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

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

Anaphylaxis – Indicated by any one of the following signs:

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.

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:

Positioning of patients

Supportive management - when skills and equipment are available

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:

Corticosteroids:

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:

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

Follow up treatment including advice for hospital discharge

Adrenaline autoinjector

Allergy specialist referral

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:

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: 

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)

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

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:

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:

Note:

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:

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

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: