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Anaphylaxis multiple Read Andrew Clark’s
choice questionnaire practice profile on
depression in primary care
Anaphylaxis: diagnosis and treatment
NS697 Bethel J (2013) Anaphylaxis: diagnosis and treatment.
Nursing Standard. 27, 41, 49-56. Date of submission: February 12 2013; date of acceptance: March 11 2013.
Abstract
Anaphylaxis is a severe and potentially life-threatening condition that
is becoming increasingly prevalent. Healthcare professionals working
in a variety of settings need to know how to recognise this condition
and the importance of treating it promptly. This article describes the
pathophysiology, causes and treatment of anaphylaxis.
Author
James Bethel
Senior lecturer and nurse practitioner, University of Wolverhampton,
Walsall.
Correspondence to: james.bethel@wlv.ac.uk
Keywords
Adrenaline, allergy, anaphylaxis, emergency care, resuscitation
Review
All articles are subject to external double-blind peer review and checked
for plagiarism using automated software.
Online
Guidelines on writing for publication are available at
www.nursing-standard.co.uk. For related articles visit the archive and
search using the keywords above.
Aims and intended learning outcomes
Anaphylaxis is an increasingly common and
potentially life-threatening allergic reaction
accounting for approximately 20 deaths a year
in the UK, with up to 50% of these deaths
being iatrogenic (Resuscitation Council (UK)
(RCUK) 2008, National Institute for Health
and Clinical Excellence (NICE) 2011).
This article aims to provide an overview
of anaphylaxis, including pathophysiology,
treatment and continuing care. After reading
© NURSING STANDARD / RCN PUBLISHING june 12 :: vol 27 no 41:: 2013  49
p49-56w41.indd 49
4 Page 60
Guidelines on
how to write a
practice profile
this article and completing the time out
activities you should be able to:
Explain
 the pathophysiology of anaphylactic
reactions.
Recognise
 the signs and symptoms of
anaphylaxis.
Identify
 common causes of anaphylaxis.
Describe
 the emergency treatment of
anaphylaxis and continuing care.
Encourage
 self-care for patients with
anaphylaxis to improve quality of life.
Pathophysiology and causation
Anaphylaxis is defined as a severe reaction of
sudden onset that has the potential to be fatal
(Arnold and Williams 2011, NICE 2011).
Most episodes of this systemic response to a
specific allergen will occur within one hour
of exposure (Arnold and Williams 2011),
although in a minority of cases response may
occur as quickly as three minutes or as long as
six hours depending on the route of exposure
and nature of the allergen (RCUK 2008,
Lockey and McCann 2012). Response may be
quicker if exposure involves ingestion of certain
food products associated with an increased
risk of an anaphylactic reaction, such as nuts or
shellfish, insect stings or bites, or intravenous
administration of medication. Conversely,
secondary to a slower rate of absorption,
response may be delayed when medication
is administered or mammalian food, such
as certain meat products, is ingested (RCUK
2008, Mustafa 2012).
Food-related reactions are most prevalent
among young children, while medication
causes the majority of anaphylactic reactions
in those over 55 years (Reading 2009, Arnold
and Williams 2011, NICE 2011). The most
common precipitants of anaphylaxis are
 
10/06/2013 12:53
 Learning zone emergency care
foods such as dairy products, nuts and shellfish,
certain medications such as antibiotics and
non-steroidal anti-inflammatory drugs,
venomous bites and stings, intravenously
administered contrast materials used in
medical investigations, and latex (Tupper and
Visser 2010, Mustafa 2012). An Australian
study found venomous stings and bites
accounted for 30% of cases of anaphylaxis,
food products were associated with 18%,
iatrogenic causes accounted for 22% of cases,
idiopathic causes for 25%, with other rarer
causes comprising the remaining 5% of
anaphylactic reactions (Brown 2006). These
figures probably over-represent the proportion
of episodes attributable to venomous stings and
bites as these are more prevalent in tropical
areas, and medication exposure may account
for a greater proportion of episodes in the UK
(Mustafa 2012).
Overall rates of anaphylaxis do not appear
to differ significantly between countries,
with rates varying between 0.05% and 2%
of the total population (González-Pérez et al
2010, Dunbar and Luyt 2011, Mustafa 2012,
Caton and Flynn 2013). Latex-associated
anaphylaxis peaked globally during the 1980s,
probably because of universal precautions
taken during the early recognition of human
immunodeficiency virus (HIV) syndrome,
however incidence has declined with the
increased use of latex-free products in health
care (Reading 2009).
The paucity and acknowledged inaccuracy
of data make accurate analysis of causative
factors challenging (House of Lords Science
and Technology Committee 2007, Sheikh
et al 2008). However, it is estimated that food
allergy affects approximately 6% of those
under three years in the UK (Department
of Health (DH) 2006) and 6-8% of all
children in the United States (US), and
that food-induced anaphylaxis is the most
common anaphylaxis treated in US hospitals
(Shah and Pongracic 2008).
The most common food products
associated with anaphylactic reactions are
tree nuts, peanuts, fish, shellfish, milk, egg
and kiwi fruit, although almost any food
may be implicated (Brown 2006, Shah and
Pongracic 2008, Arnold and Williams 2011,
Dunbar and Luyt 2011). There has been a
particularly marked rise in the incidence of
peanut allergy over the past 20 years, with
a 120% rise in incidence noted in the UK
between 2001 and 2005 (Information Centre
for Health and Social Care 2007). Peanut
50  june 12 :: vol 27 no 41:: 2013 © NURSING STANDARD / RCN PUBLISHING
p49-56w41.indd 50
allergy is the most common life-threatening
food allergy, with more than 250,000 children
in the UK thought to experience allergic or
anaphylactic reactions to peanuts or other
nuts (House of Commons Health Committee
2004, Reading 2009).
Complete time out activity 1
Anaphylaxis can be characterised as an
immunologically driven response to an allergen.
The allergen will prompt an antibody response
that leads to the activation of mast cells and
basophils, causing release of histamine, platelet
activating factor and heparin, among other
chemicals (Ben-Shoshan and Clarke 2011). At its
most severe, this causes widespread vasodilation
and tissue permeability in conjunction with
tissue swelling. Widespread tissue permeability
may lead to sequestering of fluid from the
intravascular to the extravascular space, and
patients may present with clinical shock and
associated acute respiratory distress secondary
to soft tissue swelling in the upper and lower
respiratory tract (Bryant 2007, Arnold and
Williams 2011). The immunoglobulin
most commonly associated with this
allergen-provoked reaction is immunoglobulin E
(IgE) (Arnold and Williams 2011).
Anaphylaxis that is not immunologically
driven has been termed non-immune, and
results from direct provocation of mast cells
rather than as an antibody-driven response.
These reactions might include those encountered
during the administration of contrast media in
radiology departments, for example (Carchietti
and Cecchi 2009, Arnold and Williams 2011).
In some instances, anaphylaxis is idiopathic in
nature; that is, there is no established cause for
it, and idiopathic episodes may account for up to
20% of all cases (Tupper and Visser 2010, NICE
2011). Other rare causes of the reaction include
heat, cold, sunlight and exercise (Arnold and
Williams 2011).
Anaphylaxis should be graded as immune,
non-immune or idiopathic in nature (Brown
2006). Since the clinical manifestations
and emergency treatment do not differ, the
necessity to identify immunologically driven
anaphylaxis from non-immune and idiopathic
reactions is not necessary during the initial
management of the reaction.
Complete time out activity 2
Demographic data
It is estimated that in the UK there is one
episode of anaphylaxis for approximately every
10/06/2013 12:53
 1,333 of the population (NICE 2011). In the
UK, it is reported that up to 220,000 people
under the age of 44 years have experienced
an anaphylactic reaction to nuts, with up to
500,000 having a similar reaction to venom,
predominantly in the form of insect bites and
stings (DH 2006). NICE (2011) recommends
further research on prevalence in the UK. This
is because some episodes may be unrecorded,
or recorded as episodes of asthma or acute
allergy (Caton and Flynn 2013).
Where data are available, the incidence of
anaphylaxis has been noted to be rising and
the age range of those affected varies from
five months to 85 years (House of Lords
Science and Technology Committee 2007).
The lifetime prevalence of anaphylaxis in the
UK increased by 51% from 50.0/100,000
population in 2001 to 75.5/100,000 in
2005, and the prescription of adrenaline
(epinephrine) injectors as treatment for
anaphylaxis rose by 97% (equating to more
than 21,000 prescriptions) during this
period (Sheikh et al 2008). In the US, it is
estimated that between 125 and 200 deaths
are attributable to anaphylaxis annually
(Lockey and McCann 2012, Mustafa 2012).
The majority of these deaths are attributed
to food-related anaphylaxis, and an annual
incidence of almost 11 cases per 100,000 of
the population in the US is broadly similar
to rates in Europe (Sheikh et al 2008, Mustafa
2012). Between one third and one half of
anaphylactic episodes managed in emergency
care in the US, Europe and Australia are
a result of ingestion of foods by children.
However, Denmark reported significantly
lower rates per 100,000 of the population,
with around one third of the incidence of
other developed countries, where rates overall
have been found to be generally higher than
in non-developed countries (Crusher 2004,
DH 2006, Sheikh et al 2008, Lockey and
McCann 2012).
Between 1% and 5% of people taking
penicillin will experience an allergic-type
response, with approximately 0.2% of these
being anaphylactic (Lockey and McCann
2012). Data from the US, Australia, France
and Switzerland estimate anaphylactic
reactions to venomous stings occur in 0.4-4%
of the population, with a rate of 40 deaths
annually in the US (Elsevier 2012, Lockey
and McCann 2012).
Idiopathic anaphylaxis is defined as
recurrent episodes of the reaction, where no
causative factor can be identified, and these
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p49-56w41.indd 51
may occur with varying degrees of frequency
(Greenberger 2007). Certain groups of women
appear to develop catamenial anaphylaxis
concurrently with their menstrual cycle. In
certain severe and recurrent cases, hormone
therapy may be necessary (Lieberman 2009,
Mustafa 2012). There has otherwise been no
discernible difference noted between male and
female incidence, although males are reported
to experience an increased incidence of
anaphylactic reactions subsequent to venomous
bites and stings than females (Elsevier 2012).
Complete time out activity 3
Risk factors
Certain individuals are more prone to episodes
of anaphylaxis than others, and evidence of risk
factors should be elicited during history taking
or retrieved from existing documentation. 1 What advice should
These risk factors include patients with atopic healthcare professionals
illness such as hay fever, eczema and, in give to parents of young
particular, asthma, which is most typically children who may have
the case in children and young adults with anaphylactic reactions
food-related anaphylaxis (Brown 2006). to certain foods?
Approximately 12% of those with anaphylaxis
also have a family history of allergy or 2 Consider the
anaphylaxis, making this a significant risk implications of potential
factor (NICE 2011, American Academy of non-immune reactions
Allergy, Asthma & Immunology 2013). for medical and nursing
Latex-associated anaphylaxis, as already staff working in
stated, peaked in incidence globally during radiology departments.
the 1980s, probably as a consequence of What should staff be
universal precautions in response to the particularly aware of,
dangers of HIV transmission (Reading 2009), how should they care
but remains a potential source of for patients receiving
immune-driven anaphylaxis for healthcare contrast media, and
staff and patients (Jevon 2010, Nelsons what resources will
Solicitors 2012). Cases of healthcare they need to maintain
staff and organisations being held patient safety?
medico-legally culpable for such events
have been documented (Legal Eagle Eye 3 The relatively
Newsletter for the Nursing Profession 2012). high rate of idiopathic
Certain medications also make patients anaphylaxis makes
more susceptible to anaphylaxis and/or management
inhibit their response to treatment, an challenging. What
example being beta-blockers used to treat advice and treatment
hypertension and, in certain cases, anxiety. should the healthcare
Patients taking beta-blockers for whatever professional provide
reason are more likely to experience to patients with
anaphylaxis and may be resistant to the idiopathic anaphylaxis,
effects of adrenaline treatment during an and parents of children
episode (Horn and Hansten 2009, Jacobsen with this type of
and Gratton 2011, Mustafa 2012). This reaction, to reduce the
is because the drug partly neutralises the risk of morbidity and
effect of adrenaline by maintaining an mortality?
artificially low heart rate, thereby reducing
 
10/06/2013 12:53
 Learning zone emergency care
cardiac output. This exacerbates existing
hypotension secondary to the anaphylactic
response (Goddet et al 2006). It is
recommended that patients deemed at risk
of anaphylaxis, or who have documented
anaphylaxis, are not prescribed beta-blockers
(Horn and Hansten 2009).
Assessment, diagnosis and treatment
The signs and symptoms of anaphylaxis
are related to its pathophysiological causes,
but may vary according to the allergen and
route of exposure. Diagnosis is based on history
of exposure, presence of risk factors, and
progression of typical signs and symptoms
(Sampson 2003, Younker and Soar 2010,
Arnold and Williams 2011). However,
sampling of blood tryptase levels at the time
of anaphylactic response and one to two
hours later, when it is thought that levels
peak, is recommended to assist in gauging
improvement or deterioration in the patient’s
condition (Brown et al 2004, Schwartz
2006, Younker and Soar 2010, NICE 2011).
Tryptase, along with histamine and heparin,
is released during mast cell activation to the
allergen associated with anaphylaxis (Lab
Tests Online 2010), although elevated levels
TABLE 1
Signs and symptoms of anaphylaxis on different body systems
Body system Signs and symptoms
General Feeling of impending doom, weakness, extremity
paraesthesia, behavioural change and irritability in
children, and abnormal taste in the mouth.
Neurological Severe headache, confusion, vertigo, tunnel vision
and loss of consciousness.
Gastrointestinal Nausea, vomiting, abdominal cramps and diarrhoea.
Cardiovascular Early signs may include tachycardia, clamminess,
prolonged capillary refill time progressing to
hypotensive shock, bradycardia, ST segment
elevation, particularly in those with existing heart
disease, and cardiac arrest.
Respiratory Lower airway wheezing, cough, chest tightness,
hoarseness, increased respiratory rate and effort,
cyanosis and respiratory arrest. Upper airway
symptoms may include rhinorrhoea, sneezing,
dysphagia, dyspnoea, stridor and respiratory arrest.
Dermatological Periorbital oedema, conjunctivitis, tongue and lip
swelling, urticarial hive-like or macular rash, pallor,
erythema, piloerection and angioedema.
(Sampson 2003, Erlewyn-Lajeunesse et al 2010, Jevon 2010, Younker and Soar 2010,
Arnold and Williams 2011, Jacobsen and Gratton 2011)
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p49-56w41.indd 52
are a more reliable estimate of reaction acuity
in the adult than the child (NICE 2011).
Despite the fact that diagnosis should be
based predominantly on clinical signs and
symptoms and, where possible, confirmed by the
biochemical tests outlined above, there remains
a lack of consensus on the significance of certain
clinical signs and symptoms in terms of their
relevance to diagnosis of anaphylaxis. Therefore,
some patients received doses of adrenaline as
treatment where it was not necessary (Jevon
2010, Spickett and Stroud 2011). Evidence also
suggests that patients who required adrenaline
as first-line treatment either did not receive it or
its administration was delayed (Brown 2006,
RCUK 2008, Caton and Flynn 2013). General
manifestations of anaphylactic reactions are
divided into their effect on different body
systems, as highlighted in Table 1.
Complete time out activity 4
The most common misdiagnosis made in
anaphylaxis has been that of a vaso-vagal or
syncope attack (Arnold and Williams 2011,
Ben-Shoshan and Clarke 2011). Other cases of
anaphylaxis have been mistakenly diagnosed
as ischaemic heart disease, choking episodes,
hypoglycaemia, panic attacks or anxiety states,
carcinoid syndrome, post-viral syndromes,
drug-induced angioedema usually caused
by angiotensin-converting enzyme (ACE)
inhibitors, and breath-holding episodes in
children. Conversely, although less common,
some of these patients have been treated as
being anaphylactic (Brown 2006, Jevon 2010,
Younker and Soar 2010, Arnold and Williams
2011, Spickett and Stroud 2011).
It is an important part of the assessment
process to take a thorough patient history,
including past medical history, drug history
and recent illnesses. Attempts have been made
to provide a common definition of diagnostic
criteria for anaphylaxis in an attempt to provide
clarity and timely intervention for patients
needing treatment (Brown 2004,
Erlewyn-Lajeunesse et al 2010, Younker and
Soar 2010, Arnold and Williams 2011). The
importance of systemic respiratory and/or
cardiovascular symptoms in distinguishing
anaphylaxis from other illnesses is emphasised.
They also highlight that erythema or
angioedema in isolation do not constitute
anaphylaxis; it has been noted that up to 50%
of anaphylactic reactions do not feature urticarial
rash as a component of the presentation
(Brown et al 2001, Spickett and Stroud 2011).
Angioedema as an isolated finding is more likely
10/06/2013 12:53
 to result from causes other than an anaphylactic
response; the most common cause of this type
of oedema in the absence of urticaria is drug
induced (Spickett and Stroud 2011).
Guidelines for the assessment and management
of anaphylaxis in children and adults have been
developed in an attempt to standardise care
and reduce the number of false positive and
false negative diagnoses. Guidelines have been
developed in the US (Gifford Medical Center
2011a, 2011b) and Australia (Brown 2006), and
the World Allergy Organization made an attempt
to standardise practice globally (Simons et al
2011). UK guidelines (NICE 2011) focused on
simplification of recognition and treatment, and
the use of a systematic approach to the treatment
of patients considering the ABCDE approach:
airway, breathing, circulation, disability
(conscious level), exposure (identification
of potential other ailments or injuries). UK
guidelines (NICE 2011) simplified the criteria
for the recognition of anaphylaxis, stating that
anaphylaxis is more likely to occur when in the
presence of the following three features:
1) Sudden onset and rapid symptom
progression.
2)Life-threatening airway, breathing
or circulatory problems.
3) Dermatological changes, for example flushing,
mucosal swelling, urticaria or angioedema.
Diagnosis may be supported by a history of
exposure to a known allergen and there may
or may not be gastrointestinal symptoms.
The guidelines also simplified the dose of
intramuscular adrenaline to be administered
during an episode of anaphylaxis as follows
(NICE 2011):
Adults
 and children over 12 years – 0.5mL
of 1:1,000 adrenaline.
Children
 6-12 years – 0.3mL of 1:1,000
adrenaline.
Children
 under 6 years – 0.15mL of 1:1,000
adrenaline.
Each dose may be repeated within five
minutes if there is no improvement in the
patient’s condition.
Complete time out activity 5
Access to other resources to support the
person will depend on the clinical setting or
environment that the episode takes place in;
there may be little for a responder to do apart
from administer adrenaline if available and
call the emergency services. Conversely, if
the episode occurs where more resources are
available, then using the ABCDE approach will
provide focus on the priorities of resuscitation.
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p49-56w41.indd 53
Airway support and oxygenation may be needed
and the patient may require fluid replacement if
exhibiting signs of shock. Conscious level should
be monitored using a universally accepted tool
such as the Glasgow Coma Scale (Teasdale
and Jennett 1974) or a simplified, easy to recall
system such as AVPU (A = patient is alert,
V = patient responds to verbal commands,
P = patient responds to pain, U = patient is
unresponsive) (Jevon 2008). Patients may
need to be exposed to reveal the full extent of
dermatological changes, any obvious bites or
stings, and to identify angioedema.
It has been noted that some patients receive
less than optimal care in urgent and emergency
care settings, with some individuals receiving
a less than therapeutic dose of adrenaline
(Gaeta et al 2007), while others receive
second-line drugs such as corticosteroids and
antihistamines, with or without subsequent
administration of adrenaline, despite the fact
that their use in anaphylaxis is limited (Choo
et al 2010). In up to 20% of patients, a biphasic
or ‘rebound’ episode of symptoms is observed
without further exposure to the allergen
(Caton and Flynn 2013). Although most
of these episodes occur within six hours of
treatment (NICE 2011), they may be observed 4 Consider the
up to 72 hours afterwards (Mustafa 2012). multiplicity and
Complete time out activity 6 variety of signs and
symptoms outlined
in the article. What
Education
mistaken diagnoses
NICE (2011) recommends that patients do you think some
experiencing anaphylaxis receive education patients experiencing
and training from emergency care staff in anaphylaxis may have
recognition of signs and symptoms, appropriate been given?
action to take and when to call the emergency
services. This recommendation is reinforced 5 In addition to using
by the World Allergy Organization (Simons the ABCDE approach
et al 2011) and the Australasian Society for to the assessment
Clinical Immunology and Allergy (Kemp and management of
2010) who, along with Fitzsimons et al (2012), patients, from which
recommend a written action plan be made, treatment might the
particularly for children with anaphylaxis who person with established
are too young to be taught to auto-inject. It is anaphylaxis benefit?
also recommended that patients be referred to
an allergy specialist where the aetiology of the 6 Given the dangers
reaction is unknown or where symptoms are of sub-standard care
severe (Younker and Soar 2010, NICE 2011). and biphasic episodes
Information on the management of of anaphylaxis, what
anaphylaxis may be required by: type of treatment and
Patients.
 patient education should
Parents
 or carers of a child with anaphylaxis. children and adults with
Extended
 family of a patient with these reactions receive
anaphylaxis. from staff?
Teaching
 and nursery staff.
 
10/06/2013 12:53
 Learning zone emergency care
Prison
 and custodial staff.
Pre-hospital
 nursing and ambulance staff.
NICE (2011) recommends that emergency
department staff are familiar with the
mechanisms of adrenaline injectors and are able
to demonstrate these to patients. Emergency
departments should stock adrenaline injectors
to give to patients being discharged after an
anaphylactic episode. While NICE (2011)
recommends that all patients under 16 years
are admitted to hospital after an anaphylactic
episode, emergency department staff may
find themselves required to provide advice to
patients older than this who, having undergone
a period of observation, are being discharged
home (Brown 2006). Initial education should
focus on avoidance or removal of the allergen,
recognition of signs and symptoms of
anaphylaxis, and emergency treatment.
Avoidance or removal of the allergen
The avoidance of the allergen is more readily
achieved when it is apparent what the allergen is.
While waiting for investigations to identify the
allergen, patients with anaphylaxis should wear
some sort of alert necklace or bracelet to inform
the public and clinicians of their vulnerability, in
addition to making extended family and friends
aware of the signs and symptoms of anaphylaxis
(Brown 2006, Bryant 2007, Arnold and
Williams 2011, Mustafa 2012). For those with
food-induced anaphylaxis, the involvement of
a dietitian is sometimes a necessary precaution
(Dunbar and Luyt 2011).
Particular risk factors include eating out
where food ingredients may not always be
apparent, taking new courses of medication,
and travelling abroad with potential exposure
to new allergens (Bryant 2007, Arnold and
Williams 2011, Anaphylaxis.org 2012).
Disinhibiting factors such as alcohol, drugs
and peer pressure may make the individual
more prone to an anaphylactic reaction (Bryant
2007), and patients should be made aware
of this. If the patient remains exposed to the
allergen and if the personal safety of the rescuer
is not compromised, the exposure should be
terminated. For example, if a patient experiences
an anaphylactic reaction to a bee or wasp
sting, where the sting barb remains within the
epidermis, it should be gently removed if possible
(RCUK 2008, Allergy UK 2012).
Despite recommendations that patients
are given discharge advice and education in
addition to referral to an allergy specialist where
appropriate (Younker and Soar 2010, Arnold
and Williams 2011, NICE 2011), a UK-based
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p49-56w41.indd 54
study found more than half of patients were
discharged with no education or specific
arrangement made for follow up, and none was
referred to specialist allergy services (Caton and
Flynn 2013). Research undertaken in Australia
recommended that administration by emergency
care staff of injectable adrenaline to patients
be deferred until after assessment by specialist
allergy services. In reality this presented a clinical
risk to the patient because of the paucity of
specialist services and the length of time patients
would spend waiting for specialist assessment
(Brown 2006). Therefore, it is appropriate for
emergency care staff to provide information.
Recognition of signs and symptoms
To treat the condition successfully, it is essential
to recognise the signs and symptoms of
anaphylaxis. Systemic signs and symptoms that
largely distinguish the patient with anaphylaxis
from those with severe allergy have already been
described. Training programmes that educate
the lay person, including parents and extended
family, partners, teachers, nursery workers
and patients themselves, have been found to be
successful in imparting knowledge concerning
recognition and treatment (Litarowsky et al
2004, Morris et al 2011). Potential reasons for
non-recognition and treatment of anaphylaxis
may include (Brown 2006, RCUK 2008, Jevon
2010, Arnold and Williams 2011, Dunbar and
Luyt 2011, Spickett and Stroud 2011, Caton
and Flynn 2013):
Failure
 of patients to appreciate the gravity of
their symptoms until it is too late to auto-inject.
 having a written action plan for use in
Not
an emergency.
Mistaken
 diagnosis.
Failure
 of clinical staff to provide information
needed to recognise an episode of anaphylaxis.
Emergency treatment
The use of adrenaline injectors is the
recommended first-line treatment for suspected
or confirmed anaphylaxis (RCUK 2008). The
device is quick and easy to use, and there is little
evidence to support concerns about permanent
ischaemic damage when used inappropriately
or injected in the wrong location, for example a
digit (Simons et al 2010, Arnold and Williams
2011). It is recommended that where no other
device is available, an out-of-date injector
should be used rather than none at all, as long
as no precipitates have formed in the solution
(Edwards 2009).
Despite the apparent ease of use and
unequivocal guidelines for use of adrenaline
10/06/2013 12:53
 injectors, there is evidence that medical staff
are sometimes reluctant to prescribe these
and patients or the parents or carers of young
children do not give the treatment as promptly
as necessary (Rosen 2006, Soller et al 2011,
Mustafa 2012). Medical reluctance to
prescribe has been ascribed to fear of patient
misuse and misdiagnosis, a lack of staff
confidence in providing the information
concerning training the patient to use the
device, and fear of potential cardio-toxic side
effects (Rosen 2006, Soller et al 2011, Caton
and Flynn 2013). Patients often forget how to
use the auto-injector or do not use it promptly.
Others do not have auto-injectors readily
available on a consistent basis, or allow them
to expire or degrade from improper storage
(Arnold and Williams 2011, Dunbar and Luyt
2011, Mustafa 2012).
Recommendations for effective management
of the condition in urgent and emergency care
are that (NICE 2011):
 urgent and emergency care staff should be
All
competent in patient education concerning the
use of adrenaline injectors. ‘Dummy’ injectors
are available for such teaching purposes.
 urgent and emergency care units should
All
stock adrenaline injectors for patients
who are being discharged home after an
anaphylactic episode. All patients should
have at least two auto-injectors in case one
fails, if a repeat dose needs to be given or in
the event of a biphasic episode.
Urgent
 care and emergency departments
should consider the development of a patient
information leaflet to reinforce verbal advice.
Given
 the proliferation of internet access
in the UK, patients should be directed to

References
Allergy UK (2012) Allergy to Wasp
and Bee Stings. tinyurl.com/cqn76nu
(Last accessed: May 10 2013.)
American Academy of Allergy,
Asthma & Immunology (2013)
Anaphylaxis Overview.
tinyurl.com/cxq6uyk (Last
accessed: May 10 2013.)
Anaphylaxis.org (2012) Living with
Anaphylaxis. www.anaphylaxis.org.
uk/living-with-anaphylaxis (Last
accessed: May 10 2013.)
Arnold JJ, Williams PM (2011)
Anaphylaxis: recognition and
management. American Family
Physician. 84, 10, 1111-1118.
Ben-Shoshan M, Clarke AE (2011)
Anaphylaxis: past, present and
future. Allergy. 66, 1, 1-14.
Brown AF, McKinnon D, Chu K
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 Learning zone emergency care

appropriate sites to reinforce information Conclusion

7 Now that you have
completed the article,
you might like to write
a practice profile.
Guidelines to help you
are on page 60.
already provided, expand personal
knowledge and remind themselves how to
self-inject. These sites may also be useful for
education of clinicians.
 children and young adults with
All
anaphylaxis should be admitted to hospital
for observation.
Since
 rebound or biphasic episodes occur
predominantly within six hours, all adults
should be made aware of this and observed
for this period before discharge.
 patients should be referred to an
All
allergy specialist.
Anaphylaxis is a sudden, severe and potentially
life-threatening allergic reaction. To minimise
associated mortality and morbidity, rapid
recognition of signs and symptoms of
anaphylaxis is essential. Timely treatment
should focus on the early administration of
adrenaline. Where possible, patients with
anaphylaxis should initiate treatment themselves
during an exacerbation of the illness. Emergency
staff should be aware of their responsibilities to
provide appropriate information to patients to
aid self-management of the condition.
Complete time out activity 7

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