Download Ampoule

 Anaphylaxis and severe allergic reaction
Recommend
 Rapid cardiovascular assessment including pulse, BP, and capillary refill is essential to guide treatment.
Aim for Systolic BP above 90 – 100 mm Hg in adults [1]
 The injection of Adrenaline is first line drug treatment in life threatening anaphylaxis [2]
 A severe reaction usually occurs within 20 minutes of exposure [2]
 People with diagnosed allergies, e.g. nuts, bees, medication, should avoid trigger agents and have a
readily accessible anaphylaxis action plan, medication and medical alert device [2]
Background
 Anaphylaxis is the most severe form of allergic reaction. It can be caused by many agents but the most
common ones are:
 food (especially nuts, eggs and seafood)

drugs (eg penicillin)

venom of stinging animals (eg bees, wasps or ants) [2]
Related topics:
DRABC resuscitation / the collapsed patient, page 35
Cardiac arrest, page 40
O2 Delivery systems, page 39
 Mild and moderate allergic reaction, page 224
 Bites and stings, page 201
 Acute asthma, page 70
1.
May present with: [1]

Hypoxia and cyanosis (Sp O2 92% or less)
Swelling of the lips and / or tongue (angioneurotic oedema)
Sinus
rhythm






2.
Severe respiratory distress and wheezing
Hypotension (systolic BP less than 90 mm Hg in adults)
Generalised rash
Collapse
Altered level of consciousness [2]
Immediate management:

Consult MO as soon as circumstances allow

If you are giving a drug injection, or an infusion of a drug or blood product, stop administration
immediately

Take Pulse, BP, Respirations, Glasgow coma score and capillary refill

Manage airway, breathing and circulation - give high flow oxygen (see O2 Delivery systems) to
maintain O2 saturation >94%. If >94% not maintained consult MO

Adrenaline indicated
 A – airway compromised – angioneurotic oedema (swollen lips, face mouth)
 B – severe bronchospasm present
 C – circulatory collapse – anaphylactic shock (if systolic BP less than 90 mm Hg in adults /
patient has collapsed / has altered level of consciousness AND has a history of exposure to
irritant give IMI Adrenaline)

Promethazine indicated
 diffuse urticarial skin reaction (generalised itchy red rash)

Insert IV cannula

Posture appropriate to presenting clinical condition

If hypotension (systolic BP below 90 mm Hg) / shocked, give a bolus of IV Normal Saline up to 20
mL/kg [1]

If airway obstruction, see Acute upper airway obstruction and choking and consider need for Needle
Cricothyroidotomy
Schedule
3
Adrenaline
Authorised Indigenous Health Workers may proceed for first dose
Nurse Practitioners may proceed
Route of
Form
Strength
administration
DTP
IHW / NP
Recommended Dosage /
Duration
Infant
Child
Ampoule
Ampoule
1:10,000 (1
mg/10 mL)
or
can dilute
1mL of
1:1000 up to
10 mL using
Normal
Saline
1:1,000
(1 mg/1 mL)
IMI
Lateral thigh
Not in buttock
In 1 mL syringe (not
insulin syringe) with 23g
needle
IMI
Lateral thigh
Adult
Ampoule
0.01 mg/kg body weight
For accurate dosing:
3-5 mths 0.05 mg
(0.5 mL of 1:10,000)
6-11 mths 0.075 mg
(0.75 mL of 1:10,000)
1-2 yrs 0.1 mg
(1 mL of 1:10,000)
Repeat adrenaline every 3-5
minutes as determined by BP
and bronchospasm
0.01 mg/kg body weight
2-4 yrs 0.2 mg
(0.2 mL of 1:1,000)
Not in buttock
4-5 yrs 0.25 mg
(0.25 mL of 1:1,000)
In 1 mL syringe (not
insulin syringe) with 23g
needle
6-12 yrs 0.3 mg
(0.3 mL of 1:1,000)
1:1,000 (1
mg/1 mL)
12 yrs+ (as adult) 0.3 - 0.5 mg
(0.3 - 0.5 mL of 1:1,000)
Repeat adrenaline every 3-5
minutes as determined by BP
and bronchospasm
0.3 - 0.5 mg
(0.3-0.5 mL of 1:1,000)
IMI
Lateral thigh
Not in buttock
Repeat adrenaline every 3-5
In 1 mL syringe (not
minutes as determined by BP
insulin syringe) with 23g
and bronchospasm
needle
Provide Consumer Medicine Information if available: Adrenaline may cause restlessness, anxiety,
headache and palpitations in conscious patients
Management of Associated Emergency: Consult MO
3.
Clinical assessment:

Obtain emergency patient history (from relatives or friends if present)

circumstances leading up to severe allergic reaction or anaphylaxis and potential contact with
irritants – plant, animal, marine creatures,

known allergies of any kind

previous episodes? treatment used? was it effective?

current medications

Perform standard clinical observations + O2 saturation and conscious state, see Glasgow coma
score or AVPU

Perform physical examination

inspect, auscultate, palpate and document reaction to all body systems affected, eg skin, face,
throat, breathing, heart rate, neurological state
4.
Management:

Consult MO who may order in addition to Adrenaline:

Salbutamol nebulised with oxygen, see Acute Asthma

Hydrocortisone IV stat (2-4 mg/kg, max 200 mg)

If patient on beta blocker such as metoprolol or atenolol, they may be resistant to adrenaline and
may need glucagon IV (over 5 years 1mg, child under 5 years 0.5 mg repeat at 5-10 minutes for 3
doses then infuse at 1-5mg/hour if needed ) on MO order
Schedule
4
Promethazine
Authorised Indigenous Health Workers must consult MO
Rural and Isolated Practice Endorsed Registered Nurses may proceed
Nurse Practitioners may proceed
Form
Strength
Route of Administration
DTP
IHW / RIN / NP
Recommended Dosage
Duration
Ampoule
25mg/mL
IMI
or
IV slowly (RN only)
Provide Consumer Medicine Information if available
Management of Associated Emergency:
Adult –up to 25mgs IVI slowly
OR 25mg IMI
Child –(0.5mg/kg, max 25mg)
stat
5.
Follow up:
 All cases of severe anaphylaxis must rest in the clinic for 8 hours to make sure that improvement
continues, and to ensure there is no deterioration.
 BP and respiratory rate and conscious state should be checked every 15 minutes for 2 hours then
hourly
 After resolution of all symptoms and signs observe for 4 hours or until daylight hours
 Review the next day and if no symptoms or findings review at next MO clinic
 It is important to find out exactly what happened before the attack (food or drug taken, insect bite
etc.). Make sure this is documented in the notes, as well as what treatment was required
 Patient must avoid re-exposure
 Document in medical record “ALLERGIC TO …..”
 If the adverse event follows an immunisation / medication notify the Adverse Drug Reaction Advisory
Committee (ADRAC) by completing the ADRAC form or by telephone.
 Patients with severe reactions should be instructed in the use of, and carry a Adrenaline for selfinjection and / or oral Promethazine 25mg tablets. Initial dose as per MO instructions
 Information on action plans for the prehospital management of anaphylactic reactions, can be found
at the website for the Australasian Society of Clinical Immunology and Allergy (ASCIA):
http://www.allergy.org.au/content/view/10/3/. [1]
 Some patients may benefit from allergy testing and desensitisation
6.
Referral / Consultation:
 Consult MO on all occasions