obstruction, rash, bronchospasm, and hypotension or
cardiovascular collapse. The diagnosis is largely clinical, based on history and examination findings.[11] [35]
[36]
History
Clues from the clinical history should point to the allergen exposure. Clinicians should gather details about
similar reactions in the past as well as known allergies and hypersensitivities. A determination of potential
causes includes inquiry about food or medication consumed before the event and possible insect stings
or bites. It is important to gather information about the location where the event occurred: outdoors versus
indoors; at home, work, or school, or in a restaurant. Triggers for anaphylactic reactions may include
heat, cold, or sexual activity.[37] Biphasic reactions or symptom recurrence after resolution of the initial
presentation can be identified by defining onset and clinical course, including recurrence of symptoms
after resolution of the initial reaction.[38] [39] It is recommended to observe patients after resolution of an
anaphylactic episode for 24 hours for possible second-phase reactivation. Observation periods differ as
there is no reliable predictor for biphasic or protracted anaphylaxis.[37]
Clinical presentation
There are a wide variety of signs and symptoms; therefore, a clinical evaluation should include all
organ systems. Many patients describe an sense of impending doom (angor animi). The patients
appear agitated, confused, and either flushed or pale.[40] Neurological manifestations also include
dizziness, visual disturbances, tremor, disorientation, syncope, and seizures. Rhinitis together with
bilateral conjunctivitis is often an early sign of progressive respiratory involvement. Inspiratory stridor is an
ominous sign often quickly leading to fatal laryngeal obstruction.[40] Wheezing, an over-inflated chest, the
use of accessory muscles, and preference for the forward-leaning position point to bronchoconstriction.
Cardiovascular collapse may occur in addition to hypotension.[41] Nearly all adults will show skin
manifestations of systemic mediator release, such as rash, erythema, or urticaria.[12] [42] These features
might be overshadowed by the more dramatic respiratory and cardiovascular symptoms.[43] Abdominal
pain, nausea, vomiting, and diarrhoea are common symptoms.
Laboratory evaluation in acute set ting

No laboratory test in the acute setting should delay urgent management of the patient.
Serum total tryptase measurements are not helpful for confirmation of the diagnosis of anaphylaxis
at the time of the episode because the assay takes several hours to perform; however, they can be
useful later.[44] Serum or plasma for tryptase should be obtained as soon as possible after emergency
treatment has started and a second sample ideally within 1 to 2 hours (but no later than 4 hours) from the
onset of symptoms.[45] Large elevations, however, may persist for hours. To determine the baseline level
of tryptase, an additional sample should be collected at least 24 hours after all symptoms have resolved.
Serum tryptase levels are normally undetectable (<1 nanogram/mL) in healthy individuals who have
not had anaphylaxis in the preceding hours. In anaphylaxis, elevations can range from insignificant to
DIAGNOSIS
levels above 100 nanograms/mL. For example, high levels have been seen following severe anaphylaxis
induced by medications; however, in clinically obvious food-induced anaphylaxis, tryptase levels are
seldom elevated, even if serum was collected in a timely manner.[14] Hence, normal levels do not
exclude anaphylaxis. Elevated levels of total tryptase implicate mast cell involvement and correlate with
hypotension. The sensitivity and specificity of tryptase elevation have not been determined.[46]
Plasma histamine levels and urinary histamine metabolites can be measured but are rarely used in
clinical practice. Elevated histamine levels correlate with anaphylaxis severity,[47] but histamine has a
very short half-life. N-methyl-histamine levels are elevated when compared with baseline.[48] Histamine
and histamine metabolite levels may be affected by dietary factors.
Laboratory testing to prevent recurrence

Testing for the precipitating allergen after the acute episode is recommended to ensure allergen
avoidance and to reduce the risk of recurrence.
In food allergy, challenge with the supposed allergen remains the definitive test; however, this test may
subject the patient to a risk of reaction recurrence of unpredictable severity.
9
Several skin tests are available, including the scratch test (also called the puncture or prick test), the
intradermal test, and the patch test.
Skin testing is usually preferred for the diagnosis of allergic disease; it is more rapidly obtained, less
expensive, and most of the time more sensitive.
In some circumstances in vitro testing is used, as measurement of specific IgE levels is superior over
skin testing. Evolving data obtained in children are showing that IgE levels measured by Thermo Fisher
ImmunoCAP™ in some foods have more predictive value about clinical reaction on ingestion than skin
tests.[49]
Basophil activation tests have been described as a supplemental tool in diagnosing severe peanut allergy
in adults.[50]
A referral to an allergist is always recommended.
Risk factors
Strong
<30 years old: food-associated, exercise-induced
• Food-associated, exercise-induced anaphylaxis is more common in young people.[15]
atopy/asthma
• In food allergies, a history of atopy and asthma has been shown to be a risk for more severe
anaphylaxis.[10] In contrast, the incidence of atopy and asthma in venom- and drug-allergic patients
seems to be no higher than in the general population. A clinical history of asthma is a risk factor for
respiratory compromise.[30]
hx of anaphylaxis
DIAGNOSIS
• Individuals with previous anaphylactic reactions are at higher risk for recurrence.[14] [31] However, the
severity of a previous reaction does not necessarily predict the severity of a subsequent reaction.[32]
exposure to a common sensitiser (e.g., latex)

• Exposure history to latex and latex sensitivity occurs in a significant percentage of health care workers,
in about 75% of patients with spina bifida, and in patients undergoing multiple surgeries.[33] [34]
Weak
adult age: food-, insect venom- and medicine-related
• In the adult population, food accounts for only one third to one half of cases presenting to the
emergency department.[11] [12] [15] Lethal reactions to insect venom and various drugs or other
iatrogenic causes most commonly occur in those aged 55 to 67 years. Cardiovascular collapse is the
main reaction feature.[28] Antibiotics, notably penicillin, and NSAIDs are the most common causes
of medicine-related anaphylaxis.[1] [17] Reactions to shellfish are the most commonly reported food-
associated reactions in adults.[29]
female sex
• Food-associated, exercise-induced anaphylaxis is more common in women.[15]
History & examination factors

Key diagnostic factors
presence of risk factors (common)
• Key factors include a history of atopy or asthma, exposure to a common sensitiser (e.g., latex), and
previous anaphylactic reaction.
acute onset (common)

• Onset is within minutes to a maximum of 1 hour after exposure.
• May follow a uniphasic course, with resolution of symptoms within hours of treatment and without
symptom recurrence on repeated exposure to the trigger. In about 3% to 20%, episodes are described
to follow a biphasic course, with symptom recurrence after resolution of the initial presentation.[11] [35]
• Recommended to observe patients after resolution of an anaphylactic episode for 24 hours for
possible second-phase reactivation. Observation periods differ as there is no reliable predictor for
biphasic or protracted anaphylaxis.[37]
urticaria (common)
• Commonly known as hives. A common symptom characterised by blanching, raised, palpable wheals,
which can be linear, annular (circular), or arcuate (serpiginous). Occur on any skin area and are
usually transient and migratory.
angio-oedema (common)
• A manifestation of immediate hypersensitivity with a circumscribed swelling of any part of the body.
Immediate treatment is warranted if it involves the airways.
flushing (common)
DIAGNOSIS
• A frequent sign of anaphylaxis due to vasodilation.
• Has to be distinguished from other causes such as carcinoid syndrome, post-menopause,
chlorpropamide, alcohol, idiopathic flush, medullary carcinoma of the thyroid, and related to autonomic
epilepsy.
dyspnoea (common)
• May be caused by upper airway obstruction or increased resistance to air movement due to lower
airway bronchoconstriction in response to allergen exposure.
wheezing (common)
• Most often due to reactive airway disease. Wheezing, in conjunction with an overinflated
chest, the use of accessory muscles, and preference for the forward-leaning position, points to
bronchoconstriction and requires immediate treatment with bronchodilators. A peak flow meter will
indicate a reduction of the forced expiratory volume.
rhinitis (common)
• Together with bilateral conjunctivitis, is often an early sign of progressive respiratory involvement.
11
Other diagnostic factors

allergen ingestion (common)
• Accounts for about one third to one half of cases.[12] Can be caused by ingestion, but also by
handling and inhalation of the food aerosol.
• Prevalence is greatest in the paediatric population and decreases with age.[51]
• In most cases peanuts, tree nuts, fish, and shellfish are responsible. Eating habits of a population
influence the type of food causing the allergic reaction (e.g., peanut allergy in the US and sesame
allergy in children in Israel).
• Many patients are unaware of their food allergy and may be unaware that the meal includes the
allergen.
insect stings or bites (common)

• A common cause around the world. Hymenoptera (e.g., bee or wasp) stings and ant stings are
common in differing geographical locations.
pruritus (common)
• Together with rash, is an early sign of urticaria.
inspiratory stridor and hoarse voice (common)

• The most ominous sign of upper airway obstruction; may quickly lead to fatal laryngeal obstruction and
angio-oedema.[40]
bilateral conjunctivitis (common)

• As a result of allergen exposure, redness, excessive tearing, sensitivity to light, a feeling of grittiness,
swelling of the eyelids, and itchiness may occur.
• Both eyes are usually affected simultaneously. Together with rhinitis, is often an early sign of
progressive respiratory involvement.
nausea and vomiting (common)

DIAGNOSIS
• Suggests the ingestion of an allergen and may be associated with other GI symptoms, such as
abdominal cramps or diarrhoea.
abdominal cramping or pain (common)

• Often painful; points to a food allergen and may be associated with other GI symptoms, such as
nausea and vomiting or diarrhoea.
agitation/anxiety (common)
• Anaphylaxis may present with a complex combination of emotions that include fear, apprehension,
worry, and disorientation. These may be accompanied by physical sensations such as heart
palpitations, nausea, chest pain, or shortness of breath. These neuropsychological symptoms of
anaphylaxis may be worsened by hypotension, and may even be triggered by administration of
epinephrine (adrenaline), but tend to resolve as the other allergic symptoms abate.
confusion/disorientation (common)
• Refers to loss of orientation by time, location, and personal identity, and often loss of memory. This
neuropsychological symptom of anaphylaxis may be worsened by hypotension, and may be triggered
by administration of epinephrine (adrenaline), but tends to resolve as the other allergic symptoms
abate.
tachycardia (common)
• Often associated with hypotension and may herald cardiovascular collapse. The pulse may be so
weak that heartbeats may be missed on radial palpation. May lead to underestimation of the cardiac
frequency and hence the severity of the patient's condition. The true heart rate is best documented on
an ECG monitor.
dizziness (common)
• Common descriptions include words such as light-headed, floating, woozy, giddy, confused, helpless,
or fuzzy. Presyncope is the medical term. Anaphylaxis can lead to dizziness and eventually to syncope
due to the hypotension associated with the intravascular fluid shifts to the third space, mediated by
vasoactive substances released from mast cells and basophils.
syncope (common)
• Characterised by temporary loss of consciousness and posture, described as fainting or passing out.
Usually related to temporary insufficient blood flow to the brain. Anaphylaxis can lead to syncope
due to the hypotension associated with the intravascular fluid shifts to the third space, mediated by
vasoactive substances released from mast cells and basophils.
sense of impending doom (angor animi) (common)

• Describes a person's perception that they are in fact dying. Although it may be more typical for patients
suffering from acute coronary syndrome such as angina, the inspiratory stridor, the dyspnoea, and
the faint feeling and dizziness secondary to hypotension compound the psychological stress of severe
allergic reactions.
recent exercise (uncommon)

• Exercise-induced anaphylaxis is triggered by physical activity and typically occurs 2 to 4 hours
after allergen ingestion. Initial symptoms include diffuse warmth, pruritus, erythema, and urticaria.
DIAGNOSIS
Progression to angio-oedema, GI symptoms, fatigue, laryngeal oedema, and/or vascular collapse is
common.
• Factors associated with this type of anaphylaxis include medicines (e.g., aspirin or other NSAIDs) and
food ingestion (wheat, shellfish, and celery, among others) before or after the exercise. Therefore, in
predisposed individuals, exercise should be avoided in the immediate postprandial period. A higher
rate of atopy has been described.
hot or cold exposure (uncommon)

• A complication of cold urticaria is anaphylaxis.[52] Systemic symptoms, occasionally severe and
anaphylactoid, may occur after extensive exposure such as immersion in cold water.
• May be a recent history of an infection (e.g., Mycoplasma pneumoniae ).
• Spontaneous improvement occurs in an average of 2 to 3 hours. Patients must learn to protect
themselves from a sudden change in temperature.
hypotension (uncommon)
• Vasodilation leads to a relative hypovolaemia and severe hypotension, the cardinal clinical feature of
anaphylaxis.[42] Increased capillary permeability causes fluid loss to the extravascular space, thus
compounding hypotension.
13
bradycardia (uncommon)
• Sometimes secondary to concomitant cardiac medicines, such as beta-blockers.Sudden positional
change should be avoided in these patients, as this may lead to collapse.[41]
cardiac arrest (uncommon)

• The abrupt cessation of normal circulation or the absence of effective perfusion of vital organs.
Diagnosed by absent pulses. The patient will be unresponsive and stop breathing, and the skin will
appear dusky.
diarrhoea (uncommon)
• May accompany other symptoms of the GI system, such as nausea and vomiting and abdominal pain,
after allergen ingestion.
visual disturbances (uncommon)

• Rare, caused by anaphylactic shock secondary to isolated ischaemia of both lateral geniculate bodies.
In several cases, the allergen was an antibiotic. Visual field losses occurred, but resolved within 7
weeks.[53]
tremor (uncommon)
• Both endogenous catecholamines and epinephrine (adrenaline) administered by first responders may
cause tremor and nervousness.
seizures (uncommon)
• Neurological manifestations, although uncommon, may include seizures.
Diagnostic tests
1st test to order
DIAGNOSIS
Test Result
serum tryptase level elevated
• Serum samples should be taken as soon as possible after
emergency treatment has started, with a second sample ideally
within 1 to 2 hours (but no later than 4 hours) from the onset of
symptoms.[45]
• Serum tryptase levels are normally undetectable (<1 nanogram/mL)
in healthy individuals who have not had anaphylaxis in the preceding
hours. In anaphylaxis, elevations can range from insignificantly
elevated to levels above 100 nanograms/mL.
• It is not useful for some conditions, such as food-induced anaphylaxis
with local reaction. Elevation of tryptase levels may also exist in non-
anaphylactic conditions, such as systemic mastocytosis.
• Available in all major labs (e.g., as ImmunoCAP), and can be
measured post mortem.
• To determine the baseline level of tryptase, an additional sample
should be collected at least 24 hours after all symptoms have
resolved.
• Not necessary when diagnosis of anaphylaxis is definite.
Other tests to consider
Test Result
in vitro IgE testing >0.35 international units/L
• An in vitro quantitative assay measuring allergen-specific IgE in
human serum.
• Provides a clinically relevant means of confirming or excluding
the presence of atopy. Also accurately identifies specific allergen
sensitivities in patients with confirmed allergy. Unfortunately, an
abnormal value does not imply clinical reaction or indicate the
severity.[54] [55]
• For food allergy, sensitivity is 86% and specificity 83%.[56]
skin test >3 mm diameter and
greater than control
• Three main types are: the scratch test, also called puncture or prick
test; the intradermal test; and the patch test.[57] [58]
• A variety of allergen extracts for skin testing are commercially
available. For food allergy diagnosis, skin testing has low value, with
a positive predictive value of <40% and a negative predictive value of
>95%.[59] Few extracts are available to test for drug allergy.
challenge test objective symptoms of
allergy response
• The patient is challenged with increasing amounts of the offending
allergen. This is the best method to confirm a diagnosis of allergy;
however, it is often avoided if patient has a history of anaphylaxis.[57]
If a causative food has not been identified but food allergy is
suspected, a food challenge might be necessary as the specific food
avoidance might be life-saving.
Emerging tests
Test Result
basophil activation test basophil activation
DIAGNOSIS
• Flow-cytometry test assessing reaction of basophils to allergens. Has
been described as a supplemental tool in diagnosing severe peanut
allergy in adults.[50]
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Septic shock • Absence of previous allergic • Increased WBC count and
reactions, lack of allergen increased temperature.
exposure, slower onset, • CXR with a pulmonary
fever, and other signs of infiltrate is suggestive of
localised infection often underlying pneumonia as
differentiate septic shock source of infection.
from anaphylaxis.
15

symptoms
Cardiogenic shock • Age, risk factors for CAD, • Elevated cardiac enzymes
previous angina episodes, (CK and troponin). ECG may
absence of an allergic show signs of myocardial
history, no indication of ischaemia (elevated
allergen exposure, typical ST segments or flipped
cardiac signs and symptoms T waves). CXR may
(such as chest pain on show signs of CHF (e.g.,
exercise) help to distinguish. pulmonary oedema, changes
Severe anaphylactic in the cardiac silhouette).
reactions can trigger cardiac
events.
Hypovolaemic shock • Water or fluid loss occurs • A drop in haematocrit

via heat exposure, profuse suggests blood loss.
sweating, significant • A serum urea/creatinine
blood loss, vomiting, and ratio >20 suggests volume
diarrhoea. Patients report depletion.
thirst and a drop in urinary
output. Anaphylaxis is
a form of hypovolaemic
shock secondary to
intravascular fluid shifts.
Establishing an alternative
cause of hypovolaemia
will differentiate from
anaphylaxis.
Vasovagal reaction • The characteristic feature • There is no differentiating

is hypotension, with test.
pallor, weakness, nausea,
vomiting, and diaphoresis.
The sudden onset, the
cardiovascular collapse, and
DIAGNOSIS
unconsciousness are all also

typical of anaphylaxis.
• May be differentiated by
the lack of cutaneous
manifestations, the absent
allergic history, and the
presence of bradycardia
instead of the tachycardia,
even though either can be
absent or misleading.
Asthma • Absence of allergen • There is no differentiating

exposure, or of cutaneous or test.
digestive findings, and a hx
of previous asthma episodes
help to differentiate. A
rapid onset is suggestive
of anaphylaxis and should
at least trigger referral to
higher-level medical care.

symptoms
Acute COPD exacerbation • Absence of allergen • There is no differentiating
exposure, or of cutaneous or test.
digestive findings, and a hx
of established chronic lung
disease help to differentiate.
Hereditary angio-oedema • Characterised by recurrent • Deficiency or underactivity

episodes of slowly of the C1 esterase inhibitor
progressing angio-oedema enzyme.
of the skin, mucosa, and • Serum complement C4 and
submucosal tissue. There is CH50 are low.
no urticaria, hypotension, or
history of allergen exposure
as in anaphylaxis. FHx is
positive.
Vocal cord dysfunction • Cutaneous signs, digestive • Pharyngeal endoscopy by

syndrome findings, hypotension, and an ENT consultant will not
allergen exposure are not show laryngeal oedema but
present. instead vocal cord adduction.
Foreign body aspiration • No allergen exposure, no • Imaging and bronchoscopy

cutaneous or digestive are used to locate and
findings, but a hx of foreign document the foreign body.
body aspiration differentiate If the object inhaled is radio-
this diagnosis. opaque (e.g., a small coin), a
plain radiograph of the chest
may show its location.
Monosodium glutamate • In reaction to MSG • Serum histamine levels and

(MSG) ingestion exposure, the following mast cell tryptase are not
MSG symptom complex elevated.
may occur. One or more of
DIAGNOSIS
the following are present:
burning sensation in the
back of the neck, forearms,
and chest; numbness
in the back of the neck,
radiating to the arms and
back; tingling, warmth,
and weakness in the face,
temples, upper back, neck,
and arms; facial pressure
or tightness; chest pain;
headache; nausea; rapid
heartbeat; bronchospasm;
drowsiness; and weakness.
No urticaria, angio-oedema,
or hypotension occurs.
Carcinoid syndrome • On examination, there is • Urinalysis will show high

an associated right heart levels of hydroxy indole
murmur. acetic acid.
17

symptoms
Postmenopausal hot • Flush appears several times • There is no differentiating
flushes a day and lasts for 4 to test.
5 minutes. There are no
respiratory tract symptoms
and no hypotension.
Red man syndrome • This syndrome usually • There is no differentiating

appears within 4 to 10 test.
minutes after start or soon
after the completion of a
vancomycin infusion. It is
characterised by flushing
and/or an erythematous
rash that affects the face,
neck, and upper torso.
Hypotension and angio-
oedema may also occur, but
less frequently.
Panic disorder • In some, functional stridor • There is no differentiating

develops as a result of test.
forced adduction of the vocal
cords; however, there is no
urticaria, angio-oedema, or
hypotension.
Scombrotoxic food • Symptoms resemble IgE- • Skin test to suspected

poisoning mediated food allergy, seafood is negative.
but most prominent on Histamine level in consumed
upper torso and face. fish elevated.
Erythematous rash, but no
urticaria noted. Resolves
untreated within 12 hours.
DIAGNOSIS
Diagnostic criteria
Clinical criteria for diagnosing anaphylaxis[3]
Anaphylaxis is highly likely when any 1 of the following 3 criteria are fulfilled:
1. Acute onset of an illness (minutes to hours)
• Involvement of skin, mucosal tissue, or both (i.e., generalised hives, pruritus, or flushing,
swollen lips-tongue-uvula) and at least 1 of the following: respiratory compromise (i.e.,
dyspnoea, wheeze-bronchospasm, stridor, reduced peak expiratory flow [PEF], hypoxaemia)
or reduced BP or associated symptoms of end-organ dysfunction (i.e., hypotonia/collapse,
syncope, incontinence)
2. Occurrence of 2 or more of the following symptoms or signs after exposure to a likely allergen (minutes
or hours)
• Involvement of skin, mucosal tissue, or both (i.e., generalised hives, pruritus, or flushing,
swollen lips-tongue-uvula)
• Respiratory compromise (i.e., dyspnoea, wheeze-bronchospasm, stridor, reduced PEF,
hypoxaemia)
• Reduced BP or associated symptoms of end-organ dysfunction (i.e., hypotonia/collapse,
syncope, incontinence)
• Persistent GI symptoms (i.e., crampy abdominal pain, vomiting)
3. Reduced BP after exposure to a known allergen (minutes to several hours)
• Systolic BP of <90 mmHg or >30% decrease from baseline.
DIAGNOSIS
19
Anaphylaxis Treatment
Step-by-step treatment approach

Appropriate preparation is the key to good patient outcomes in anaphylaxis.[44] In all patients the primary
goal is cardiopulmonary support and reversal of the effects of anaphylaxis with epinephrine (adrenaline).
Patients may present with a range of severities, but cardiac collapse and respiratory compromise cause the
most urgent concern as they can be fatal. Patients presenting with milder symptoms can rapidly deteriorate
and should be closely monitored.[1]
Cardiopulmonary arrest
If patient is in cardiopulmonary arrest, CPR with intubation and ventilation, intravenous (IV) fluid
replacement, and IV epinephrine (adrenaline) are indicated. Tracheal intubation animated demonstration
Equipment needed
• Personal protective equipment, including gloves

• Laryngoscope (ensure light is working)
• Cuffed tracheal tube; an average size adult will require a size 7 or 8 cuffed tracheal tube, which
corresponds to a 7 or 8 mm internal diameter. (Paediatric intubation is done with uncuffed tubes
and should be carried out by an experienced clinician.)
• Syringe for inflating and deflating cuff (ensure cuff inflates and deflates before intubation)
• Bag-valve apparatus, including mask for pre-oxygenation
• Suction
• Oxygen
• End-tidal CO2 monitor (if available)
• Cotton tape to secure the tube
• Ventilator
• Magills forceps (in case of foreign material in the oropharynx)
• Gum elastic bougie (to use as guide wire in case of difficult intubation)
Contraindications
Lack of skilled, experienced personnel is a contraindication; tracheal intubation should be used only when
trained personnel are available to carry out the procedure, with a high level of skill and confidence.
If there is suspicion of a cervical spine injury, airway opening should ideally be achieved by jaw thrust or
chin lift rather than head tilt. If needed perform a head tilt using small increments.
Note: Laryngospasm due to anaphylaxis, an inhalation burn, near drowning, or a foreign body will not
improve significantly with simple airway manoeuvres, and occasionally tracheal intubation may not even
be possible. In this case, the patient may need an advanced airway procedure such as cricothyroidotomy.
The tracheal tube has generally been considered the optimal method of managing the airway during
cardiac arrest, and is indicated in an ongoing resuscitation event. Its use is restricted to scenarios where
personnel who are experienced and competent in tracheal tube insertion are present.
TREATMENT
Tracheal intubation has a number of perceived advantages over other forms of airway management:
• It enables ventilation without interruption of chest compressions

• It allows effective ventilation, even when lung or chest compliance is poor
• It minimises gastric inflation, and therefore minimises regurgitation
• It protects against aspiration of gastric contents into the lungs
• It frees up the rescuer’s hands for other tasks.
Tracheal intubation is also used for airway management during general anaesthesia.
Complications
In inexperienced hands, attempts at tracheal intubation can have negative consequences for the patient.
The incidence of incorrect intubation varies with experience, some studies showing rates of inadvertent
oesophageal intubation can be as high as 50% in inexperienced hands.
Complications of tracheal intubation include:
• Failed intubation
• Spinal cord and vertebral column injury
• Occlusion of central artery of the retina and blindness
• Corneal abrasion
• Trauma to lips, teeth, tongue, and nose
• Hypertension, tachycardia, bradycardia, and arrhythmia
• Raised intracranial and intraocular tension
• Laryngospasm
• Bronchospasm
• Aspiration
• Laryngeal trauma
• Cord avulsions, fractures, and dislocation of arytenoids
• Airway perforation
• Nasal, retropharyngeal, pharyngeal, uvular, laryngeal, tracheal, oesophageal, and bronchial trauma
• Oesophageal intubation
• Bronchial intubation.
Aftercare
If the tube is not correctly positioned, the stomach or the right lung only may be ventilated. Deflate the
cuff and re-position the tube and again auscultate to check position. Continue to resuscitate the patient in
keeping with life support guidelines using ABCDE principles.
Bag-valve-mask ventilation animated demonstration

Equipment needed
• Personal protective equipment, including gloves

• Bag-valve-mask apparatus
• Oxygen
• Reservoir bag attached to the bag-valve-mask apparatus
• Suction
• Oropharyngeal airway (have available to use if needed)
• Nasopharyngeal airway (have available to use if needed)
TREATMENT
• Resuscitation kit.
Contraindications
Complete upper airway obstruction is an absolute contraindication for bag-valve-mask ventilation.
21
If there is suspicion of a cervical spine injury, airway opening should ideally be achieved by jaw thrust or
chin lift rather than head tilt, while maintaining manual inline stabilisation (MILS). If the airway remains
obstructed despite these measures, perform a head tilt using small increments until the airway is open,
while maintaining MILS.[60]
When it is clear from the outset that the patient needs a definitive airway (e.g., in the unconscious patient
with a severe head and facial injury) call for help early while maintaining a patent airway by simple means
until skilled help arrives.
Consider the level of the airway obstruction. Laryngospasm due to anaphylaxis, an inhalation burn, near
drowning, or a foreign body will not improve significantly with simple airway manoeuvres, and the patient
may need intubation or advanced airway procedure.
Indications
• Respiratory failure
• Failed intubation.
Complications
• Aspiration
• Hypoventilation
• Hyperventilation
• Cervical spine injury.
Any significant leak will cause hypoventilation of the airway and can cause gas to be forced into the
stomach, heightening the risk of aspiration.
Aftercare
Continue to resuscitate the patient in keeping with life support guidelines, using ABCDE principles. Send
for assistance as soon as possible.
If resuscitation is successful and the patient regains control of their own airway, this should be regularly
reassessed. Measure arterial blood oxygen saturation as soon as practical by arterial blood gas sampling
and/or pulse oximetry and titrate inspired oxygen to maintain a blood arterial oxygen saturation in the
range of 94% to 98%.[60]
If the resuscitation continues or the patient’s Glasgow Coma Scale is less than 8, consider insertion of an
endotracheal tube.
Airway management
As even minor airway compromise can quickly progress to complete airway occlusion, immediate
airway assessment and support is critical. If possible, airway assessment and management should be
performed by a skilled anaesthesiologist or emergency physician. Early prophylactic intubation or even
cricothyrotomy may be necessary, especially if there is inspiratory stridor.[1] Inadequate respiratory efforts
TREATMENT
may indicate the need for ventilatory support. Supplemental oxygen is indicated in all patients unless
there are contra-indications (e.g., in cases of advanced COPD, chronic severe CO2 retention causes
the respiratory drive to become dependent on a certain degree of hypoxia; administering oxygen to this
patient population may cause them to stop breathing).
Cardiac support
Unless precluded by shortness of breath or vomiting, the patient should be placed in a flat supine
position with legs elevated (shock or Trendelenburg position). This will augment venous return, and
thereby increase pre-load and enhance cardiac output. Studies have shown that an upright position may
contribute to a fatal outcome.[61] Aggressive IV fluid replacement is indicated due to the intravascular
volume redistribution into venous capacitance vessels and the interstitial tissue. The human vascular
system consists of a high-pressure small-volume arterial system and a large low-pressure venous
reservoir that expands in anaphylaxis, absorbing much of the circulating blood volume. To make up for
this intravascular fluid loss, adults should be administered 1 L to 2 L of normal saline intravenously. Fluid
overload is a potential complication in patients with renal failure or CHF.
Epinephrine (adrenaline)
All patients with signs of a systemic reaction (especially hypotension, airway swelling, or difficulty
in breathing) should receive intramuscular (IM) epinephrine (adrenaline) in the anterolateral thigh
immediately.[62] [63] [64] [65] [66] 1[C]Evidence This dose may be repeated every 5 to 15 minutes as
needed.[1] [3] [14] [41] [69] The anterolateral thigh is superior over IM administration in the deltoid or
subcutaneous injection.[70] [71] If the patient has severe hypotension, IV epinephrine (adrenaline) is an
option. Continuous infusion of epinephrine (adrenaline), titrated to effect, is reserved for experienced
practitioners. No IV dose regimen is universally recognised. The alpha-1, beta-1, and beta-2 agonist
actions of epinephrine (adrenaline) play a key role in reversing effects of anaphylaxis. Stimulation of
the alpha-1 receptors leads to increased vascular tone and thus reversal of the effects of massive
vasodilation triggered by immune mediators. However, alpha-1 stimulation can also lead to severe
hypertension, especially in those with poorly controlled hypertension. Beta-1 receptor stimulation has
positive inotropic and chronotropic effects (i.e., the heart rate and contractility are increased), but an
overshooting response can result in unwanted tachycardia, potentially harming a patient with CAD. Beta-2
agonism causes bronchodilation and impairs release of mediators from mast cells and basophils.[32]
A prescription for two epinephrine (adrenaline) auto-injectors must be given after any episode of
anaphylaxis.[6] [72] The patient or carer should carry both at all times and be familiar with their use.[64]
For children at risk of anaphylaxis, the epinephrine (adrenaline) auto-injectors should be prescribed in
conjunction with a personalised written emergency plan.[64] [73] [American Academy of Pediatrics:
allergy and anaphylaxis emergency plan]
Adjuvant glucagon treatment in patients with CAD on beta-

blocker therapy
Patients may be on beta-blockers for CAD. Both the medicine and the underlying comorbidity complicate
the treatment of severe anaphylaxis. The beta-blocker counteracts adrenaline by limiting heart rate,
compromising cardiac output. CAD limits cardiac reserve, which might compound the hypotension
occurring due to the release of vasoactive mediators. The stresses of hypotension, tachycardia, and
endogenous or iatrogenic adrenergic agents may cause myocardial ischaemia by reducing perfusion
during diastole. Glucagon may be used to overcome beta blockade, but the resulting tachycardia can be
detrimental in patients with severe CAD.[3] Therefore, early consultation of a cardiologist is warranted.
TREATMENT
Other treatments in acute phase

Inhaled beta agonists are indicated if patients have persistent respiratory symptoms (wheeze, dyspnoea)
despite epinephrine (adrenaline). Supplemental oxygen should continue in these patients.
23
H1 and H2 antagonists are commonly used agents.2[C]Evidence Serum histamine levels peak early in
anaphylaxis and quickly return to baseline despite the persistence of severe physical compromise.[10]
[76] [77] With a slow onset of action, antihistamines cannot block events that occur after acute histamine
receptor binding. Most antihistamines can be given intravenously, intramuscularly, or orally. Oral
administration may be sufficient for very mild reactions. Non-sedating antihistamines may have some
advantages over diphenhydramine in the management of anaphylaxis; however, because these newer
antihistamines (second generation) can be given only orally, their use is limited to mild reactions. H1 and
H2 antihistamines in combination are more effective in palliating the cutaneous manifestations.[78] [79]
For example, diphenhydramine should be administered in conjunction with ranitidine. These agents are
slower in onset, but are useful in the treatment of urticaria-angio-oedema or pruritus. Studies have shown
that treatment with a combination of H1 and H2 antagonists is more effective than treatment with H1
antagonists alone.[1]
Maintenance treatment
Corticosteroids, orally or intravenously, have no established role in the treatment of acute anaphylaxis,
as they have a slow onset and may have no effect for 4 to 6 hours even if given intravenously.
Corticosteroids might prevent biphasic and protracted reactions, so they are used as preventative
treatment after emergency stabilisation. This regimen is the treatment of choice for persistent idiopathic
anaphylaxis. Patients previously prescribed corticosteroids, including patients with asthma, may benefit
from early use of systemic corticosteroids.
Treatment of the underlying aetiology - immunotherapy

After resolution of signs and symptoms of anaphylaxis, efforts should be made to treat the underlying
cause of anaphylaxis.
Immunotherapy is a mainstay in the treatment of allergic individuals with IgE-mediated disease, involving
repeated administration of allergen extracts. The traditional and best approach of immunotherapy is the
subcutaneous injection of incremental amounts of allergen extracts at weekly intervals for several months,
followed by monthly maintenance for 3 to 5 years.[80] [81] The long-term benefits persist for at least 3
to 5 years after discontinuation. Long-term benefits include remission of symptoms and decrease in the
onset of a new sensitisation. On re-exposure to the relevant allergen, the need for medicine is significantly
decreased.[82]
Sublingual immunotherapy is an alternative approach for immunotherapy mainly used in grass-pollen and
ragweed-pollen induced allergic rhinoconjunctivitis. Application to other allergen sources is still under
investigation. Therapy lasts for about 3 years as pre- and co-seasonal or perennial regimens. Systemic
reactions have rarely been described.[83]
Venom immunotherapy is the treatment of choice for prevention of systemic allergic reactions to insect
stings;[84] it can be 95% to 100% effective in preventing these systemic reactions. This kind of treatment
requires the input of an allergist to select the patients who will benefit from this treatment (usually patients
with a history of previous anaphylactic response to a sting and who have venom-specific IgE antibodies),
select the venoms, and select the schedule.
TREATMENT
Despite proven efficacy and benefits, there are clear limitations to immunotherapy, especially the risk of
an acute allergic reaction or anaphylactic shock during treatment. New approaches are being explored: in
particular, alternative routes of administration, especially the sublingual route.[85]
Treatment details overview

Consult your local pharmaceutical database for comprehensive drug information including contraindications,
drug interactions, and alternative dosing. ( see Disclaimer )
Presumptive ( summary )
Patient group Tx line Treatment
all patients: acute onset 1st cardiorespiratory assessment +

supportive measures
plus IM epinephrine (adrenaline)
plus assess & secure airway
plus IV normal saline
cardiopulmonary arrest plus CPR + IV epinephrine (adrenaline)
severe hypotension plus IV epinephrine (adrenaline)
severe hypotension adjunct IV glucagon
persistent respiratory plus inhaled beta-2 agonist

symptoms
symptomatic hives and adjunct antihistamine (H1 antagonist) + H2

rhinorrhoea antagonist
post-emergency adjunct corticosteroids

stabilisation
Ongoing ( summary )
patients with identified allergen 1st immunotherapy
TREATMENT
25
Treatment options
Presumptive
all patients: acute onset 1st cardiorespiratory assessment +

supportive measures
» Patients may present with a range of
severities, but cardiac collapse and respiratory
compromise cause the most urgent concern as
they can be fatal. Patients presenting with milder
symptoms can rapidly deteriorate and should be
closely monitored.[1]
» Unless precluded by shortness of breath

or vomiting, the patient should be placed in a
flat supine position with legs elevated (shock
or Trendelenburg position). This will augment
venous return, and thereby increase pre-load
and enhance cardiac output. Studies have
shown that an upright position may contribute to
a fatal outcome.[61]
» If no contra-indication, all patients should

be given oxygen. In rare cases of advanced
COPD, chronic severe CO2 retention causes
the respiratory drive to become dependent on a
certain degree of hypoxia.
» Breathing should be monitored by continuous

oxygen saturation or blood gas determination.
Inadequate respiratory efforts may indicate the
need for ventilatory support.
plus IM epinephrine (adrenaline)

» Immediate administration of adequate doses
of epinephrine (adrenaline) will decrease
patient mortality and morbidity.[14] All patients
with signs of a systemic reaction, especially
hypotension, airway swelling, or difficulty
in breathing, should receive immediate
intramuscular (IM) epinephrine (adrenaline) in
the anterolateral thigh.[62] [63] [64] [65] [66]
1[C]Evidence
» This dose may be repeated every 5 to

15 minutes as needed.[1] [3] [14] [41] [69]
The anterolateral thigh is superior over IM
TREATMENT
administration in the deltoid or subcutaneous

injection.[70] [71]
» A prescription for two epinephrine (adrenaline)

auto-injectors must be given after any episode of
anaphylaxis.[6] [72] The patient or carer should
Presumptive
carry both at all times and be familiar with their
use.[64] For children at risk of anaphylaxis, the
epinephrine (adrenaline) auto-injectors should
be prescribed in conjunction with a personalised
written emergency plan.[64] [73] [American
Academy of Pediatrics: allergy and anaphylaxis
emergency plan]
Primary options
» epinephrine: children: 0.01 mg/kg (as

a 1:1000 solution) intramuscularly every
5-15 minutes, maximum 0.3 mg/dose;
adults: 0.3 to 0.5 mg (as a 1:1000 solution)
intramuscularly every 5-15 minutes
plus assess & secure airway
» As even minor airway compromise can
quickly progress to complete airway occlusion,
immediate airway assessment and support
is critical. If possible, airway assessment
and management should be performed by
a skilled anaesthesiologist or emergency
physician. Early prophylactic intubation or even
cricothyrotomy may be necessary, especially
if there is inspiratory stridor.[1] Inadequate
respiratory efforts may indicate the need for
ventilatory support. Tracheal intubation animated
demonstration
Equipment needed
• Personal protective equipment, including

gloves
• Cuffed tracheal tube; an average size
adult will require a size 7 or 8 cuffed
tracheal tube, which corresponds to a 7
or 8 mm internal diameter. (Paediatric
intubation is done with uncuffed tubes and
should be carried out by an experienced
clinician.)
• Syringe for inflating and deflating cuff
(ensure cuff inflates and deflates before
intubation)
• Bag-valve apparatus, including mask for
TREATMENT
pre-oxygenation
• Suction
• Oxygen
27
Presumptive
• Ventilator
• Magills forceps (in case of foreign material
in the oropharynx)
• Gum elastic bougie (to use as guide wire
in case of difficult intubation)
Contraindications
Lack of skilled, experienced personnel is a

contraindication; tracheal intubation should be
used only when trained personnel are available
to carry out the procedure, with a high level of
skill and confidence.
If there is suspicion of a cervical spine injury,

airway opening should ideally be achieved
by jaw thrust or chin lift rather than head tilt.
If needed perform a head tilt using small
increments.
Note: Laryngospasm due to anaphylaxis, an

inhalation burn, near drowning, or a foreign
body will not improve significantly with simple
airway manoeuvres, and occasionally tracheal
intubation may not even be possible. In this
case, the patient may need an advanced airway
procedure such as cricothyroidotomy.
The tracheal tube has generally been considered

the optimal method of managing the airway
during cardiac arrest, and is indicated in
an ongoing resuscitation event. Its use is
restricted to scenarios where personnel who
are experienced and competent in tracheal tube
insertion are present.
Tracheal intubation has a number of perceived

advantages over other forms of airway
management:
• It enables ventilation without interruption

of chest compressions
TREATMENT
• It allows effective ventilation, even when

lung or chest compliance is poor
• It minimises gastric inflation, and therefore
minimises regurgitation
Presumptive
• It protects against aspiration of gastric
contents into the lungs
• It frees up the rescuer’s hands for other
tasks.
Tracheal intubation is also used for airway
management during general anaesthesia.
Complications
In inexperienced hands, attempts at tracheal

intubation can have negative consequences for
the patient. The incidence of incorrect intubation
varies with experience, some studies showing
rates of inadvertent oesophageal intubation can
be as high as 50% in inexperienced hands.
• Occlusion of central artery of the retina
and blindness
• Hypertension, tachycardia, bradycardia,
and arrhythmia
• Laryngospasm
• Bronchospasm
• Aspiration
• Cord avulsions, fractures, and dislocation
of arytenoids
• Nasal, retropharyngeal, pharyngeal,
uvular, laryngeal, tracheal, oesophageal,
and bronchial trauma
Aftercare
TREATMENT
If the tube is not correctly positioned, the

stomach or the right lung only may be ventilated.
Deflate the cuff and re-position the tube and
again auscultate to check position. Continue
29
Presumptive
to resuscitate the patient in keeping with life
support guidelines using ABCDE principles.
Bag-valve-mask ventilation animated

demonstration
Equipment needed

gloves
• Oxygen
• Reservoir bag attached to the bag-valve-
mask apparatus
• Suction
• Oropharyngeal airway (have available to
use if needed)
• Nasopharyngeal airway (have available to
use if needed)
Contraindications
Complete upper airway obstruction is an

absolute contraindication for bag-valve-mask
ventilation.

by jaw thrust or chin lift rather than head tilt,
while maintaining manual inline stabilisation
(MILS). If the airway remains obstructed despite
these measures, perform a head tilt using
small increments until the airway is open, while
maintaining MILS.[60]
When it is clear from the outset that the

patient needs a definitive airway (e.g., in the
unconscious patient with a severe head and
facial injury) call for help early while maintaining
a patent airway by simple means until skilled
help arrives.
Consider the level of the airway obstruction.

Laryngospasm due to anaphylaxis, an inhalation
TREATMENT
burn, near drowning, or a foreign body will

not improve significantly with simple airway
manoeuvres, and the patient may need
intubation or advanced airway procedure.
Presumptive
Indications
Complications
• Aspiration
• Hypoventilation
Any significant leak will cause hypoventilation of
the airway and can cause gas to be forced into
the stomach, heightening the risk of aspiration.
Aftercare
Continue to resuscitate the patient in keeping

with life support guidelines, using ABCDE
principles. Send for assistance as soon as
possible.
If resuscitation is successful and the patient

regains control of their own airway, this should
be regularly reassessed. Measure arterial blood
oxygen saturation as soon as practical by arterial
blood gas sampling and/or pulse oximetry
and titrate inspired oxygen to maintain a blood
arterial oxygen saturation in the range of 94% to
98%.[60]
If the resuscitation continues or the patient’s

Glasgow Coma Scale is less than 8, consider
insertion of an endotracheal tube.
plus IV normal saline

» Aggressive intravenous (IV) fluid replacement
is indicated due to the intravascular volume
redistribution into venous capacitance vessels
and the interstitial tissue. The human vascular
system consists of a high-pressure small-volume
arterial system and a large low-pressure venous
reservoir that expands in anaphylaxis, absorbing
much of the circulating blood volume. To make
TREATMENT
up for this intravascular fluid loss, adults should

be administered 1 L to 2 L of IV normal saline
at a rate of 5 to 10 mL/kg in the first 5 minutes;
volumes of up to 7 L might be required.[1]
Children should receive 30 mL/kg within the first
hour.[1] [63]
31
Presumptive
cardiopulmonary arrest plus CPR + IV epinephrine (adrenaline)
» If no pulse or breathing is present, CPR and
advanced cardiac life support (ACLS) measures
with intubation and ventilation are indicated
Tracheal intubation animated demonstration
Equipment needed

gloves
• Cuffed tracheal tube; an average size
adult will require a size 7 or 8 cuffed
tracheal tube, which corresponds to a 7
or 8 mm internal diameter. (Paediatric
intubation is done with uncuffed tubes and
should be carried out by an experienced
clinician.)
• Syringe for inflating and deflating cuff
(ensure cuff inflates and deflates before
intubation)
• Bag-valve apparatus, including mask for
pre-oxygenation
• Suction
• Oxygen
• Ventilator
• Magills forceps (in case of foreign material
in the oropharynx)
• Gum elastic bougie (to use as guide wire
in case of difficult intubation)
Contraindications
Lack of skilled, experienced personnel is a

contraindication; tracheal intubation should be
used only when trained personnel are available
to carry out the procedure, with a high level of
skill and confidence.

TREATMENT

by jaw thrust or chin lift rather than head tilt.
If needed perform a head tilt using small
increments.
Presumptive
Note: Laryngospasm due to anaphylaxis, an
inhalation burn, near drowning, or a foreign
body will not improve significantly with simple
airway manoeuvres, and occasionally tracheal
intubation may not even be possible. In this
case, the patient may need an advanced airway
procedure such as cricothyroidotomy.
The tracheal tube has generally been considered

the optimal method of managing the airway
during cardiac arrest, and is indicated in
an ongoing resuscitation event. Its use is
restricted to scenarios where personnel who
are experienced and competent in tracheal tube
insertion are present.
Tracheal intubation has a number of perceived

advantages over other forms of airway
management:
• It enables ventilation without interruption

of chest compressions
• It allows effective ventilation, even when
lung or chest compliance is poor
• It minimises gastric inflation, and therefore
minimises regurgitation
• It protects against aspiration of gastric
contents into the lungs
• It frees up the rescuer’s hands for other
tasks.
Tracheal intubation is also used for airway
management during general anaesthesia.
Complications
In inexperienced hands, attempts at tracheal

intubation can have negative consequences for
the patient. The incidence of incorrect intubation
varies with experience, some studies showing
rates of inadvertent oesophageal intubation can
TREATMENT
be as high as 50% in inexperienced hands.
33
Presumptive
• Occlusion of central artery of the retina
and blindness
• Hypertension, tachycardia, bradycardia,
and arrhythmia
• Laryngospasm
• Bronchospasm
• Aspiration
• Cord avulsions, fractures, and dislocation
of arytenoids
• Nasal, retropharyngeal, pharyngeal,
uvular, laryngeal, tracheal, oesophageal,
and bronchial trauma
Aftercare
If the tube is not correctly positioned, the

stomach or the right lung only may be ventilated.
Deflate the cuff and re-position the tube and
again auscultate to check position. Continue
to resuscitate the patient in keeping with life
support guidelines using ABCDE principles.
Bag-valve-mask ventilation animated

demonstration
Equipment needed

gloves
• Oxygen
• Reservoir bag attached to the bag-valve-
mask apparatus
• Suction
TREATMENT
• Oropharyngeal airway (have available to

use if needed)
• Nasopharyngeal airway (have available to
use if needed)
Presumptive
Contraindications
Complete upper airway obstruction is an

absolute contraindication for bag-valve-mask
ventilation.

by jaw thrust or chin lift rather than head tilt,
while maintaining manual inline stabilisation
(MILS). If the airway remains obstructed despite
these measures, perform a head tilt using
small increments until the airway is open, while
maintaining MILS.[60]
When it is clear from the outset that the

patient needs a definitive airway (e.g., in the
unconscious patient with a severe head and
facial injury) call for help early while maintaining
a patent airway by simple means until skilled
help arrives.
Consider the level of the airway obstruction.

Laryngospasm due to anaphylaxis, an inhalation
burn, near drowning, or a foreign body will
not improve significantly with simple airway
manoeuvres, and the patient may need
intubation or advanced airway procedure.
Indications
Complications
• Aspiration
• Hypoventilation
Any significant leak will cause hypoventilation of
the airway and can cause gas to be forced into
TREATMENT
the stomach, heightening the risk of aspiration.
Aftercare
35
Presumptive
Continue to resuscitate the patient in keeping
with life support guidelines, using ABCDE
principles. Send for assistance as soon as
possible.
If resuscitation is successful and the patient

regains control of their own airway, this should
be regularly reassessed. Measure arterial blood
oxygen saturation as soon as practical by arterial
blood gas sampling and/or pulse oximetry
and titrate inspired oxygen to maintain a blood
arterial oxygen saturation in the range of 94% to
98%.[60]
If the resuscitation continues or the patient’s

Glasgow Coma Scale is less than 8, consider
insertion of an endotracheal tube.
» High-dose intravenous epinephrine

(adrenaline) is given.[63]
Primary options
» epinephrine: children: 0.01 mg/kg (as a

1:10,000 solution) intravenously every 3-5
minutes, maximum 1 mg/dose; adults: 1 mg
(as a 1:10,000 solution) intravenously every
3-5 minutes
severe hypotension plus IV epinephrine (adrenaline)
» Intravenous administration of epinephrine
(adrenaline) should only be considered in
profoundly hypotensive patients who have
not responded to intravenous (IV) fluids and
several doses of intramuscular epinephrine
(adrenaline).[1] [63] Continuous IV infusion of
epinephrine (adrenaline), titrated to effect, is
reserved for experienced practitioners.
Primary options
» epinephrine: children: 0.01 mg/kg (as a

1:10,000 solution) intravenously every 5
minutes, maximum 0.3 mg/dose; adults: 0.1
mg (as a 1:10,000 solution) intravenously
every 5 minutes
severe hypotension adjunct IV glucagon
TREATMENT
» Patients may be taking beta-blockers for

CAD. Both the medication and the underlying
comorbidity complicate the treatment of severe
anaphylaxis. Beta-blocker therapy counteracts
epinephrine (adrenaline) by limiting heart rate,
resulting in compromised cardiac output. CAD
Presumptive
limits cardiac reserve, which might compound
the hypotension occurring due to the release
of vasoactive mediators. The stresses of
hypotension, tachycardia, and endogenous
or iatrogenic adrenergic agents may cause
myocardial ischaemia by reducing perfusion
during diastole. Glucagon can be used to
overcome beta blockade, but the resulting
tachycardia can be detrimental in patients
with severe CAD.[3] Early consultation of a
cardiologist is warranted.
Primary options
» glucagon: children: consult specialist for

guidance on dose; adults: 5 mg intravenously
initially, may repeat in 10-15 min if no
response, followed by 5-15 micrograms/min if
response seen
persistent respiratory plus inhaled beta-2 agonist
symptoms
» Persistent respiratory symptoms after the
administration of epinephrine (adrenaline) may
benefit from inhaled beta-2 agonists.[1] The
beta-2 agonist also has crossover activity at
the beta-1 receptor, and may therefore cause
tachycardia and hypertension. Repeat dosing is
limited by these adverse effects.
Primary options
» salbutamol inhaled: children: 0.15 mg/

kg nebulized every 20 minutes for 3 doses,
then 0.15 to 0.3 mg/kg every 1-4 hours when
required; adults: 1.25 to 5 mg nebulized every
20 minutes for 3 doses, then every 1-4 hours
when required
symptomatic hives and adjunct antihistamine (H1 antagonist) + H2
rhinorrhoea antagonist
» Antihistamines relieve itching, hives, and
rhinorrhoea but not the more severe symptoms
of anaphylaxis such as airway obstruction and
shock. An antihistamine (H1 antagonist) plus
an H2 antagonist in combination are effective in
palliating the cutaneous manifestations.[78] [79]
2[C]Evidence
» With a slow onset of action, antihistamines

cannot block events that occur after histamine
TREATMENT
receptor binding. Serum histamine levels,

however, peak early in anaphylaxis and quickly
return to baseline despite the persistence of
severe physical compromise, suggesting that
37
Presumptive
administration has little benefit in later phases of
anaphylactic shock.[10] [76] [77] [86]
Primary options
» diphenhydramine: children: 1-2 mg/kg

intravenously/intramuscularly; adults: 25-50
mg intravenously/intramuscularly
-and-
» ranitidine: children: 1 mg/kg intravenously
given over 5 minutes; adults: 50 mg
intravenously given over 5 minutes
post-emergency adjunct corticosteroids
stabilisation
» Corticosteroids, orally or intravenously, have
no established role in the treatment of acute
anaphylaxis, as they have a slow onset and
may have no effect for 4 to 6 hours even if given
intravenously. Corticosteroids might prevent
biphasic and protracted reactions, so they are
used as preventative treatment after emergency
stabilisation.
» Corticosteroids are the treatment of choice

for persistent idiopathic anaphylaxis. Patients
previously prescribed corticosteroids, including
patients with asthma, may benefit from early use
of systemic corticosteroids.
» A Cochrane review did not find any

randomised controlled clinical trials regarding the
use of glucocorticoids in anaphylaxis.[87]
Primary options
» methylprednisolone: children and adults:

1-2 mg/kg/day intravenously
OR
Primary options
» prednisolone: children and adults: 0.5 to 1

mg/kg/day orally
Ongoing
TREATMENT
patients with identified allergen 1st immunotherapy

» Immunotherapy is a mainstay in the treatment
of allergic individuals with IgE-mediated disease,
Ongoing
involving repeated administration of allergen
extracts.
» The traditional and best approach of

immunotherapy is the subcutaneous injection
of incremental amounts of allergen extracts at
weekly intervals for several months, followed by
monthly maintenance for 3 to 5 years.[80] [81]
The long-term benefits persist for at least 3 to 5
years after discontinuation.
» Venom immunotherapy is the treatment

of choice for prevention of systemic allergic
reactions to insect stings;[84] [88] it can be 95%
to 100% effective in preventing these systemic
reactions. This kind of treatment requires the
input of an allergist to select the patients who
will benefit from this treatment (usually patients
with a history of previous anaphylactic response
to a sting and who have venom-specific IgE
antibodies), select the venoms, and select the
schedule.
TREATMENT
39
Emerging
New forms of immunotherapy administration
Subcutaneous immunotherapy is a mainstay in the treatment of seasonal allergies. Over the last 10 years,
significant advances in the field of food allergy immunotherapy have been made.[89] Food allergy studies
are under way to determine the safety and efficacy of new ways of immunomodulation to induce clinical
tolerance. Sublingual, subcutaneous, and epicutaneous routes of immunotherapy are possible approaches to
the treatment of food allergies. However, no approach is approved by the US Food and Drug Administration
yet, and the use remains experimental. Oral immunotherapy is another possible approach. The rationale
is that oral administration of food allergens will eventually lead to an active immune response without
triggering an allergic reaction. Oral tolerance is thought to be mediated by induction of regulatory T cells
and lymphocyte anergy or depletion in high allergen doses. A combination of oral immunotherapy and anti-
IgE is possible and under investigation. Sublingual immunotherapy, together with oral immunotherapy,
seems to be safer than subcutaneous immunotherapy.[90] [91] Sublingual mucosa has fewer effector cells
(such as mast cells) and there is no systemic absorption. Antigens are taken up by dendritic cells in the
mucosa and presented to T lymphocytes in the draining lymph nodes. A randomised trial with 23 adults with
DBPCFC hazelnut allergy showed an increase of hazelnut-specific IgG4 and IL-10 in the active treatment
group.[83] Fifty percent of patients in the active treatment group tolerated the highest dose of hazelnut,
compared with only 9% in the placebo group. However, pre-and post-treatment IgE levels did not change.
Epicutaneous immunotherapy has been found to be safer and better tolerated than other forms of IT, leading
to desensitisation, but it is unclear whether it leads also to sustained unresponsiveness.[92]
Peptide immunotherapy
Peptide immunotherapy aims at elimination of IgE binding by administration of vaccines that consist of
overlapping peptides of a length of 10 to 20 amino acids. These peptides represent the entire sequence of
the allergen and eliminate IgE binding. However, mast cells are not activated, because the peptides are too
short to cross-link two IgE molecules.[93] Peptide immunotherapy seems to induce T-cell unresponsiveness
in a dose-dependent manner. The T-cell epitopes are preserved and allow targeting of allergen-specific T
cells for induction of tolerance. Clinical studies have been performed and show promising results. However,
optimal dosages have yet to be established.[94] [95] [96] Standardisation of the vaccine containing hundreds
of different sequences is extremely difficult and thus approval in human studies is awaited. A vaccine
containing only a few target peptides is a more feasible option.
Recombinant food proteins

Uses engineered recombinant proteins missing the ability to interact with IgE (thus low allergenicity), but
retaining T cell interaction and immunogenicity. They are expected to improve the safety profile of the
therapy by not activating mast cells.[97] Two main techniques have been applied in production of these
“hypoallergenic molecules” - site-directed mutagenesis and polymerisation. They are found to be more potent
in combination with immunomodulatory adjuvants. Bacteria are potent stimulants of Th1 immune responses.
Modified bacterial products can be used as adjuvants in immunotherapy. In a murine model, heat-killed
Lysteria monocytogenes was found to reverse allergic airway hyper-reactivity. [98] A non-pathogenic strain
of Escherichia coli was selected as a bacterial adjuvant in human studies because of safety concerns.
The long-term effect of treatment with mutated Arah 1,2,3-producing E coli strains administered rectally
in a murine peanut anaphylaxis model showed promising results by inducing long-term down-regulation of
peanut hypersensitivity.[97] A standardisation of the rectal vaccine to use in a phase I human clinical trial is in
preparation.
Immunostimulatory sequences (ISS)

TREATMENT
Immunostimulatory DNA sequences such as ISS or CpG motifs (synthetic DNA-based immunotherapy
agents composed of unmethylated cytosine-guanine dinucleotides) have been shown to act as strong TH1
response-inducing adjuvants. The CpG motif in DNA can induce cell-mediated immune responses of the
TH1 type. Coupling of ISS to major allergens enhances TH1-biased immunogenicity (IFN gamma secretion)
and reduces allergenicity. For example, immunotherapy utilising ISS with the major ragweed allergen Amb
a1 caused a promoted TH1 response and reduced allergenicity in mice, rabbits, and primates.[99] Similar
approaches are being investigated for food allergy. The use of ISS in immunotherapy is still in the early
stages of development. So far it has been shown to be both well tolerated and effective. This novel approach
offers the potential for a better tolerated, more rapid, more efficacious, and longer-lasting therapy.
Humanised monoclonal anti-IgE

With the aim to calm type I hypersensitivity reactions, anti-IgE antibodies (humanised IgG1 antibodies
binding to free and basophil and mast cell membrane-bound IgE) aim to neutralise and inhibit IgE production.
In the last 20 years, more than 30 phase 2 and 3 clinical trials have been performed. A pilot antibody,
omalizumab, has been FDA-approved for the treatment of patients (12 years or older) with moderate-to-
severe allergic asthma.[100] A trial with omalizumab in food allergy has been discontinued because of safety
issues related to anaphylactic reactions. Further studies are being designed with an alternative protocol.
Treatment has been investigated in a multi-centre trial with 84 peanut-allergic patients. Patients receiving
a maximum dose of anti-IgE antibodies had a significant decrease in symptoms after peanut challenge,
when compared with placebo. The therapy was well tolerated; however, 25% of the patients failed to show
any response to the therapy. Their tolerance of peanuts did not change.[101] A combination of anti-IgE
with specific immunotherapy is a consideration, as the anti-IgE decreases the possible life-threatening side
effects of the immunotherapy. Anti-IgE, however, is not a cure but requires indefinite administration in regular
intervals.
Traditional Chinese medicine (TCM)

Herbal medicine has been used for centuries in Asia as part of traditional Chinese medicine. It is beginning
to play a role in Western medicine as complementary and alternative medicine. Because of several
fundamental differences between traditional Chinese medicine and western medicine, the concepts cannot
be easily translated. Research on efficacy and safety of several herbal formulas is ongoing to establish it
as a possible treatment in allergic diseases in the western hemisphere. The formula FAHF-2, derived from
traditional Chinese herbs, was shown to protect peanut-sensitised mice from anaphylaxis. Treated mice
showed no anaphylaxis after stimulation, whereas sham-treated mice had severe reactions. The effect lasted
for up to 6 months, which is about 25% of the lifespan of a mouse. The clinical effect has been associated
with decreased peanut-specific IgE levels and TH2 cytokine production.[102] [103] Clinical trials are currently
being undertaken to prove safety and efficacy in humans.
Blockade of vasoactive mediators

In anaphylaxis, vasoactive mediators are released from mast cells and basophils, such as histamine,
proteases, leukotrienes, and platelet-activating factor (PAF). Blockage of the mediators or their effect is
another possible approach. A mouse model of peanut-induced anaphylaxis showed a decrease of reaction
severity and duration after treatment with a PAF receptor-antagonist prior to peanut challenge.[104]
TREATMENT
41
Anaphylaxis Follow up
Recommendations
Monitoring
FOLLOW UP
Because of the possibility of a biphasic reaction or recurrence after resolution of the initial presentation,
monitoring as an inpatient is indicated for 24 hours.[38] [39] [45] Patients should notify their general
practitioner about their condition and obtain prompt follow-up with an allergist.
Patient instructions
If an allergic reaction to a substance is suspected, with difficulties in breathing or raised splotches on the
skin, patients are advised to contact emergency services immediately.
Refer the patient to an allergy/immunology specialist, who can play a uniquely important role in preparing
the patient for self-treatment in the community, confirmation of the trigger of an anaphylactic episode,
education regarding allergen avoidance, and immune modulation.[44]
Identification of the causative allergen must be attempted, and patients advised to avoid this material and
to carry two epinephrine (adrenaline) auto-injectors to prevent dangerous outcomes after exposure.[6]
[72]
The American Academy of Pediatrics recommends providing a written emergency plan for children at risk
of anaphylaxis.[73] [American Academy of Pediatrics: allergy and anaphylaxis emergency plan]
Complications
Complications Timeframe Likelihood

myocardial infarction short term low
Although myocardial infarction during anaphylaxis is uncommon, it will become more frequent as the
general population ages and allergic reactions of senescence become more prevalent. Cardiac ischaemia
may be triggered by hypotension associated with anaphylaxis or the hypertension and tachycardia that
often follows the administration of epinephrine (adrenaline).
death short term low
Occurs following cardiovascular shock or cardiac arrest if there are delays in intramuscular epinephrine
(adrenaline) administration.
recurrence variable high
Individuals with previous anaphylactic reactions are at higher risk for recurrence.[14] [31] However, the
severity of a previous reaction does not necessarily predict the severity of a subsequent one.[32]
Treatment involves immediate administration of epinephrine (adrenaline), crucial for outcome and
prognosis.
If the inciting allergen is unknown, clinical and laboratory tests should be performed to determine the
cause. Patients must avoid this allergen in the future.
Anaphylaxis Follow up
Prognosis
FOLLOW UP
Moderate anaphylaxis
Individuals with previous reactions are at higher risk for recurrence.[14] [31] However, the severity of the
previous reaction does not necessarily predict the severity of a subsequent reaction.[32] The outlook
will depend on the success of immune therapy, allergen avoidance, and compliance with carrying their
epinephrine (adrenaline) auto-injectors.
Cardiac arrest due to anaphylaxis

If the diagnosis is made early and the appropriate management is initiated promptly, the outcome of cardiac
arrest in this population may be better. However, serious sequelae of inadequate brain perfusion may still
occur, and prognosis depends mainly on comorbidities and patient age.
43
Anaphylaxis Guidelines
Diagnostic guidelines
Europe
Emergency treatment of anaphylactic reactions

Published by: Resuscitation Council Last published: 2012
Summary: This guideline summarises the diagnosis, treatment, investigation, and follow-up of patients
with anaphylactic reactions. 2008 guideline annotated with links to NICE guidance in July 2012.
Anaphylaxis: assessment and referral after emergency treatment

Published by: National Institute for Health and Care Excellence Last published: 2011
Summary: This guideline offers evidence-based advice on the care of adults, young people, and children
following emergency treatment for suspected anaphylaxis.
Food allergy in under 19s: assessment and diagnosis

GUIDELINES
Published by: National Institute for Health and Care Excellence Last published: 2011
Diagnosis and management of hymenoptera venom allergy

Published by: British Society for Allergy and Clinical Immunology Last published: 2011
International
Exercise-induced hypersensitivity syndromes in recreational and competitive

athletes: a PRACTALL consensus report (what the general practitioner should
know about sports and allergy)
Published by: European Academy of Allergology and Clinical Last published: 2008
Immunology; American Academy of Allergy, Asthma & Immunology
Summary: Information on diagnosis of exercised-induced anaphylaxis and the subgroup of food-
dependent exercise-induced anaphylaxis. Exercise and the identification and timing of foods ingested
during the preceding 24 hours are noted in the history. Measurements of IgE against relevant allergens
should be performed by skin testing (including to fresh fruits and vegetables) and/or laboratory tests. An
'exercise ± food' provocation test can be considered.
North America
Stinging insect hypersensitivity: a practice parameter update 2016

Published by: American Academy of Allergy, Asthma & Immunology; Last published: 2016
American College of Allergy, Asthma & Immunology
Summary: This practice parameter seeks to refine guidelines for the diagnosis of stinging insect
hypersensitivity.
North America
Anaphylaxis: a practice parameter update 2015

Summary: Guidelines on the evaluation of a patient with a history of anaphylaxis.
Guidelines for the diagnosis and management of food allergy in the United
States
Published by: National Institute of Allergy and Infectious Disease Last published: 2010
Summary: NIAID, working with 34 professional organisations, federal agencies, and patient advocacy
groups, has led the development of clinical guidelines for the diagnosis and management of food
allergy. The guidelines include a consensus definition for food allergy, discuss comorbid conditions often
associated with food allergy, and focus on both IgE-mediated and non-IgE-mediated reactions to food.
Topics addressed include the epidemiology, natural history, diagnosis, and management of food allergy, as
well as the management of severe symptoms and anaphylaxis.
GUIDELINES
Allergy diagnostic testing: an updated practice parameter
Summary: Discusses the current utility and validity of diagnostic tests for allergy. Part 1 provides
detailed information on individual tests and part 2 recommends testing based on the suspected underlying
aetiology of the allergy.
Treatment guidelines
Europe
Emergency treatment of anaphylactic reactions

Published by: Resuscitation Council (UK) Last published: 2012
Summary: This guideline summarises the diagnosis, treatment, investigation, and follow-up of patients
with anaphylactic reactions.
Diagnosis and management of hymenoptera venom allergy

Published by: British Society for Allergy and Clinical Immunology Last published: 2011
Reducing the risk of anaphylaxis during anesthesia

Published by: French Society for Anaesthesia and Intensive Care Last published: 2011
(Societe Francaise d'Anesthesie et de Reanimation); French Society of
Allergology (Societe Francaise d'Allergologie)
Summary: Updated guidelines for clinical practice. The members of the European Network for Drug
Allergy approved the guidelines.
45
Europe
Guideline for the management of acute allergic reaction

Published by: College of Emergency Medicine (UK) Last published: 2009
Summary: Evidence-based guide to management of adult patients who present to the ED following an
acute allergic reaction.
The management of anaphylaxis in childhood: position paper of the

European Academy of Allergology and Clinical Immunology
Published by: EAACI Task Force on Anaphylaxis in Children Last published: 2007
Summary: This position paper by the EAACI Taskforce on Anaphylaxis in Children gives practical
guidelines for managing anaphylaxis in childhood based on the limited evidence available. Intramuscular
epinephrine (adrenaline) is the acknowledged first-line therapy both in hospital and in the community,
and should be given as soon as anaphylaxis is recognised. Additional treatments such as volume
support, nebulised bronchodilators, antihistamines, or corticosteroids are supplementary to epinephrine
(adrenaline). There are no absolute contra-indications to giving epinephrine (adrenaline) in children. All
GUIDELINES
children with a history of anaphylaxis should undergo allergy assessment.
Prevention and treatment of hymenoptera venom allergy: guidelines for

clinical practice
Published by: EAACI Interest Group on Insect Venom Hypersensitivity Last published: 2005
Summary: Gives detailed recommendations on avoiding bee and wasp stings; these measures
can greatly reduce the risk of re-sting. Also gives guidelines on emergency treatment of systemic
allergic reactions to stings, the subsequent evaluation of patients by the allergist, and the use of venom
immunotherapy.
International
Exercise-induced hypersensitivity syndromes in recreational and competitive

athletes: a PRACTALL consensus report (what the general practitioner should
know about sports and allergy)
Published by: European Academy of Allergology and Clinical Last published: 2008
Immunology; American Academy of Allergy, Asthma & Immunology
Summary: Prophylactic management for exercise-induced anaphylaxis is to avoid the trigger(s),
particularly foods. Specific food allergens should be avoided for at least 6 hours prior to exercise. Patients
should exercise with a trained companion and learn to recognise the clinical features of an attack. Exercise
needs to be immediately discontinued and intramuscular epinephrine (adrenaline) self-administered.
Emergency services should be called, and further management of anaphylaxis should proceed according
to published guidelines.
North America
Guidance on completing a writ ten allergy and anaphylaxis emergency plan

Published by: American Academy of Pediatrics Last published: 2017
Summary: Information to help healthcare professionals complete a written emergency plan for children at
risk of anaphylaxis.
North America
Stinging insect hypersensitivity: a practice parameter update 2016

Summary: Seeks to refine guidelines for the management of stinging insect hypersensitivity, with
particular emphasis on the appropriate use of immunotherapy.
Anaphylaxis: a practice parameter update 2015

Summary: Comprehensive guidelines on the management of anaphylaxis.
2015 American Heart Association and American Red Cross guidelines update
for first aid
GUIDELINES
Published by: American Heart Association Last published: 2015
Summary: Provides brief guidance on emergency treatment of anaphylaxis.
47
Anaphylaxis Online resources
Online resources
1. World Allergy Organization Allergic Diseases Resource Center: anaphylaxis (external link)
2. American Academy of Pediatrics: allergy and anaphylaxis emergency plan (external link)
ONLINE RESOURCES
Anaphylaxis Evidence scores
Evidence scores
1. Reduction in systemic symptoms: there is poor-quality evidence that epinephrine (adrenaline) is
effective in alleviating systemic symptoms of anaphylaxis. A Cochrane review found no prospective
controlled trials on the benefits of epinephrine (adrenaline) in anaphylaxis eligible for inclusion.
However, the review’s authors, as with all other guidelines, recommend epinephrine (adrenaline) as
first-line treatment for anaphylaxis, based on expert consensus and indirect observational data.[67]
[68]
Evidence level C: Poor quality observational (cohort) studies or methodologically flawed randomized
controlled trials (RCTs) of <200 participants.
2. Reduction in persistent respiratory symptoms: there is poor-quality evidence that H1-antihistamines

are effective in reducing symtoms that persist despite treatment with epinephrine (adrenaline). A
recent Cochrane review found no evidence on the use of H1-antihistamines in anaphylaxis according
to its inclusion criteria.[74] [75]
Evidence level C: Poor quality observational (cohort) studies or methodologically flawed randomized
controlled trials (RCTs) of <200 participants.
EVIDENCE SCORES
49
Anaphylaxis References
Key articles
• Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis: a practice parameter update 2015. Ann
REFERENCES
Allergy Asthma Immunol. 2015;115:341-384. Abstract
• Sampson HA, Mendelson L, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children
and adolescents. N Engl J Med. 1992;327:380-384. Abstract
• Simons FE, Ardusso LR, Bilò MB, et al. 2012 Update: World Allergy Organization Guidelines for the
assessment and management of anaphylaxis. Curr Opin Allergy Clin Immunol. 2012;12:389-399.
Abstract
• National Institute for Health and Care Excellence. Anaphylaxis: assessment and referral after
emergency treatment. December 2011. http://www.nice.org.uk/ (last accessed 18 August 2017). Full
text
• Dinakar, C. Anaphylaxis in children: Current understanding and key issues in diagnosis and treatment.
Curr Allergy Asthma Rep. 2012;12:641-649. Full text Abstract
• Sheikh A, Shehata YA, Brown SG, et al. Adrenaline for the treatment of anaphylaxis: Cochrane
systematic review. Allergy. 2009;64:204-212. Full text Abstract
• Boyle RJ, Elremeli M, Hockenhull J, et al. Venom immunotherapy for preventing allergic reactions to
insect stings. Cochrane Database Syst Rev. 2012;(10):CD008838. Full text Abstract
• Wang J, Sampson HA. Food allergy: recent advances in pathophysiology and treatment. Allergy
Asthma Immunol Res. 2009;1:19-29. Full text Abstract
References
1. Lieberman P, Kemp SF, Oppenheimer J, et al. The diagnosis and management of anaphylaxis: an
updated practice parameter. J Allergy Clin Immunol. 2005;115(3 Suppl 2):S483-S523. Abstract
2. Sampson HA, Muñoz-Furlong A, Bock SA, et al. Symposium on the definition and management of
anaphylaxis: summary report. J Allergy Clin Immunol. 2005;115:584-591. Abstract
3. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition
and management of anaphylaxis: summary report - second National Institute of Allergy and
Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol.
2006;117:391-397. Full text Abstract
4. Moneret-Vautrin DA, Morisset M, Flabbee J, et al. Epidemiology of life-threatening and lethal

anaphylaxis: a review. Allergy. 2005;60:443-451. Abstract
5. Campbell RL, Hagan JB, Manivannan V, et al. Evaluation of National Institute of Allergy and Infectious
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6. Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis: a practice parameter update 2015. Ann
Allergy Asthma Immunol. 2015;115:341-384. Abstract
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epidemiology. Arch Intern Med. 2001;161:15-21. Full text Abstract
8. Lieberman P, Camargo CA Jr, Bohlke K, et al. Epidemiology of anaphylaxis: findings of the American
College of Allergy, Asthma and Immunology Epidemiology of Anaphylaxis Working Group. Ann Allergy
Asthma Immunol. 2006;97:596-602. Abstract
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57
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DISCLAIMER
Contributors:
// Authors:
Doerthe Adriana Andreae, MD

Instructor
Department of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
DISCLOSURES: DAA is an author of a number of references cited in this monograph.
Michael Henning Andreae, MD

Assistant Professor of Anesthesiology
Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York,
NY
DISCLOSURES: MHA is an author of a reference cited in this monograph.
// Acknowledgements:
Dr Doerthe Adriana Andreae and Dr Michael Henning Andreae would like to gratefully acknowledge Dr
Andrea Vereda, a previous contributor to this monograph. AV declares that she is currently employed by
Almirall SA, which manufactures Kestin (ebastine, a second-generation antihistaminic). AV wrote the main
content of this topic before taking up this appointment.
// Peer Reviewers:
Frank J. Domino, MD
Associate Professor
Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA
DISCLOSURES: FJD declares that he has no competing interests.
Wayne Shreffler, MD, PhD

Assistant Professor of Pediatrics
Mount Sinai School of Medicine, New York, NY
DISCLOSURES: WS declares that he has no competing interests.
Lawrence Youlten, FRCP (Edin), PhD

Visiting Consultant in Allergy
Addenbrooke’s Hospital NHS Trust, Cambridge, UK
DISCLOSURES: LY declares that he has no competing interests.
Grant Hayman, MBChB, MRCP, DTM and H, MSc, FRCPath

Consultant Immunologist
Department of Immunology, Epsom & St Helier University Hospitals NHS Trust, Carshalton, Surrey, UK
DISCLOSURES: GH declares that he has no competing interests.

Anaphylaxis: The Right Clinical Information, Right Where It's Needed

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Anaphylaxis

The right clinical information, right where it's needed

Last updated: Oct 27, 2017

◊ Sudden onset of respiratory or cardiovascular compromise, usually with a history of allergen

III. Immunological but not IgE-mediated anaphylaxis

• mediated by anaphylatoxins C3a and C5a

• IgE-mediated, due to purposeful self-exposure to an allergen

• radiographical contrast medium (mechanism uncertain)

Allergic Diseases Resource Center classification [World Allergy

Step-by-step diagnostic approach

Laboratory evaluation in acute set ting

Laboratory testing to prevent recurrence

A referral to an allergist is always recommended.

exposure to a common sensitiser (e.g., latex)

History & examination factors

acute onset (common)

Other diagnostic factors

insect stings or bites (common)

inspiratory stridor and hoarse voice (common)

bilateral conjunctivitis (common)

nausea and vomiting (common)

abdominal cramping or pain (common)

sense of impending doom (angor animi) (common)

recent exercise (uncommon)

hot or cold exposure (uncommon)

cardiac arrest (uncommon)

visual disturbances (uncommon)

Other tests to consider

Condition Differentiating signs / Differentiating tests

Condition Differentiating signs / Differentiating tests

Hypovolaemic shock • Water or fluid loss occurs • A drop in haematocrit

Vasovagal reaction • The characteristic feature • There is no differentiating

unconsciousness are all also

Asthma • Absence of allergen • There is no differentiating

Condition Differentiating signs / Differentiating tests

Hereditary angio-oedema • Characterised by recurrent • Deficiency or underactivity

Vocal cord dysfunction • Cutaneous signs, digestive • Pharyngeal endoscopy by

Foreign body aspiration • No allergen exposure, no • Imaging and bronchoscopy

Monosodium glutamate • In reaction to MSG • Serum histamine levels and

Carcinoid syndrome • On examination, there is • Urinalysis will show high

Condition Differentiating signs / Differentiating tests

Red man syndrome • This syndrome usually • There is no differentiating

Panic disorder • In some, functional stridor • There is no differentiating

Scombrotoxic food • Symptoms resemble IgE- • Skin test to suspected

1. Acute onset of an illness (minutes to hours)

• Systolic BP of <90 mmHg or >30% decrease from baseline.

Step-by-step treatment approach

• Personal protective equipment, including gloves

• It enables ventilation without interruption of chest compressions

Complications of tracheal intubation include:

Bag-valve-mask ventilation animated demonstration

• Personal protective equipment, including gloves

Complete upper airway obstruction is an absolute contraindication for bag-valve-mask ventilation.

Adjuvant glucagon treatment in patients with CAD on beta-

Other treatments in acute phase

Treatment of the underlying aetiology - immunotherapy

Treatment details overview

all patients: acute onset 1st cardiorespiratory assessment +

plus IM epinephrine (adrenaline)

plus assess & secure airway

plus IV normal saline

cardiopulmonary arrest plus CPR + IV epinephrine (adrenaline)

severe hypotension plus IV epinephrine (adrenaline)