MANAGEMENT OF ANAPHYLAXIS IN THE VACCINATION SETTING

This guidance has been extracted from the Resuscitation Council UK (RCUK) Anaphylaxis
MANAGEMENT
guideline OF ANAPHYLAXIS
(2021) and Public Health England (PHE) IN THEadviceVACCINATION
in the Green Book.SETTING It has been
approved by RCUK, PHE, the British Society for Allergy and Clinical Immunology (BSACI)
This guidance has been extracted from the Resuscitation Council UK (RCUK) Anaphylaxis guideline (2021) and Public Health
and the Royal College of General Practitioners. Further information at www.resus.org.uk
England (PHE) advice in the Green Book. It has been approved by RCUK, PHE, the British Society for Allergy and Clinical
Immunology (BSACI) and the Royal College of General Practitioners. Further information at www.resus.org.uk

Anaphylaxis?

A = Airway B = Breathing C = Circulation D = Disability E = Exposure

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Resuscitation Council UK and Public Health England, Dec 2020 Product code: COV2020380 1p 30K DEC (APS)
Vaccines stimulate an immune response to cause protection. Most adverse events after vaccination are
due to this immune response and are not allergic. Allergic reactions can happen after vaccination, but
these are uncommon. Anaphylaxis following vaccination is rare, occurring at less than 1 per million doses
MANAGEMENT OF ANAPHYLAXIS IN THE VACCINATION SETTING
for vaccines in the UK. “COVID-19 vaccines” are new, so it is uncertain if the risk of anaphylaxis is higher
compared to other vaccines.
This guidance has been extracted from the Resuscitation Council UK (RCUK) Anaphylaxis guideline (2021) and Public Health
Anaphylaxis
Englandis a serious
(PHE) advice inallergic
the Greenreaction
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anaphylaxis is characterised by life-threatening compromise in airway, breathing and/or
Immunology (BSACI) and the Royal College of General Practitioners. Further information at www.resus.org.uk the circulation,
but may occur without typical skin features or circulatory shock being present.

Anaphylaxis is likely when all of the following 3 criteria are met:

Sudden onset and rapid progression of symptoms

Airway and/or Breathing and/or Circulation problems

Skin and/or mucosal changes (itching, flushing, urticaria, angioedema)

Anaphylaxis?
Remember:

Skin orAmucosal
= Airway changes alone
B = Breathing are
C = not a sign
Circulation D = of anaphylaxis
Disability E = Exposure

Skin and mucosal changes can be subtle or absent in 10-20% of reactions

(e.g. some patients can present'LDJQRVLV
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closing.
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> Shortness of breath – increased > Signs of shock: pale, clammy
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the effort of breathing (dizziness), collapse
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inspiratory noise caused by upper Give adrenaline2 > Decreased conscious level or
due to hypoxia
intramuscular,0
airway obstruction) loss of consciousness
> Cyanosis (a late sign)
> Cardiac arrest
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Fainting is relatively common following vaccination.
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Onset Before, during or within minutes of vaccination Usually within 15 minutes, but can occur later
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Normal respiration – may be shallow, but not (angioedema) e.g. lips. face
laboured • Airway/Breathing symptoms (see above)
• 1. Life-threatening
Bradycardia, but with strong
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adrenaline pulse; • Tachycardia, with weak/absent central pulse;
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©Resuscitation Council UK and Public Health England, Dec 2020 Product code: COV2020380 1p 30K DEC (APS)
Treatment of anaphylaxis is based on general life support principles:
Call for help immediately.
MANAGEMENT
Use OF Circulation
the Airway, Breathing, ANAPHYLAXIS
approachIN THE VACCINATION
to recognise SETTING
and treat problems.
Treatment of anaphylaxis is based on general life support principles:
Intramuscular
This guidance has•been
Call adrenaline
for help
extracted fromimmediately. is the
the Resuscitation first-line
Council treatment
UK (RCUK) Anaphylaxis guideline for
(2021) and Public Health
Englandanaphylaxis
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• Use the Airway, Breathing, Circulation approach to recognise IV
the adrenaline
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treat problems.
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theand the Royalof
context College of General
cardiac arrestPractitioners.
is dangerous.Further information at www.resus.org.uk
> GiveIntramuscular
intramuscular (IM) adrenalineistothe
adrenaline treat Airway/Breathing/Circulation
first-line treatment for anaphylaxis (even if
problems.
intravenous access is available). IV adrenaline bolus outside the context of cardiac arrest is dangerous.
> Do not delay initial treatment if the diagnosis is unclear: a single dose of IM
• Give
adrenaline intramuscular
is well-tolerated and(IM) adrenaline
poses minimaltorisk.
treat Airway/Breathing/Circulation problems.
• Do not delay initial treatment if the diagnosis
> Repeat IM adrenaline every 5 minutes if features of anaphylaxis is unclear: do
a single dose of IM
not resolve.
adrenaline is well-tolerated and poses minimal risk.
• Repeat IM adrenaline every 5 minutes if features of anaphylaxis do not resolve.
Further treatment of anaphylaxis depends on:
Further treatment of anaphylaxis depends on:
1. Location 1. Location Anaphylaxis?
Treating a patient with anaphylaxis in the community will not be the same as in an acute hospital. Dial
Treatingsupport
999 urgently for ambulance a patientand
with anaphylaxis
clearly in the community will not be the same as in an acute
state “ANAPHYLAXIS”.
hospital. Dial 999
A = Airway B = urgently for ambulance support and clearly state “ANAPHYLAXIS”.
Breathing C = Circulation D = Disability E = Exposure
2. Training of rescuers
2. Training of rescuers
All clinical staff should
All be ablestaff
clinical to recognise
should beanaphylaxis,
able to recognise call for help and start
anaphylaxis, treatment.
call for help andStaff
startwho give
treatment.
immunisations should have annual updates in anaphylaxis 'LDJQRVLV management.
Staff who give immunisations
Look for: should have annual updates in anaphylaxis management.
3. Number of responders
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several rescuers, several
several rescuers,
actions
several actions can be undertaken simultaneously.
can be undertaken simultaneously.
4. Equipment and drugs available
4. Equipment and drugs available &DOOIRUKHOS
An anaphylaxis packAn anaphylaxis
normally packatnormally
contains least: contains at least:
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> Two ampoules of • adrenaline
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ampoules
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1mg/mL (1:1000)
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A pack should be immediately available in each location where vaccines are being given, and
A pack should be immediately available in each location where vaccines are being given, and should not
should
be stored in a locked not be stored
cupboard in aCheck
or trolley. lockedpackscupboard or trolley.
regularly to ensureCheck packs
the regularly
contents to ensure
are within the
their
expiry dates. contents are within their expiry dates.
Give intramuscular,0 adrenaline 2

Antihistamines
Antihistamines and steroids areand
no steroids are no longer recommended
longer recommended for themanagement
for the immediate immediate management of of
anaphylaxis, andanaphylaxis,
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In all healthcare
In all healthcare settings, settings, •giving
giving adrenaline adrenaline by ampoule/needle/syringe
by ampoule/needle/syringe
,9IOXLGEROXV  (QVXUH$PEXODQFHRU is preferred, since
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Patient positioning
Patient positioning
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Death can occur
Death •can within
occur minutes
within minutesif a patient stands,
if a patient walks
stands,
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or sits
walks up suddenly.
or sits up suddenly.
Patients must NOT walk or stand during acute reactions. Use caution when
Patientspatients
transferring must NOT whowalkhaveor stand during acute reactions. Use caution when
been stabilised.
transferring
1. Life-threatening patients2.who
problems have been
IM adrenaline stabilised. 3. IV fluid EROXV
Airway • Patients with Airway and Breathing problems may prefer
,0GRVHVRIPJLQP/DGUHQDOLQH Useto sit up.
crystalloid
> Patients
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> Lying • or
flat with
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Lying flat with
without leg or withoutisleg
elevation elevation
helpful
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low blood
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are breathing normally andshould
and unconscious unconscious
±P/ be placedshould be side
on their
(recovery position). Monitor
Pale, clammy, low blood pressure,
placed on their
faintness, drowsy/coma breathing and intervene if needed.
side (recovery position). Monitor breathing and intervene if needed.
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> Pregnant patients should lie on their left side to prevent aortocaval compression.
• Pregnant patients should lie on their left side to prevent aortocaval compression.

©Resuscitation Council UK and Public Health England, Dec 2020 Product code: COV2020380 1p 30K DEC (APS)
©Resuscitation Council UK and Public Health England, Dec 2020 Product code: COV2020380 1p 30K DEC (APS)
Other supportive measures:
Give further repeat doses of IM adrenaline every 5 minutes if symptoms do not resolve.
Give oxygen and apply pulse oximetry (if available), to achieve oxygen saturations of 94-98%,


MANAGEMENT OF ANAPHYLAXIS IN THE VACCINATION SETTING
but do not delay giving oxygen while waiting for a pulse oximeter.
Severe upper airways obstruction is uncommon.
> Seek
This guidance urgent
has been expert
extracted from help if there isCouncil
the Resuscitation airway obstruction.
UK (RCUK) Anaphylaxis guideline (2021) and Public Health
> Nebulised adrenaline (5mL of 1mg/mL adrenaline)
England (PHE) advice in the Green Book. It has been approved by RCUK, PHE, the can be used
British Societytofortreat
Allergyupper airways
and Clinical
Immunology obstruction but must not be prioritised over further IM adrenaline
(BSACI) and the Royal College of General Practitioners. Further information at www.resus.org.ukevery 5 minutes.
Bronchospasm - consider further inhaled bronchodilator therapy with salbutamol and/or
ipratropium, but must not be prioritised over IM adrenaline.
A reduction in blood flow is common in anaphylaxis, even in the absence of obvious circulatory
compromise. Give a fluid bolus if there is an inadequate response to initial IM adrenaline, to
support tissue perfusion and drug delivery.

Possible cross-reactivity between vaccines and drugs

Antihistamines and steroids are no longer recommended for management of
anaphylaxis. Some oral medicines used to treat more mild reactions contain the
same substances found in some vaccines Anaphylaxis?
(and which can cause allergic reactions).
Caution is recommended following allergic reactions to vaccines. In the UK, use
an oral liquid antihistamine (e.g. liquid cetirizine). Chlorphenamine tablets can
also be used, Abut these Bcan
= Airway cause drowsiness
= Breathing andD therefore
C = Circulation = Disability mimic symptoms of
E = Exposure
anaphylaxis.
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CARDIAC ARREST: Look for:
Recognise cardiac arrest has occurred if the
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is absent or abnormal. &LUFXODWLRQSUREOHPV
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Start chest compressions as soon as cardiac arrest is suspected.

Ensure expert help (resuscitation team &DOOIRUKHOS
or ambulance) has been called.
Follow standard cardiac arrest guidelines (use IV/IO adrenaline in preference to IM route,
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as per protocol), available at www.resus.org.uk.
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The specific test to help confirm a diagnosis of anaphylaxis is measurement of mast cell tryptase. Ideally,
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three timed samples (serum or plasma, e.g. yellow top bottle) are needed:

Give
1.An initial sample as soon as intramuscular,0
feasible, adrenaline
but do not delay starting2 resuscitation.
2.A second sample at 1-2 hours (but no later than 4 hours) from the onset of symptoms.
If possible, take 5-10mL extra for serum store to facilitate further investigations.
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A convalescent sample should be obtained at least 24 hours after complete
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GHVSLWH7:2GRVHVRIDGUHQDOLQH

allergy clinic), to provide a baseline tryptase value.

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Report all suspected vaccine-induced adverse drug reactions (ADRs) via the DGUHQDOLQHLQIXVLRQ
MHRA’s Yellow Card scheme: https://coronavirus-yellowcard.mhra.gov.uk
All patients with suspected anaphylaxis should be referred to an allergy clinic – see bsaci.org
for details of clinics.
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This1.guidance
Life-threatening problems
has been extracted 2. IM adrenaline
from the Resuscitation Council UK 3.(RCUK) Anaphylaxis
IV fluid EROXV
,0GRVHVRIPJLQP/DGUHQDOLQH
guideline
Airway (2021) and Public
Swelling, hoarseness, stridor
Health England (PHE) advice in the Green
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Book.
Use It has been
crystalloid
approved
Breathing
by RCUK, PHE, the British Society
&KLOG±\HDUV for Allergy and Clinical
PLFURJUDPV,0P/ Immunology
Adults: 500–1000 (BSACI)
Children: 20 mL/kg
mL

and Rapid
the breathing,
Royal College of General
wheeze, fatigue, Practitioners. PLFURJUDPV,0P/)
&KLOGPRQWKVWR\HDUV Further information at www.resus.org.uk
cyanosis, SpO2 <94%, confusion ±PLFURJUDPV,0
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©Resuscitation Council UK and Public Health England, Dec 2020 Product code: COV2020380 1p 30K DEC (APS)