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Ahmad Thanin
Emergency Treatment
of Anaphylaxis
Definition of Anaphylaxis
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.
Anaphylaxis is
characterized by
Rapidly developing, life threatening, Airway
and/or Breathing and or Circulation problems
Usually with skin and/or mucosal changes
Who gets anaphylaxis?
Mainly children and young adults
Commoner in females
Incidence seems to be increasing
Examples of some cause's anaphylaxis
Stings
Bee
Wasp
Scorpions
Snakes
Nuts
Peanut
Walnut
Almond
Food
milk
Fish
Chickpea
Crustacean
banana
snail
Antibiotics
Penicillin
Cephalosporin
Amphotericin
Ciprofloxacin
Vancomycin
Anesthetic
drugs
suxamethonium
vecuronium
Atracurium
Other drugs
NSAID
ACEI
Gelatins
Protamine
vitamin K,
diamox,
pethidine,
local anaesthetii
Streptokinase
Contrast
media
iodinated
technetium
fluorescine
Others
Latex
hair dye
Signs and
symptoms of
Allergic
Reactions
Mild or Moderate
reactions (may
not always occur
before
anaphylaxis):
• 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
Signs and
symptoms of
Allergic
Reactions
Anaphylaxis –
Indicated by
any one of the
following signs:
• Difficult or noisy breathing
• Swelling of tongue
• Swelling or tightness in throat
• Difficulty talking or hoarse voice
• Wheeze or persistent cough - unlike the
cough in asthma, the onset of coughing
during anaphylaxis is usually sudden
• Persistent dizziness or collapse
• Pale and floppy (young children)
• Abdominal pain, vomiting - for insect
stings or injected drug (medication)
allergy.
Anaphylaxis is highly likely when any one of the following
two criteria are fulfilled:
• Acute onset of an illness (minutes to several hours) with simultaneous involvement of the skin, mucosal
tissue, or both (e.g., generalized hives, pruritus or flushing, swollen lips-tongue-uvula), and at least one of
the following:
• Respiratory compromise (e.g., dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow,
hypoxemia).
• Reduced blood pressure or associated symptoms of end-organ dysfunction (e.g., hypotonia [collapse],
syncope, incontinence).
• Severe gastrointestinal symptoms (e.g., severe crampy abdominal pain, repetitive vomiting), especially
after exposure to non-food allergens.
Criteria 1.
• Acute onset of hypotension or bronchospasm or laryngeal involvement after exposure to a known or
highly probable allergen for that patient (minutes to several hours), even in the absence of typical skin
involvement.
Criteria 2.
Immediate actions for anaphylaxis
Remove allergen (if still
present), stay with
person, call for
assistance and locate
adrenaline injector.
LAY PERSON FLAT - do
NOT allow them to
stand or walk
GIVE ADRENALINE
INJECTOR
Give oxygen (if
available).
Phone ambulance
Phone
family/emergency
contact.
Further adrenaline may
be given if no response
after 5 minutes
Transfer person to
hospital for at least 4
hours of observation.
Commence CPR at any
time if person is
unresponsive and not
breathing normally.
LAY PERSON FLAT - Do NOT allow them to stand or walk
LAY PERSON FLAT -
do NOT allow them
to stand or walk
If unconscious or
pregnant, place in
recovery position - on
left side if pregnant, as
shown below
If breathing is difficult
allow them to sit with
legs outstretched
Hold young children
flat, not upright
GIVE ADRENALINE INJECTOR
Give intramuscular injection (IMI) adrenaline into outer mid-thigh without delay using an
adrenaline autoinjector if available OR adrenaline ampoule/syringe.
Adrenaline (epinephrine) is the first line treatment for anaphylaxis
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.
Anaphylaxis triggers and reaction times
The most common triggers of anaphylaxis are foods, insect stings and drugs (medications).
• Less common triggers include latex, tick bites, exercise (with or without food), cold temperatures, radiocontrast
agents, immunization (rare) and unidentified (idiopathic).
Anaphylaxis usually occurs within one to two hours of ingestion in food allergy.
• The onset of a reaction may occur rapidly (within 30 minutes) or may be delayed several hours (for example, in
mammalian meat allergy and food dependent exercise induced anaphylaxis, where symptoms usually occur
during exercise).
Anaphylaxis to stings and injected medications (including radiocontrast agents and
vaccines) usually occurs within 5-30 minutes but may be delayed.
• Anaphylaxis to oral medications can also occur but is less common than to injected medications
Management of Anaphylaxis in Pregnancy
Management of anaphylaxis in pregnant women is the same as for non-pregnant women.
Adrenaline should be the first line treatment for anaphylaxis in pregnancy, and prompt
administration of adrenaline (1:1,000 IM adrenaline 0.01mg per kg up to 0.5mg per dose)
should not be withheld due to a fear of causing reduced placental perfusion.
The left lateral position is recommended
Management of Anaphylaxis in Infants
Whilst 10-20kg was the previous weight guide for a 150-microgram adrenaline injector device, a 150-
microgram device may now also be prescribed for an infant weighting 7.5-10 kg by health professionals who
have made a considered assessment.
Use of a 150-microgram device for treatment of infants weighing 7.5 kg 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 2-3 doses of adrenaline, and this can resolve without further
doses.
More than 2-3 doses of adrenaline in infants may cause hypertension and tachycardia, which is often
misinterpreted as an ongoing cardiovascular compromise or anaphylaxis.
Blood pressure measurement can provide a guide to the effectiveness of treatment, to check if additional
doses of adrenaline are required
Intra-muscular Adrenaline
Age Dose
Adult or child more than 12 years 500 micrograms IM (0.5 mL)
Child 6 ‐12 years 300 micrograms IM (0.3 mL)
Child 6 months ‐ 6 years 150 micrograms IM (0.15 mL)
Child less than 6 months 150 micrograms IM (0.15 mL)
Fluids
Once IV access established
500 – 1000 mL IV bolus in adult
20 mL/Kg IV bolus in child
Monitor response - give further bolus as necessary
Colloid or crystalloid (0.9% sodium chloride or Hartmann’s)
Avoid colloid, if colloid thought to have caused reaction
Steroids and anti-histamines(Hydrocortisone
and chlorphenamine)
Second line drugs
Use after initial
resuscitation started
Do not delay initial ABC
treatments
Can wait until transfer to
hospital
Positioning of patients with anaphylaxis - 1
Fatality can occur within minutes if a patient stands, walks or sits suddenly.
Patients must NOT walk or stand, even if they appear to have recovered.
A wheelchair, stretcher or trolley bed should be used to transfer the patient:
• To the ambulance and from the ambulance to the treatment room bed.
• From the treatment room bed to and from the toilet.
Laying the patient flat (see image above) will improve venous blood return to the heart.
• By contrast, placing the patient in an upright position (standing or walking) can impair blood returning to the
heart, resulting in insufficient blood for the heart to circulate and low blood pressure.
• This means that patients should not stand or walk, and this includes not being showered.
If unconscious, vomiting or pregnant, lay the patient on their side in the recovery position.
Positioning of patients with anaphylaxis - 2
The left lateral (recovery) position is recommended for patients who are pregnant.
•This reduces the risk of compression of the inferior vena cava by the pregnant uterus and improves venous return to the heart.
Patients with mostly respiratory symptoms may prefer to sit with their legs outstretched in front of them
•which may help support breathing and improve ventilation.
•They should not sit on a chair as this may trigger hypotension.
•Monitor closely and immediately lay the patient flat if there is any alteration in conscious state or drop in blood pressure.
The correct way to hold an infant or young child is flat not upright nor over a shoulder.
Do not allow the patient to stand or walk
•until they are hemodynamically stable, which is usually a minimum of 1 hour after 1 dose of adrenaline and 4 hours if more than 1
dose of adrenaline.
Equipment required for acute management of
anaphylaxis
• Adrenaline 1:1,000 (consider adrenaline injector availability for initial administration by nursing staff)
• 1mL syringes; 22-25 G needles (25mm length) are recommended for IM injections for all ages
• Exceptions are preterm/very small infants (23-25G needle length 16mm) and very large adults (22-25G and needle
length up to 38mm).
• Oxygen, airway equipment, including rebreather oxygen masks, nebulizer masks and suction.
• Defibrillator
• Manual blood pressure cuff
• IV access equipment (including large bore cannula)
• At least 3 liters 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.
Additional measures - IV adrenaline infusion in clinical
setting:
If there is an inadequate response after 2-3 adrenaline doses, or
deterioration of the patient, start IV adrenaline infusion, given by
staff trained in its use or in liaison with an emergency 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
specialized training as they
may increase the risk of
cardiac arrhythmia.
Additional measures
to consider if IV
adrenaline infusion
is ineffective
• Nebulized adrenaline (5mL e.g., 5 ampoules of 1:1000).
• Consider need for advanced airway management if skills and
equipment are available
For upper airway obstruction
• 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.
For persistent hypotension/ shock
• Bronchodilators: Salbutamol 8-12 puffs of 100microgram
(spacer) or 5mg (nebuliser).
• Corticosteroids: Oral prednisolone 1 mg/kg (maximum of 50
mg) or intravenous hydrocortisone 5 mg/kg (maximum of 200
mg).
For persistent wheeze
Important
Notes
Bronchodilators must not be used as first line medication
for anaphylaxis as they do not prevent or relieve upper
airway obstruction, hypotension or shock.
Steroids must not be used as a first line medication in
place of adrenaline as the benefit of corticosteroids in
anaphylaxis is unproven.
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.
Using an autoinjector
Many people at risk of anaphylaxis carry an
autoinjector.
• This device is a combined syringe and concealed needle that
injects a single dose of medication when pressed against the
thigh.
• Replace epinephrine before its expiration date, or it might not
work properly.
Using an autoinjector immediately can keep
anaphylaxis from worsening and could save your life.
• Be sure you know how to use the autoinjector. Also, make sure
the people closest to you know how to use it.
Thank you

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Emergency treatment of anaphylaxis

  • 2. Definition of Anaphylaxis 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.
  • 3. Anaphylaxis is characterized by Rapidly developing, life threatening, Airway and/or Breathing and or Circulation problems Usually with skin and/or mucosal changes
  • 4. Who gets anaphylaxis? Mainly children and young adults Commoner in females Incidence seems to be increasing
  • 5. Examples of some cause's anaphylaxis Stings Bee Wasp Scorpions Snakes Nuts Peanut Walnut Almond Food milk Fish Chickpea Crustacean banana snail Antibiotics Penicillin Cephalosporin Amphotericin Ciprofloxacin Vancomycin Anesthetic drugs suxamethonium vecuronium Atracurium Other drugs NSAID ACEI Gelatins Protamine vitamin K, diamox, pethidine, local anaesthetii Streptokinase Contrast media iodinated technetium fluorescine Others Latex hair dye
  • 6. Signs and symptoms of Allergic Reactions Mild or Moderate reactions (may not always occur before anaphylaxis): • 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
  • 7. Signs and symptoms of Allergic Reactions Anaphylaxis – Indicated by any one of the following signs: • Difficult or noisy breathing • Swelling of tongue • Swelling or tightness in throat • Difficulty talking or hoarse voice • Wheeze or persistent cough - unlike the cough in asthma, the onset of coughing during anaphylaxis is usually sudden • Persistent dizziness or collapse • Pale and floppy (young children) • Abdominal pain, vomiting - for insect stings or injected drug (medication) allergy.
  • 8.
  • 9. Anaphylaxis is highly likely when any one of the following two criteria are fulfilled: • Acute onset of an illness (minutes to several hours) with simultaneous involvement of the skin, mucosal tissue, or both (e.g., generalized hives, pruritus or flushing, swollen lips-tongue-uvula), and at least one of the following: • Respiratory compromise (e.g., dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia). • Reduced blood pressure or associated symptoms of end-organ dysfunction (e.g., hypotonia [collapse], syncope, incontinence). • Severe gastrointestinal symptoms (e.g., severe crampy abdominal pain, repetitive vomiting), especially after exposure to non-food allergens. Criteria 1. • Acute onset of hypotension or bronchospasm or laryngeal involvement after exposure to a known or highly probable allergen for that patient (minutes to several hours), even in the absence of typical skin involvement. Criteria 2.
  • 10. Immediate actions for anaphylaxis Remove allergen (if still present), stay with person, call for assistance and locate adrenaline injector. LAY PERSON FLAT - do NOT allow them to stand or walk GIVE ADRENALINE INJECTOR Give oxygen (if available). Phone ambulance Phone family/emergency contact. Further adrenaline may be given if no response after 5 minutes Transfer person to hospital for at least 4 hours of observation. Commence CPR at any time if person is unresponsive and not breathing normally.
  • 11. LAY PERSON FLAT - Do NOT allow them to stand or walk LAY PERSON FLAT - do NOT allow them to stand or walk If unconscious or pregnant, place in recovery position - on left side if pregnant, as shown below If breathing is difficult allow them to sit with legs outstretched Hold young children flat, not upright
  • 12. GIVE ADRENALINE INJECTOR Give intramuscular injection (IMI) adrenaline into outer mid-thigh without delay using an adrenaline autoinjector if available OR adrenaline ampoule/syringe. Adrenaline (epinephrine) is the first line treatment for anaphylaxis 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.
  • 13. Anaphylaxis triggers and reaction times The most common triggers of anaphylaxis are foods, insect stings and drugs (medications). • Less common triggers include latex, tick bites, exercise (with or without food), cold temperatures, radiocontrast agents, immunization (rare) and unidentified (idiopathic). Anaphylaxis usually occurs within one to two hours of ingestion in food allergy. • The onset of a reaction may occur rapidly (within 30 minutes) or may be delayed several hours (for example, in mammalian meat allergy and food dependent exercise induced anaphylaxis, where symptoms usually occur during exercise). Anaphylaxis to stings and injected medications (including radiocontrast agents and vaccines) usually occurs within 5-30 minutes but may be delayed. • Anaphylaxis to oral medications can also occur but is less common than to injected medications
  • 14. Management of Anaphylaxis in Pregnancy Management of anaphylaxis in pregnant women is the same as for non-pregnant women. Adrenaline should be the first line treatment for anaphylaxis in pregnancy, and prompt administration of adrenaline (1:1,000 IM adrenaline 0.01mg per kg up to 0.5mg per dose) should not be withheld due to a fear of causing reduced placental perfusion. The left lateral position is recommended
  • 15. Management of Anaphylaxis in Infants Whilst 10-20kg was the previous weight guide for a 150-microgram adrenaline injector device, a 150- microgram device may now also be prescribed for an infant weighting 7.5-10 kg by health professionals who have made a considered assessment. Use of a 150-microgram device for treatment of infants weighing 7.5 kg 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 2-3 doses of adrenaline, and this can resolve without further doses. More than 2-3 doses of adrenaline in infants may cause hypertension and tachycardia, which is often misinterpreted as an ongoing cardiovascular compromise or anaphylaxis. Blood pressure measurement can provide a guide to the effectiveness of treatment, to check if additional doses of adrenaline are required
  • 16. Intra-muscular Adrenaline Age Dose Adult or child more than 12 years 500 micrograms IM (0.5 mL) Child 6 ‐12 years 300 micrograms IM (0.3 mL) Child 6 months ‐ 6 years 150 micrograms IM (0.15 mL) Child less than 6 months 150 micrograms IM (0.15 mL)
  • 17. Fluids Once IV access established 500 – 1000 mL IV bolus in adult 20 mL/Kg IV bolus in child Monitor response - give further bolus as necessary Colloid or crystalloid (0.9% sodium chloride or Hartmann’s) Avoid colloid, if colloid thought to have caused reaction
  • 18. Steroids and anti-histamines(Hydrocortisone and chlorphenamine) Second line drugs Use after initial resuscitation started Do not delay initial ABC treatments Can wait until transfer to hospital
  • 19. Positioning of patients with anaphylaxis - 1 Fatality can occur within minutes if a patient stands, walks or sits suddenly. Patients must NOT walk or stand, even if they appear to have recovered. A wheelchair, stretcher or trolley bed should be used to transfer the patient: • To the ambulance and from the ambulance to the treatment room bed. • From the treatment room bed to and from the toilet. Laying the patient flat (see image above) will improve venous blood return to the heart. • By contrast, placing the patient in an upright position (standing or walking) can impair blood returning to the heart, resulting in insufficient blood for the heart to circulate and low blood pressure. • This means that patients should not stand or walk, and this includes not being showered. If unconscious, vomiting or pregnant, lay the patient on their side in the recovery position.
  • 20. Positioning of patients with anaphylaxis - 2 The left lateral (recovery) position is recommended for patients who are pregnant. •This reduces the risk of compression of the inferior vena cava by the pregnant uterus and improves venous return to the heart. Patients with mostly respiratory symptoms may prefer to sit with their legs outstretched in front of them •which may help support breathing and improve ventilation. •They should not sit on a chair as this may trigger hypotension. •Monitor closely and immediately lay the patient flat if there is any alteration in conscious state or drop in blood pressure. The correct way to hold an infant or young child is flat not upright nor over a shoulder. Do not allow the patient to stand or walk •until they are hemodynamically stable, which is usually a minimum of 1 hour after 1 dose of adrenaline and 4 hours if more than 1 dose of adrenaline.
  • 21. Equipment required for acute management of anaphylaxis • Adrenaline 1:1,000 (consider adrenaline injector availability for initial administration by nursing staff) • 1mL syringes; 22-25 G needles (25mm length) are recommended for IM injections for all ages • Exceptions are preterm/very small infants (23-25G needle length 16mm) and very large adults (22-25G and needle length up to 38mm). • Oxygen, airway equipment, including rebreather oxygen masks, nebulizer masks and suction. • Defibrillator • Manual blood pressure cuff • IV access equipment (including large bore cannula) • At least 3 liters 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.
  • 22. Additional measures - IV adrenaline infusion in clinical setting: If there is an inadequate response after 2-3 adrenaline doses, or deterioration of the patient, start IV adrenaline infusion, given by staff trained in its use or in liaison with an emergency specialist. IV adrenaline infusions should be used with a dedicated line, infusion pump and anti-reflux valves wherever possible.
  • 23. CAUTION: • IV boluses of adrenaline are NOT recommended without specialized training as they may increase the risk of cardiac arrhythmia.
  • 24. Additional measures to consider if IV adrenaline infusion is ineffective • Nebulized adrenaline (5mL e.g., 5 ampoules of 1:1000). • Consider need for advanced airway management if skills and equipment are available For upper airway obstruction • 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. For persistent hypotension/ shock • Bronchodilators: Salbutamol 8-12 puffs of 100microgram (spacer) or 5mg (nebuliser). • Corticosteroids: Oral prednisolone 1 mg/kg (maximum of 50 mg) or intravenous hydrocortisone 5 mg/kg (maximum of 200 mg). For persistent wheeze
  • 25. Important Notes Bronchodilators must not be used as first line medication for anaphylaxis as they do not prevent or relieve upper airway obstruction, hypotension or shock. Steroids must not be used as a first line medication in place of adrenaline as the benefit of corticosteroids in anaphylaxis is unproven. 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.
  • 26.
  • 27.
  • 28.
  • 29. Using an autoinjector Many people at risk of anaphylaxis carry an autoinjector. • This device is a combined syringe and concealed needle that injects a single dose of medication when pressed against the thigh. • Replace epinephrine before its expiration date, or it might not work properly. Using an autoinjector immediately can keep anaphylaxis from worsening and could save your life. • Be sure you know how to use the autoinjector. Also, make sure the people closest to you know how to use it.
  • 30.