Anaphylaxis | Acute Management | ABCDE
geekymedics.com/anaphylaxis/
Dr Grace Farrington June 24, 2012
Anaphylaxis is a life-threatening condition that you need to be able to recognise and manage in an
acute setting. This guide gives an overview of the recognition and immediate management of
anaphylaxis (using an ABCDE approach). You can check out our overview of the ABCDE approach
here.
This guide has been created to assist students in preparing for emergencysimulation sessions as
part of their training, it is not intended to be relied upon for patient care .
Clinical features of anaphylaxis
Anaphylaxis can present in a wide variety of ways, making early diagnosis sometimes difficult.
The resuscitation council (UK) have devised the following set of criteria that if met
suggest anaphylaxis is likely:
Sudden onset and rapid progression of symptoms (most reactions occur over several minutes)
Life-threatening Airway and/or Breathing and/or Circulation problems
Skin and/or mucosal changes (flushing, urticaria, angioedema)
The exposure to a known allergen also helps support the diagnosis of anaphylaxis.
Other key points:
Skin or mucosal changes alone are not a sign of an anaphylactic reaction
Skin and mucosal changes can be subtle or absent in up to 20% of reactions
There can also be gastrointestinal symptoms (e.g. vomiting, abdominal pain, incontinence)
Tips before you begin
Treat all problems as you find them
Re-assess regularly and after every intervention to see if your management is effective
Make use of the team around you todelegate tasks where appropriate – is another clinical
member of staff available to help you?
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All critically unwell patients should have continuous monitoring equipment attached for
accurate observations, blood pressure and if necessary ECG readings – this will save you time!
Communicate how often would you like these readings to be relayed to you
If you need senior input for your patient,call for help early using an appropriate SBARR
handover structure (check out the guide here)
Review results e.g. laboratory investigations as they become available
Make use of medical school/hospital guidelines and algorithms in managing specific
situations such as anaphylaxis
Any medications or fluids will need to beprescribed
Your assessment and management should be documented in the notes
Initial steps
You are likely to see this patient after a brief handover from another member of staff.
Introduction
Introduce yourself to whoever has requested a review of the patient.
Inspection
Perform a quick general inspection of the patient to get a sense of how unwell they
are:
Check consciousness level using AVPU
How do they look?
How is their breathing?
Are there obvious skin/mucosal changes?
What is around the bedside? (look for IV lines, monitoring equipment etc).
Interaction
Introduce yourself to the patient
Ask the patient how they are feeling – patients’ with anaphylaxis often experience an initial
sense of anxiety that progresses rapidly to them feeling and looking very unwell
Preparation
Make sure the patient’s notes, observation chart and prescription chart are on hand
Ask for another clinical member of staff to assist you if possible
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per
resuscitation guidelines.
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Airway
If anaphylaxis is suspected, the immediate removal of potential anaphylactoid triggers such as
IV antibiotics should be performed. In addition, you should ask another member of staff to source
adrenaline (1:1000) to allow this to be administered quickly once you have confirmed the diagnosis.
Assessment
Assess the patient’s ability to speak, listen to the patient’s breathing for added sounds
and inspect the mouth:
Airway swelling may be present (pharyngeal/laryngeal oedema) causing the patient to have
difficulty speaking (hoarse voice), breathing, and swallowing (the patient may complain of
feeling like their airway is closing up)
Stridor (a high pitched inspiratory noise) indicates upper airway obstruction
Angioedema (tongue and lip swelling) may be present
Intervention
If any of the above features are present you should immediately put out a crash call as you require
urgent anaesthetic input to secure the airway. In the meantime, you can perform some basic airway
manoeuvres to help maintain the airway.
Maintaining the airway whilst awaiting senior input
1. Perform head tilt, chin lift manoeuvre
2. If noisy breathing persists try a jaw thrust
3. If airway still appears compromised use an airway adjunct:
Insert an oropharyngeal airway (Guedel) only if unconscious (as otherwise may
gag/aspirate)
Alternatively, use a nasopharyngeal airway (better tolerated if the patient is partially
conscious)
Re-assess after any intervention.
Breathing
Assessment
Observations
Respiratory rate:
Tachypnoea is concerning and suggestive of significant respiratory compromise.
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A falling or normal respiratory rate in the context of hypoxia is a sign of impending respiratory
arrest and need for urgent critical care review.
Oxygen saturation monitoring – aim for 94-98%
Examination
Auscultate both lungs:
Assess air entry – reduced air entry suggests significant airway compromise and need for
critical care input
Note any wheezing – wheeze becomes less apparent with increasing airway obstruction
Cyanosis may be present in severe cases and is a late sign.
Investigations
Arterial blood gas
An arterial blood gas may be useful in quantifying the degree of hypoxia, however, it should not
delay emergency management of anaphylaxis.
Chest x-ray
A portable chest x-ray may be useful in ruling out other respiratory diagnoses if shortness of breath
is the primary issue (e.g. pneumothorax/pneumonia/pulmonary oedema). Chest x-ray should not
delay emergency management of anaphylaxis and should only be performed if the diagnosis is in
doubt.
Intervention
Administer oxygen
Sit the patient upright if hypoxia is the primary issue, however, if the patient is hypotensive this
can result in loss of consciousness and therefore may need to be avoided.
Give high-flow oxygen (15 litres) via a non-rebreathe mask.
In practice, high flow oxygen should be administered as soon as it is available whilst you
continue your assessment.
Maintain oxygen saturations between 94–98%.
Administer nebulised bronchodilators
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Give nebulised bronchodilators if there is suspicion of bronchospasm (e.g. wheezing):
Salbutamol – doses vary – in severe cases, continuous nebulisation is advised
Ipratropium bromide – 500mcg nebulised
Re-assess after any intervention.
Circulation
Assessment
Observations
Pulse:
Tachycardia is common due to hypovolaemic shock
Bradycardia is a late sign, often preceding cardiac arrest
Blood pressure:
Haemodynamic shock occurs secondary to fluid compartment shifts resulting in significant
hypotension
The patient may complain of feeling faint or lose consciousness if hypotension is severe
Examination
Inspection – patient may be pale/clammy
Palpation:
Peripherally cool due to hypotension
Pulse – weak/thready due to hypotension
Prolonged capillary refill time (normally <2 seconds)
Investigations
Take blood samples (ideally during cannulation) – FBC / U&E / LFT / Clotting / CRP / Mast cell
tryptase
Record an ECG – this should not delay any other treatment however an ECG should be performed
at some point as anaphylaxis can cause myocardial ischaemia (even in patients with normal coronary
arteries). ²
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Intervention
Administer intramuscular (IM) adrenaline
Administer IM adrenaline (1:1000) immediately: ²
Adult dose – 0.50 mL of 1:1000 adrenaline
Repeat administration every 5 minutes if patient remains in haemodynamic shock (max 5mL)
The recommended site for injection is the anterolateral aspect of the middle third of the thigh
If the patient remains shocked after 2 doses then an adrenaline infusion may be needed (this
will be a consultant/critical care led decision).
Administer intravenous (IV) fluids and medication
Gain IV access – large bore cannulas required for rapid fluid resuscitation
Intravenous fluids (STAT) – NaCl 0.9% / Hartmann’s solution – titrate to fluids depending on
haemodynamic stability – large volumes may be required (an initial bolus of 500-1000mls is
recommended) 2
Chlorphenamine – 10mg IV (adult) – stabilises mast cells – reducing histamine release ¹ (give
after fluid resuscitation – DO NOT delay fluid resuscitation)
Hydrocortisone – 200mg IV (adult) – prevents rebound of inflammation over next few hours
¹ (give after fluid resuscitation – DO NOT delay fluid resuscitation)
If the patient remains hypotensive, they will need admission to critical care for inotropic support.
If the patient has a cardiac arrest, commence CPR as per advanced life support guidelines.
Re-assess after any intervention.
Disability
Assess level of consciousness – AVPU/GCS:
The above Airway, Breathing and Circulation problems can all alter the patient’s neurological
status because of decreased cerebral perfusion, causing the patient to be confused and
agitated.
Loss of consciousness can occur due to hypotension and severe hypoxia.
A falling level of consciousnesses is a sign of serious deterioration and will require critical care input
for further support (e.g. intubation).
Re-assess after any intervention.
Exposure
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Allergens – identify and remove any potential anaphylactoid triggers
Expose the patient’s body looking for any skin or mucosal changes (often the first
feature present in anaphylaxis):
Erythema – patchy or generalised red rash
Urticaria:
Can appear anywhere on the body (weals may be pale, pink or red and may look like
nettle stings)
They can be different shapes/sizes and are often surrounded by a red flare
They are usually itchy
Angioedema:
Similar to urticaria but involves the swelling of deeper tissues
Most commonly the areas affected include the eyelids, lips, mouth and throat
Re-assess after any intervention.
Reassess ABCDE
It is essential to continually reassess ABCDE and treat issues as you encounter them. This allows
continual reassessment of the response to treatment and early recognition of deterioration.
If anaphylaxis is suspected then critical care should be contacted immediately as their support will
be needed.
Next steps
Well done! You’ve stabilised the patient and they’re doing much better. Just a few more things to
do…
Take a history
Take a more detailed history of what has happened and how the patient has been. Involve staff or
family members as appropriate.
Check out our history taking guides here
Review
Review the patient’s notes, observations, fluid charts, and any investigation findings. Double check
the medications you have just prescribed, and any routine medications the patient is taking.
Document
Document your ABCDE assessment clearly, including examination, observations, investigations,
interventions, and patient response/changing condition. Write down any pertinent details from your
history-taking. If you suspect a particular substance caused the anaphylactic reaction this should be
documented clearly in the patient’s allergy status on all drug charts and in the notes.
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See documentation guide
Discuss
If a senior doctor hasn’t already been involved, it is important to contact them and make them aware
of the unwell patient. As a junior doctor, it would be appropriate to give an SBARR handover
outlining your assessment and actions, and to discuss the following:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Should they be referred for a review by a speciality doctor?
Should any changes be implemented to the management of any underlying conditions?
Handover
The next team of doctors on shift should be made aware of any patient in their department who has
become acutely unwell.
References
1. Australian Prescriber – Emergency management of Anaphylaxis – [LINK]
2. Resuscitation Council (UK) – Emergency treatment of anaphylactic reactions – [LINK]
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