# Anaphylaxis Management

## Overview

This module describes how to recognise and manage anaphylaxis.

## Indications

Anaphylaxis presents with

1. Symptoms
   Symptoms

   Respiratory symptoms include stridor, wheeze, voice change, hypoxemia, or distress. Cardiovascular symptoms include shock, hypotension, syncopy, or collapse.

   related to respiratory difficulty and/or cardiovascular dysfunction after exposure to a known allergen

2. Symptoms
   Symptoms

   Skin/mucosal symptoms include rash/swelling. Gastrointestinal symptoms include repeated vomiting or abdominal pain.

   related to skin/mucosal involvement, combined with respiratory difficulty, cardiovascular dysfunction and/or severe gastrointestinal symptoms

## Contraindications

1. Pulseless patients should be treated according to cardiac arrest algorithms

## Patient information and consent

Some patients may be haemodynamically unstable and unable to understand; communicate with family members if present.

### How do I explain this procedure?

“You are having a very serious allergic reaction called anaphylaxis. Your body is overreacting to a harmless substance, such as bee venom or peanuts, which we call an allergen. Your immune cells react to it as though it is a threat, releasing a flood of chemicals such as histamine. This flooding can cause you to go into shock, lowering your blood pressure and/or narrowing your airways. I’m going to give you emergency medication to counteract the reaction.”

### What can my patient expect?

“I’m going to give you an injection, some medication through a drip, and I might give you oxygen or medication through a mask. We will also keep you connected to monitors to show how you are doing. We will need to keep you in hospital for at least 4-6 hours to prevent flare-ups.”

### What is my patient’s role?

“Although anaphylaxis is frightening, try to stay calm and follow my instructions. Tell me how you’re doing and if you’re feeling better or worse. When it’s time to discharge you, we need to talk about a home management plan for your allergies.”

## Preparation

Anaphylaxis management is an emergency procedure. Always:

1. Know where defibrillators, transcutaneous pads, and red trolleys are kept. Know the relevant staff and keep your seniors’ contact details close at hand.

2. Familiarise yourself with the defibrillators in your work area. Check that they are maintained regularly and have pads and the correct connections.

3. Keep unstable patients in resuscitation bays with continuous monitoring.

## Site & Positioning

The patient should be supine or semi-recumbent on a firm surface. If hypotensive, raise the legs. Ensure space behind the head of the bed for staff to administer rescue breaths if the patient deteriorates.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Hazards
   Hazards

   Look for any body fluid spills, trip hazards etc. and put on gloves. Follow Transmission-Based Precautions as required.

2. Hello

   1. Tap the patient’s shoulder and call hello. Look for a response.
   2. Feel and listen for breathing with your ear close to the patient’s mouth. Look for chest rise. Don’t take more than 10 seconds.
   3. Feel for a pulse on the neck. Don’t take more than 10 seconds. Identify tachycardia.
3. Help
   Help

   Call for assistance from other healthcare workers. Get someone to bring a defibrillator. Get someone more senior than yourself involved.

4. Airway: open and maintain if necessary. Consider early intubation if compromised.

5. Breathing: attach sats probe. Administer oxygen/ventilation if necessary.

6. Circulation: attach BP cuff and cardiac monitoring.

7. Give

   adrenaline
   adrenaline

   0.01mg/kg of 1:1000 dilution IM (Max 0,5ml IM).

   Repeat every 5-15 minutes if no improvement.

8. Establish two large-bore IV lines. Administer

   Ringers Lactate.
   Ringers Lactate.

   Rapid infusion of 20ml/kg (max 1-2 litres)
   Repeat IV infusion as necessary

   Give adjunctive treatment as required, which may include the following drugs:

9. Adrenaline infusion
   Adrenaline infusion

   0,1 - 1 ug/kg/min

   ONLY if unresponsive to IM adrenaline & fluids

10. Promethazine
    Promethazine

    2-6 yrs: 6,25 mg IM or slow IV

    6-12 yrs: 12,5 mg IM or slow IV

    >12 yrs: 25 mg IM or slow IV

    Avoid if <2yrs old and low BP

11. Cimetidine
    Cimetidine

    5mg/kg (max 300 mg) diluted in 20 ml over 2 min.
    Give IM or slow IV.

12. Hydrocortisone
    Hydrocortisone

    <1 yr: 25 mg
    1-6 yrs: 50 mg
    6-12 yrs: 100 mg
    >12 yrs: 200 mg

    Give IM or slow IV

13. Nebulised salbutamol & ipratropium
    Nebulised salbutamol & ipratropium

    Salbutamol 5 mg with Ipratropium 0,5 mg.
    Repeat every 15-20 mins if severe bronchospasm.

14. Glucagon
    Glucagon

    20 ug/kg (max 1-2 mg)
    IM or slow IV every 5 mins if unresponsive to adrenaline (look out for vomiting and hyperglycaemia)

## Troubleshooting

When can I discharge this patient?

Keep in casualty 4-6 hours after resuscitation and discharge only if clinically stable.

## Risks

1. Poor response & death

2. Adverse reaction to medication

## References

1. Resuscitation Council of Southern Africa. Emergency Management of Adult and Child Anaphylaxis. 2021.