ASCIA Acute Management of Anaphylaxis Guidelines 2015

Acute management of anaphylaxis guidelines
These guidelines are intended for primary care physicians and nurses providing
first responder emergency care.
Immediate action
1. Remove allergen (if still present).
2. Call for assistance.
3. Lay patient flat. Do not allow them to stand or walk. If breathing is difficult, allow them to sit.
4. Give INTRAMUSCULAR INJECTION (IMI) OF ADRENALINE without delay using an adrenaline
autoinjector if available OR adrenaline ampoules and syringe.
• 1:1000 IMI into outer mid-thigh
• 0.01mg per kg up to 0.5mg per dose
• Repeat every 5 minutes as needed.
• If multiple doses required or a severe reaction consider adrenaline infusion if skills and equipment
available.
5. Call ambulance to transport patient if not already in a hospital setting.
If required at any time, commence cardiopulmonary resuscitation.
Supportive management (when skills and equipment 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.
Disclaimer: ASCIA information is reviewed by ASCIA members and represents the available published literature at the
time of review. The content of this document is not intended to replace professional medical advice and any questions
regarding a medical diagnosis or treatment should be directed to a medical practitioner. © ASCIA 2015.
ASCIA Guidelines: Acute Management of Anaphylaxis 2015
Additional measures - IV adrenaline infusion in clinical setting
If inadequate response or deterioration start IV adrenaline infusion, given by staff who are trained in its use or
in liaison with an emergency/critical care specialist.
• Mix 1 mL of 1:1000 adrenaline in 1000 mL of normal saline.
• Start infusion at 5 mL/kg/hour (~0.1 µg/kg/minute).
• Titrate rate up or down according to response.
• Monitor continuously.
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.
Additional measures to consider if IV adrenaline infusion is ineffective
For Upper airway  Nebulised adrenaline (5mL i.e. 5 ampoules of 1:1000).

obstruction  Consider intubation if skills and equipment are available
For persistent • Give normal saline (maximum of 50mL/kg in first 30 minutes).
hypotension/shock • Glucagon (1-2mg IMI or IV as starting dose) especially for patients on beta
blockers or has heart failure.
• In adults, selective vasoconstrictors metaraminol (2-10mg) or vasopressin (10-
40 units) only after advice from an emergency medicine/critical care specialist.
For persistent Bronchodilators:
wheeze • 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.
2
Corticosteroids:
• The benefit of corticosteroids in anaphylaxis is unproven.
• It is common practice to prescribe a 2-day course of oral steroids (e.g. oral prednisolone 1 mg/kg,
maximum 50 mg daily) to hopefully reduce the risk of symptom recurrence after a severe reaction or a
reaction with marked or persistent wheeze.
Observe patient for at least 4 hours after last dose of adrenaline
Relapse, protracted and/or biphasic reactions may occur.

• Patients will 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.
The true incidence of biphasic reactions is estimated to occur following 3-20% of anaphylactic reactions.
Follow up treatment
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.
• Train the patient in autoinjector use and give them an ASCIA Action Plan for Anaphylaxis (see ASCIA
website www.allergy.org.au).
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 6-
8 hours preceding the onset of symptoms. The ASCIA anaphylaxis event record can be used to collect this
information (www.allergy.org.au/health-professionals/anaphylaxis-resources/anaphylaxis-event-record).
Preparation: Equipment required for acute management of anaphylaxis
The equipment on your emergency trolley should include:

• Adrenaline 1:1000 (consider adrenaline autoinjector availability 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)
• Pressure sleeve (aids rapid infusion of fluid under pressure)
• At least 3 litres of normal saline
3
A wall chart has been developed for use by health professionals and published in Australian Prescriber
www.australianprescriber.com (August 2011).
© ASCIA 2015
The Australasian Society of Clinical Immunology and Allergy (ASCIA) is the peak professional body of clinical immunology
and allergy specialist in Australia and New Zealand.
Website: www.allergy.org.au
Email: [email protected]
Postal address: PO Box 450 Balgowlah NSW Australia 2093
Disclaimer
This document has been developed and peer reviewed by ASCIA members and is based on expert opinion and the
available published literature at the time of review. Information contained in this document is not intended to replace
medical advice and any questions regarding a medical diagnosis or treatment should be directed to a medical practitioner.
The development of this document is not funded by any commercial sources and is not influenced by commercial
organisations.

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Acute management of anaphylaxis guidelines

5. Call ambulance to transport patient if not already in a hospital setting.

If required at any time, commence cardiopulmonary resuscitation.

Supportive management (when skills and equipment available)

• Check pulse, blood pressure, ECG, pulse oximetry, conscious state.

Additional measures - IV adrenaline infusion in clinical setting

Additional measures to consider if IV adrenaline infusion is ineffective

For Upper airway  Nebulised adrenaline (5mL i.e. 5 ampoules of 1:1000).

Antihistamines and corticosteroids

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

Relapse, protracted and/or biphasic reactions may occur.

Allergy specialist referral

Preparation: Equipment required for acute management of anaphylaxis

The equipment on your emergency trolley should include:

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