ASCIA Guidelines - Acute management of anaphylaxis

These guidelines are intended for medical practitioners and nurses providing first responder emergency care. The appendix includes additional information for emergency department staff, ambulance staff, rural or remote medical practitioners and nurses providing emergency care.

pdfASCIA Guidelines Acute Management Anaphylaxis 2019295.31 KB 

Anaphylaxis definitions

  • Any acute onset illness with typical skin features (urticarial rash or erythema/flushing, and/or angioedema), PLUS involvement of respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms; or
  • Any acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is considered possible, even if typical skin features are not present.

The most common triggers of anaphylaxis (severe allergic reaction) are foods, insect stings and drugs (medications).

Signs and symptoms of allergic reactions

Mild or moderate reactions

  • Swelling of lips, face, eyes
  • Hives or welts
  • Tingling mouth
  • Abdominal pain, vomiting (these are signs of anaphylaxis for insect sting or injected drug (medication) allergy 

Anaphylaxis – Indicated by any one of the following signs:

  • Difficult/noisy breathing
  • Swelling of tongue
  • Swelling/tightness in throat
  • Difficulty talking and/or hoarse voice
  • Wheeze or sudden persistent cough*
  • Persistent dizziness or collapse
  • Pale and floppy (young children)
  • Abdominal pain, vomiting (for insect sting or injected drug (medication) allergy).

Immediate actions

ASCIA AMGL Lie down

  1. Remove allergen (if still present).
  2. Call for assistance.
  3. Lay patient flat. Do not allow them to stand or walk.
    Do not hold infants upright. 
    If breathing is difficult, allow the patient to sit.
  4. Give INTRAMUSCULAR INJECTION (IMI) ADRENALINE (epinephrine) into outer mid thigh without delay using an adrenaline autoinjector if available OR adrenaline ampoule and syringe.
  5. Give oxygen (if available).
  6. Call ambulance to transport patient if not already in a hospital setting.
ALWAYS give adrenaline FIRST, then asthma reliever if someone with known asthma and allergy to food, insects or medication has SUDDEN BREATHING DIFFICULTY (including wheeze, persistent cough* or hoarse voice) even if there are no skin symptoms. 

*Unlike the cough in asthma, the onset of coughing during anaphylaxis is usually sudden.

  • If required at any time, commence cardiopulmonary resuscitation (CPR).

To access ASCIA Action Plans and other anaphylaxis resources go to www.allergy.org.au/anaphylaxis

Adrenaline administration and dosages

Adrenaline (epinephrine) is the first line treatment of anaphylaxis and acts to reduce airway mucosal oedema, induce brochodilation, induce vasoconstriction and increase strength of cardiac contraction.

Give INTRAMUSCULAR INJECTION (IMI) OF ADRENALINE (1:1000) into outer mid thigh (0.01mg per kg up to 0.5mg per dose) without delay using an adrenaline autoinjector if available OR adrenaline ampoule and syringe, as follows. 

Adrenaline (epinephrine) dosages chart

Age (years)

Weight (kg)

Vol. adrenaline 1:1000

Adrenaline autoinjector

~<1

<7.5kg

0.1 mL

Not available

~1-2

10

0.1 mL

7.5*-20 kg (~<5yrs)

0.15mg device

(e.g. EpiPen Jr)

~2-3

15

0.15 mL

~4-6

20

0.2 mL

~7-10

30

0.3 mL

>20kg (~>5yrs)

0.3mg device

(e.g. EpiPen)

~10-12

40

0.4 mL

~>12 and adults

>50

0.5 mL

* Whilst 10-20kg was the previous weight guide for a 0.15mg adrenaline autoinjector device, a 0.15mg device may now also be prescribed for an infant weighting 7.5-10kg by health professionals who have made a considered assessment. Use of a 0.15mg device for treatment of infants weighing 7.5kg or more poses less risk, particularly when used without medical training, than use of an adrenaline ampoule and syringe.

Infants with anaphylaxis may retain pallor despite two to three doses of adrenaline, and this can resolve without further doses. More than two to three doses of adrenaline in infants may cause hypertension and tachycardia.

Pregnant women experiencing anaphylaxis need to be treated without delay and there are no absolute contraindications to adrenaline use in anaphylaxis. If clinical judgement deems that there is a risk of maternal death or foetal compromise due to inadequately treated anaphylaxis, then in pregnant women weighing > 50kg, consider giving 500 mcg IM adrenaline.

Note:

  • If multiple doses are required for severe reactions (e.g. two the three doses administered at five minute intervals), consider adrenaline infusion if skills and equipment are available.
  • For emergency treatment of anaphylaxis, ampoules of adrenaline 1:1000 should be used for both IM doses and infusion if required (adrenaline 1:10 000 should not be used).

Positioning of patients

  • Laying the patient flat will improve venous blood return to the heart.
  • By contrast, placing the patient in an upright position, including holding infants upright over a shoulder, can impair blood returning to the heart, resulting in insufficient blood for the heart to circulate and low blood pressure.
  • The left lateral position is recommended for patients who are pregnant to reduce the risk of compression of the inferior vena cava by the pregnant uterus and thus impairing venous return to the heart.
  • Fatality can occur within minutes if a patient stands or sits suddenly.
  • For mainly respiratory reactions, the patient may prefer to sit and this may help support breathing and improve ventilation. BEWARE that even sitting may trigger hypotension. Monitor closely. Immediately lay the patient flat again, if there is any alteration in conscious state or drop in blood pressure.
  • If vomiting, lay the patient on their side (recovery position).
  • Patients must not be walked to/from the ambulance, even if they appear to have recovered.
  • Infographics (see above) are included in ASCIA Action Plans to reinforce correct positioning.

Supportive management - when skills and equipment are available

  • Check pulse, blood pressure, ECG, pulse oximetry, conscious state.
  • Give high flow oxygen if available and airway support if needed.
  • Obtain IV access in adults and hypotensive children.
  • If hypotensive, give IV normal saline 20mL/kg rapidly and consider additional wide bore IV access.

See Appendix for additional information.

Additional measures - IV adrenaline infusion in clinical setting

If inadequate response after two to three adrenaline doses, or deterioration of patient, start IV adrenaline infusion, given by staff trained in its use or in liaison with an emergency/critical care specialist. IV adrenaline infusions should be used with a dedicated line, infusion pump and anti-reflux valves wherever possible.

CAUTION: IV boluses of adrenaline are NOT recommended without specialised training as they may increase the risk of cardiac arrhythmia.

See Appendix for additional information.

Additional measures to consider if IV adrenaline infusion is ineffective 

For Upper airway obstruction

  • Nebulised adrenaline (5mL e.g. 5 ampoules of 1:1000).
  • Consider need for advanced airway management if skills and equipment are available.

For persistent hypotension/  shock

  • Give normal saline (maximum of 50mL/kg in first 30 minutes).
  • Glucagon
  • In adults, selective vasoconstrictors only after advice from an emergency medicine/critical care specialist.

See Appendix for dosage and additional information.

For persistent wheeze

Bronchodilators: Salbutamol 8 - 12 puffs of 100µg using a spacer OR 5mg salbutamol by nebuliser.

Note: Bronchodilators do not prevent or relieve upper airway obstruction, hypotension or shock.

Corticosteroids: Oral prednisolone 1 mg/kg (maximum of 50 mg) or intravenous hydrocortisone 5 mg/kg (maximum of 200 mg).

Note: Steroids must not be used as a first line medication in place of adrenaline.

 Antihistamines and corticosteroids

Antihistamines:

  • Antihistamines have no role in treating or preventing respiratory or cardiovascular symptoms of anaphylaxis.
  • Do not use oral sedating antihistamines as side effects (drowsiness or lethargy) may mimic some signs of anaphylaxis.
  • Injectable promethazine should not be used in anaphylaxis as it can worsen hypotension and cause muscle necrosis.

Corticosteroids:

  • The benefit of corticosteroids in anaphylaxis is unproven.

Observe patient for at least 4 hours after last dose of adrenaline

Relapse, protracted and/or biphasic reactions may occur. Patients require overnight observation if they:

  • Had a severe or protracted anaphylaxis (e.g. required repeated doses of adrenaline or IV fluid resuscitation), OR
  • Have a history of asthma or severe/protracted anaphylaxis, OR
  • Have other concomitant illness (e.g. asthma, history or arrhythmia), OR
  • Live alone or are remote from medical care, OR
  • Present for medical care late in the evening.

True biphasic reactions are estimated to occur following 3-20% of anaphylactic reactions.

Follow up treatment including advice for hospital discharge

Adrenaline autoinjector

  • If there is a risk of re-exposure (e.g. stings, foods, unknown cause) then prescribe an adrenaline autoinjector before discharge, pending specialist review.
  • Teach the patient how to use the adrenaline autoinjector using a trainer device and provide them with an ASCIA Action Plan for Anaphylaxis - see ASCIA website www.allergy.org.au/anaphylaxis

Allergy specialist referral

  • Refer ALL patients who present with anaphylaxis for specialist review
  • The allergy specialist will:
    • Identify/confirm cause.
    • Educate regarding avoidance/prevention strategies, management of comorbidities.
    • Provide ASCIA Action Plan for Anaphylaxis - preparation for future reactions.
    • Initiate immunotherapy where available (some insect venoms).

Documentation of episodes

Patients should be advised to document the circumstances of episodes of anaphylaxis to facilitate identification of avoidable causes (e.g. food, medication, herbal remedies, bites and stings, co-factors like exercise) in the six to eight hours preceding the onset of symptoms. 

The ASCIA allergic reactions event record form can be used to collect and document this information.

https://allergy.org.au/hp/anaphylaxis/anaphylaxis-event-record/

Preparation:  Equipment required for acute management of anaphylaxis

The equipment on the emergency trolley should include:

  • Adrenaline 1:1000 (consider adrenaline autoinjector availability, particularly in rural locations, for initial administration by nursing staff)
  • 1mL syringes; 21-gauge needles
  • Oxygen
  • Airway equipment, including nebuliser and suction
  • Defibrillator
  • Manual blood pressure cuff
  • IV access equipment (including large bore cannulae)
  • At least 3 litres of normal saline
  • A hands-free phone in resuscitation room, to allow health care providers in remote locations to receive instructions by phone whilst keeping hands free for resuscitation.

Acknowledgements

The information in these guidelines is consistent with the Australian Prescriber Anaphylaxis Management wall chart www.australianprescriber.com

These guidelines are based on the following international guidelines: 

  • International Liaison Committee on Resuscitation (ILCOR) and Australian and New Zealand Committee on Resuscitation (ANZCOR) guidelines
  • American Academy of Allergy, Asthma and Immunology (AAAAI) anaphylaxis parameter
  • World Allergy Organisation (WAO) anaphylaxis guidelines

The appendix includes information on advanced acute management of anaphylaxis for emergency department staff, ambulance staff, rural or remote medical practitioners and nurses providing emergency care.   This additional information was previously in a separate document titled ASCIA Guidelines for advanced acute management of anaphylaxis.

© ASCIA 2019  

ASCIA is the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand.

ASCIA resources are based on published literature and expert review, however, they are not intended to replace medical advice. The content of ASCIA resources is not influenced by any commercial organisations.

For more information go to www.allergy.org.au

To donate to allergy and immunology research go to www.allergyimmunology.org.au

Content updated August 2019 

Appendix: Advanced Acute Management of Anaphylaxis

This additional information is intended for health professionals working in emergency departments, ambulance staff, and rural or remote medical practitioners and nurses providing emergency care.

Supportive management (when skills and equipment are available)

  • Monitor pulse, blood pressure, respiratory rate, pulse oximetry, conscious state.
  • Give high flow oxygen (6-8 L/min) and airway support if needed.
  • Supplemental oxygen should be given to all patients with respiratory distress, reduced conscious level and those requiring repeated doses of adrenaline.
  • Supplemental oxygen should be considered in patients who have asthma, other chronic respiratory disease, or cardiovascular disease.
  • Obtain intravenous (IV) access in adults and in hypotensive children.
  • If hypotensive:
    • Give intravenous normal saline (20 mL/kg rapidly under pressure), and repeat bolus if hypotension persists.
    • Consider additional wide bore (14 or 16 gauge for adults) intravenous access.

During severe anaphylaxis with hypotension, marked fluid extravasation into the tissues can occur: DO NOT FORGET FLUID RESUSCITATION.

Assess circulation to reduce risk of overtreatment

  • Monitor for signs of overtreatment (especially if respiratory distress or hypotension were absent initially) – including pulmonary oedema, hypertension.
  • In this setting (anaphylaxis) it is recommended that if possible a simple palpable systolic blood pressure (SBP) should be measured:
    • Attach a manual BP cuff of an appropriate size and find the brachial or radial pulse.
    • Determine the pressure at which this pulse disappears/reappears (the "palpable" systolic BP).
    • This is a reliable measure of initial severity and response to treatment
    • Measurement of palpable SBP may be more difficult in children.

Note: If a patient is nauseous, shaky, vomiting, or tachycardic but has a normal or elevated SBP, this may be adrenaline toxicity (side effects) rather than worsening anaphylaxis.

Additional measures - IV adrenaline infusion

IV adrenaline infusions should only be given by, or in liaison with, an emergency medicine/critical care specialist.

If your centre has a protocol for IV adrenaline infusion for critical care, this should be utilised and titrated to response with close cardio-respiratory monitoring.

If there is not an established protocol for your centre, two protocols for IV adrenaline infusion are provided, one for pre-hospital settings and a second for emergency departments/tertiary hospital settings only.

It is important to note that the two infusion protocols have different concentrations and different rates of IV fluid infusion, resulting in the same initial rate of adrenaline infusion.

It is vital that IV adrenaline infusions should be used with the following equipment wherever possible:

  • Dedicated line,
  • Infusion pump,
  • Anti-reflux valves in intravenous line.

Additional measures - IV adrenaline infusion for pre-hospital settings

If there is inadequate response to IMI adrenaline or deterioration, start an intravenous adrenaline infusion.  IV adrenaline infusions should only be given by, or in liaison with, an emergency medicine/critical care specialist. Infusions can be given with or without using an infusion pump.

The protocol for 1000 mL normal saline is as follows:

  • Mix 1 mL of 1:1000 adrenaline in 1000 mL of normal saline.
  • Start infusion at ~5 mL/kg/hour (~0.1 microgram/kg/minute).
  • If you do not have an infusion pump, a standard giving set administers ~20 drops per mL, therefore, start at ~2 drops per second for an adult.
  • Titrate rate up or down according to response and side effects.
  • Monitor continuously – ECG and pulse oximetry and frequent non-invasive blood pressure measurements as a minimum to maximise benefit and minimise risk of overtreatment and adrenaline toxicity.

Note:

  • This protocol is intended for temporary use, when no infusion pump is available.
  • Most anaphylactic reactions settle with only 1 mg adrenaline in 1 litre.
  • Indefinite continuation of low concentration infusion increases risk of fluid overload.
  • Caution - Intravenous boluses of adrenaline are NOT recommended due to risk of cardiac ischaemia or arrhythmia UNLESS the patient is in cardiac arrest.

Additional measures: IV adrenaline infusion for emergency departments/tertiary hospitals only

This infusion will facilitate a more rapid delivery through a peripheral line and should only be used in emergency departments and tertiary hospital settings.

The protocol for 100 mL normal saline is as follows:

  • Mix 1 mL of 1:1000 adrenaline in 100 mL normal saline.
    • Initial rate adjusted accordingly to 0.5 mL/kg/hour (~0.1 microgram/kg/minute).
    • Should only be given by infusion pump.
  • Monitor continuously – ECG and pulse oximetry and frequent non-invasive blood pressure measurements as a minimum to maximise benefit and minimise risk of overtreatment and adrenaline toxicity. 

Additional measures to consider if IV adrenaline infusion is ineffective

For persistent hypotension/shock

  • Give normal saline (maximum of 50mL/kg in first 30 minutes).
  • In patients with cardiogenic shock (especially if taking beta blockers) consider an intravenous glucagon bolus of:
    -   1-2mg in adults
    -   20-30 microgram/kg up to 1mg in children

This may be repeated or followed by an infusion of 1-2mg/hour in adults.

  • In adults, selective vasoconstrictors metaraminol (2-10mg) or vasopressin (10-40 units) only after advice from an emergency medicine/critical care specialist.  Beware of side effects including arrhythmias, severe hypotension and pulmonary oedema.
  • In children, metaraminol 10 micrograms/kg/dose can be used.  Noradrenaline infusion may be used in the critical care setting only with invasive blood pressure monitoring.

Advanced airway management

  • Oxygenation is more important than intubation.
  • Always call for help from the most experienced person available.
  • If airway support is required, first use the skills you are most familiar with (e.g. jaw thrust, Guedel or nasopharyngeal airway, bag-valve-mask with high flow oxygen attached). This will save most patients, even those with apparent airway swelling (these patients have often stopped breathing due to circulatory collapse rather than airway obstruction and can be adequately ventilated with basic life support procedures).
  • DO NOT make prolonged attempts at intubation - remember the patient is not getting any oxygen while you are intubating.

If unable to maintain an airway and the patient's oxygen saturations are falling further approaches to the airway (e.g. cricothyrotomy) should be considered in accordance with established difficult airway management protocols.  Specific training is required to perform these procedures.

Special situation:  Overwhelming anaphylaxis (cardiac arrest)

Key points:

  • Massive vasodilatation and fluid extravasation.
  • Unlikely that IMI adrenaline will be absorbed in this situation due to poor peripheral circulation.
  • Even if absorbed, IMI adrenaline on its own may be insufficient to overcome vasodilatation and extravasation.
  • Need both IV adrenaline bolus (cardiac arrest protocol, 1 mg every 2-3 minutes) AND aggressive fluid resuscitation in addition to CPR (Normal Saline 20mL/kg stat, through a large bore IV under pressure, repeat if no response).
  • Do not give up too soon - this is a situation when prolonged CPR should be considered, because the patient arrested rapidly with previously normal tissue oxygenation, and has a potentially reversible cause. Consider extracorporeal membrane oxygenation (ECMO) if resource is available.
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