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  

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  
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
  • 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)

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)

Supporting resources