Remote Primary Health Care Manuals

Anaphylaxis — severe allergic reaction

Medical emergency — life threatening allergic reaction

Reaction usually happens very soon after person comes in contact with a substance they are allergic to (eg medicine, food, insect bite, some plants and chemicals)

Anaphylaxis kit

  • Make sure anaphylaxis kit is in designated box and clearly labelled
  • Use-by/expiry date of adrenaline (epinephrine) on the front

Table 2.1  

3 x

Adrenaline (epinephrine) ampoules 1:1,000 (1mg/mL) — 1mL ampoules

3 x Alcohol swabs
3 x Syringes — 1mL
3 x Drawing up needles — 18G or 19G blunt
3 x 22–25G needles (25mm length) suitable for most IM injections*
1 x Adrenaline (epinephrine) doses card (laminated)
*Exceptions are preterm or very small infants — 23–25G needles (length 16mm) and very large adults — 22–25G needle (length up to 38mm)

Do Not

  • Do not use antihistamines or hydrocortisone for immediate management of anaphylaxis

Do First

  • Immediately when you suspect moderate or severe anaphylaxis
    • Get anaphylaxis kit and give adrenaline (epinephrine) by deep IM
    • Start CPR if needed

Ask

  • Do they know what caused this
  • Feeling hot and itchy
  • Tingling or swelling in lips or tongue
  • Short of breath
  • Worried or frightened
  • Crampy abdominal pain, vomiting, diarrhoea
  • Light-headedness

Check

If any of signs in bold — severe anaphylaxis

  • Abdominal pain, vomiting — severe symptoms for insect or injected medicine allergy
  • Tongue or throat swelling
  • Difficult breathing, stridor (noisy breathing), difficulty talking or hoarse voice, wheeze or persistent cough
  • Low BP, weak fast pulse, pale, persistent dizziness
  • Pale and floppy (young children)
  • Collapse — shock or respiratory arrest
  • Lumpy or red rash (welts, hives)
  • Swelling of lips, face or eyes

Do

  • Remove allergen if still present (eg anaphylaxis caused by injection/infusion — stop giving medicine straight away)
    • For insect allergy, flick out bee stinger
  • Lay person flat
  • Stay with person and call for help — get someone to bring anaphylaxis kit
  • If severe anaphylaxis (any sign in bold) — give adrenaline (epinephrine) by deep IM injection preferably into lateral thigh
  • Repeat dose every 5 minutes until person improves — always IM
  • Give oxygen to target O2 sats 94–98% OR if moderate/severe COPD — 88–92%
  • Lay on back if needing to have airway opened OR put in recovery position to keep airway clear
    • If unconscious place in recovery position to keep airway clear — lay on left side if pregnant, as shown below — Figure 2.9
    • If breathing is difficult allow them to sit up with legs outstretched
    • Hold young children flat, not upright

Figure 2.9  

Unconscious person positioned on side with lower arm at 90 degrees to body, upper leg bent.

Giving adrenaline (epinephrine) for anaphylaxis — deep IM injection
  • Get 1 ampoule of adrenaline (epinephrine) (1:1,000) and draw up correct dose — Table 2.2
  • Give adrenaline (epinephrine) by deep IM injection preferably into lateral thigh
  • Repeat dose every 5 minutes until person improves — always IM
  • Consider nebulised adrenaline (epinephrine) if noisy breathing — 5 x 1mg ampoule in nebuliser
    • Nebulisers have high risk of transmitting infection and should only be used if absolutely necessary — wear full PPE

Table 2.2   Adrenaline (epinephrine) 1:1000 IM doses by age

Age
(years)		 Approximate weight
(kg)		 Dose of adrenaline (epinephrine)
(mL of 1:1,000)		 Adrenaline (epinephrine) injector
Under 2 5–10 0.1 Not available
2–3 15 0.15 Under 5 years (7.5–20kg)
150microgram device
4–6 20 0.2
7–10 30 0.3 Over 5 years (over 20kg)
300microgram device
11–12 40 0.4
Over 12 50+ 0.5

Over 12 years (over 50kg)
300 or 500microgram device

  • Put in IV cannula (largest possible)
  • If condition severe and can’t get cannula in within 1 minute — put in intraosseous needle
  • Run normal saline or Hartmann’s solution fast
  • When person starts to improve — slow to maintenance IV fluid
    • Be careful with large amounts of fluid in children, elderly, people with heart or kidney disease
  • Medical consult
  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • If improving — keep person resting in clinic and monitor for 4–6 hours
  • Check for signs of recurrence — rash, swelling, hoarseness, trouble breathing, abdominal pain
  • If getting worse or not completely recovered and well in 4–6 hours — medical consult about sending to hospital
    • If child under 16 years — use lower threshold for transfer to hospital

Follow-up

  • Find out what caused anaphylaxis, record in file notes
  • Doctor must talk with everyone involved and decide if it was true anaphylactic reaction
  • If it was true anaphylactic reaction
    • Carefully explain to person what this means — must not take that medicine, eat that food
    • Record what caused allergic reaction (if known) in large red letters as alert in clinical record Example: ALLERGIC TO PENICILLIN ALLERGIC TO PEANUTS
  • Must tell local hospital and other places with medical records for person
  • Consider reporting to Therapeutic Goods Administration — online portal 
  • Consider person getting Medic Alert Bracelet — from local chemist or phone 1800 882 222 
  • Consider referral for assessment, possible desensitisation — especially if reaction to medicine that is important for treatment (eg penicillin for RHD)
  • If person could be exposed to cause again (eg bee sting) OR the cause is unclear/unknown — doctor needs to arrange access to self-injecting adrenaline (epinephrine) pen, educate in storage and use
  • Doctor should also provide an Action Plan for anaphylaxis

Procaine reactions

Cause not known. Also called pseudo-anaphylaxis or procaine psychosis

Number of possible reactions to procaine benzylpenicillin (procaine penicillin) injections — Table 2.3

Table 2.3   Reactions to procaine benzylpenicillin (procaine penicillin)

Faint Anaphylaxis Procaine reaction
Frequency Common Rare Very rare
Mental state Goes quiet Feels scared Feels very scared, may see or hear things that are not there, may think they are dying
Skin Looks pale and sweaty Red lumpy rash (hives), feels itchy, may have swelling May be perspiring (sweaty) 
Pulse Slow Weak, fast Strong, fast
BP Normal or slightly low Low – shock Normal or high
Breathing May groan Wheeze or stridor (noisy breathing) May be fast
Other signs May go stiff with twitching limbs Irregular heartbeat, may collapse Metallic taste, twitching limbs or fit

Do

  • Stop giving injection straight away
  • Protect person from injury
  • Call for help, ask someone to get anaphylaxis kit
  • Give oxygen to target O2 sats 94–98% OR if moderate/severe COPD — 88–92%
  • Check pulse, RR, BP
    • If weak fast pulse, low BP — anaphylaxis
    • If slow pulse, normal BP — faint
    • If fast pulse, normal or high BP — procaine reaction
  • Medical consult to confirm type of reaction
  • Reassure person, try to keep them comfortable
  • Understand that reaction is harmless and will stop in 15–30 minutes

Follow-up

  • Reactions can be stressful for person, relatives and clinic staff. Important for clinic staff and community to understand what happened and that no-one was to blame
  • Talk with person and relatives about ‘procaine reactions'. Explain that reactions do not usually happen again
  • Person can still have procaine benzylpenicillin (procaine penicillin) but may not want to
  • Record in health record — PROCAINE REACTION (NOT PENICILLIN ALLERGY)