NAME OF DOCUMENT Management of mild allergic reactions …...NAME OF DOCUMENT Anaphylaxis – Management of mild allergic reactions and moderate to life-threatening anaphylaxis in

NAME OF DOCUMENT Anaphylaxis – Management of mild allergic reactions and moderate to life-threatening anaphylaxis in the Adult

TYPE OF DOCUMENT Guideline (GL)

DOCUMENT NUMBER ISLHD CLIN GL 22

DATE OF PUBLICATION July 2019

RISK RATING Medium

LEVEL OF EVIDENCE Australasian Society of Clinical Immunology and Allergy (ASCIA)

Australian & New Zealand Anaesthetic Allergy Group

Australian & New Zealand Council of Resuscitation

REVIEW DATE June 2020

FORMER REFERENCE(S) None

EXECUTIVE SPONSOR or

EXECUTIVE CLINICAL SPONSOR

ISLHD CERS Committee

ISLHD Drug & Therapeutic Committee

AUTHORS’

Adam Purdon - ICU Staff Specialist [email protected]

Margaret Jordan - Senior Pharmacist [email protected]

Gai Vereker - CPR/Resuscitation Educator [email protected]

Ruchit Agrawal – Advanced Trainee. ED [email protected]

Clinical Associate Professor E. Grant Simmons, Senior Intensive Care Consultant, ISLHD. [email protected]

KEY TERMS Anaphylaxis; Refractory; Adrenaline; Anaphylaxis Pack;

Classification & grades of anaphylaxis; Anaphylaxis management flow charts;

FUNCTIONAL GROUP Resuscitation and Pharmacy

NSQHS STANDARD Standard 4 – Medication Safety

SUMMARY

The purpose of this policy is to provide recommendations for the recognition and management of mild hypersensitivity, moderate and life-threatening anaphylaxis and the therapeutic options when response is refractory to conventional treatments.

mailto:[email protected]





HYPER-LINK INDEX

Title / Heading Hyper-Link

Definitions / Glossary Glossary

Background Section 1

Principles / Responsibilities Sections 2 - 3

Guideline Content Section 4

ABCDE signs and symptoms of anaphylaxis 4.1

Classification of allergen reactions 4.2

Use of medications in anaphylaxis 4.3

Investigations and follow-up

- Blood tests (4.4.1) - Documentation (4.4.3) - Period of observation (4.4.4)

4.4

Accreditation for Community staff who administer medicines without a Medical Officer

4.5

Anaphylaxis Kits & Emergency bags 4.6

Documentation & related documents Section 5

References Section 6

Revision & approval history Section 7

GRADE 1: MILD Hypersensitivity Appendix 1

GRADE 2: MODERATE Anaphylaxis Appendix 2

GRADE 3: LIFE-THREATENING Anaphylaxis Appendix 3

GRADE 4: CARDIAC ARREST Appendix 4

Management of refractory Anaphylaxis Appendix 5

Classification of allergen reactions and anaphylaxis Table 1

Medications used to treat hypersensitivity reactions and anaphylaxis

Table 2

Use of adrenaline dose for anaphylaxis Table 3

Contents of anaphylaxis packs (in-hospital) Table 4

Contents of mobile anaphylaxis pack (off-site) Table 5

To return to hyper-link index select (BACK TO INDEX) at the bottom of each page throughout

document

Definitions & Glossary

Revision: 1 Trim No: DT17/82698 July 2019 Page 3 of 21

DEFINITIONS & GLOSSARY

Adrenaline 1:1,000: 1mg of adrenaline in 1ml ampoule (draw up each ampoule separately) Adrenaline 1:10,000: 1mg of adrenalin in 10ml ampoule (pre-loaded) Anaphylaxis: is a severe, life-threatening, generalised or systemic hypersensitivity reaction, characterised by rapidly developing life threatening airway and/or breathing and/or circulation problems, usually, but not always, associated with skin, mucosal or gastrointestinal changes3 Anaphylaxis is triggered by a broad range of triggers; food and drugs being the most common in the hospital setting, however a significant number of anaphylaxis are idiopathic3 Anaphylaxis Kit. A pack put together by Pharmacy department with the medications and stock to manage Moderate to Life-threatening anaphylaxis. Angioedema: Swelling of deeper tissue most commonly seen in the eyelids and lips ANZAAG: Australian & New Zealand Anaesthetic Allergy Group ANZCOR: Australian & New Zealand Council of Resuscitation ASCIA: Australasian Society of Clinical Immunology and Allergy Auto-injector: A medical device designed to deliver a dose of a particular drug. Most auto-injectors are spring-loaded syringes activated when the device is pushed firmly against the body BVM: Bag-Valve-Mask Classification of grades: Anaphylaxis is graded into 4 classifications to recognised severity of reactions to allergens. (See TABLE 1) Grade 1: Mild Hypersensitivity Grade 2: Moderate Grade 3: Life Threatening Grade 4: Cardiac Arrest

Erythema: Patchy or generalised red rash Flushing: Redness of the skin together with a sensation of warmth or burning of the face, neck and less frequently the upper trunk or abdomen Hypoxia: Deficient amount of oxygen reaching the tissues IM: Intramuscular IV: Intravascular LOC: Level of consciousness

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Definitions & Glossary


Mild allergic / hypersensitivity reaction: A local immune reaction to an allergen and characterised by local irritation to skin which may cause itchiness, rash, hives and in some cases mucosal changes. It is not fatal and does not usually progress to severe anaphylaxis3 Mobile Anaphylaxis bag: A bag with drugs and equipment to treat anaphylaxis carried by staff who treat patients off-site. Mucosal: Mucosa membrane that lines various body passages and cavities such as respiratory, digestive and genitourinary tracts. Mucosal lining can inflame with a hypersensitive or anaphylactic reaction. Off-Site Services: Services that attend patients off hospital site. Usually don’t have a medical officer in attendance (e.g. HITH or Respiratory Medicine). Pharyngeal/laryngeal oedema: Throat and tongue swelling. Patient complains of difficulty in breathing and feels that their throat is closing up (Medical emergency). Refractory Anaphylaxis: Resistant or non-responsive to first line treatment for moderate to life-threatening anaphylaxis (Management of refractory anaphylaxis Appendix 5). Stridor: High pitched inspiratory noise caused by upper airway obstruction. Trigger: Substance that is ingested, injected, inhaled or administered to patients which causes a hypersensitive or anaphylactic reaction. Tryptase blood test: This test measures the amount of tryptase in the blood. Tryptase is an enzyme that is released, along with histamine and other chemicals, from mast cells when they are activated, often as part of an allergic immune response. Urticaria: Hives, nettle rash or welts.

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Section 1: Background


SECTION 1: BACKGROUND

These recommendations cover the recognition and management of mild sensitivity to life-threatening anaphylaxis and the therapeutic options when response is refractory to conventional treatment. These guidelines are for the adult patient. Anaphylaxis causing cardiac arrest should be treated by following the Australian Resuscitation

Council (ARC) Advanced Life Support algorithm for the adult.

Anaphylaxis is a severe, generalised allergic or hypersensitivity reaction that is rapid in onset and may cause death. Adrenaline can be life-saving when administered as rapidly as possible once anaphylaxis is recognised. 11 KEY POINTS include the following: (1) validated clinical criteria are available to facilitate prompt diagnosis of anaphylaxis; (2) prompt intramuscular adrenaline injection in the mid-outer thigh reduces hospitalisation, morbidity, and mortality; (3) the management of anaphylaxis also involves education about anaphylaxis recognition and first-aid.11 CLINICAL FEATURES OF ANAPHYLAXIS 11 Clinical criteria for anaphylaxis have been proposed and validated. Anaphylaxis is highly likely where any ONE of the following criteria is fulfilled: 1. Acute onset of an illness (minutes to several hours), with involvement of the skin, mucosal tissue, or both (e.g. generalized urticaria, itching or flushing, swollen lips/tongue/uvula), and at least ONE of the following: (1) respiratory compromise (e.g. dyspnoea, wheeze/bronchospasm, stridor, hypoxaemia) or (2) reduced blood pressure or associated symptoms of end-organ dysfunction (e.g. hypotonia [collapse], syncope, incontinence);

OR

2. TWO or more of the following that occur suddenly after exposure to a likely allergen for that patient (minutes to several hours): (1) Involvement of the skin/ mucosal tissue (e.g. generalised urticaria, itch/flush, swollen lips/ tongue/uvula), (2) respiratory compromise (e.g. dyspnoea wheeze/bronchospasm, stridor, hypoxaemia), (3) reduced blood pressure or associated symptoms (e.g. hypotonia [collapse], syncope, incontinence), or (4) persistent gastrointestinal symptoms (e.g. crampy, abdominal pain; vomiting);

OR

3. Reduced blood pressure after exposure to a known allergen for that patient (minutes to several hours): For adults, systolic blood pressure of less than 90mm Hg or greater than 30% decrease from that person’s baseline. 11 Foods, especially peanut, tree nuts, milk, eggs, crustacean shellfish, and finned fish, are common triggers of anaphylaxis. Insect stings, drugs such as antibiotics, and various other allergens can also trigger anaphylaxis. However, vaccinations to prevent infectious diseases seldom trigger it.11

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Section 2: Principles Section 3: Responsibilities


SECTION 2: PRINCIPLES

This policy will outline the:-

Definition of mild hypersensitivity and anaphylaxis Indicator for recognising the signs and symptoms of mild hypersensitivity and anaphylaxis Classification and grades of anaphylaxis Treatment and management for each grade of anaphylaxis Management of refractory anaphylaxis Medications used to treat hypersensitivity reactions and anaphylaxis Contents of anaphylaxis kits and bags

SECTION 3: RESPONSIBILITIES

Clinical Governance Unit ISLHD CERS Committee Drug & Therapeutic Committees Managers and Nursing staff in high risk areas Target Audience

Clinical Staff: All Medical and Nursing Staff and Community & Public Health Nursing staff Non-Clinical staff: Pharmacy Department

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Section 4: Guideline Content


SECTION 4: GUIDELINE CONTENT

This guideline should be followed when treating hypersensitivity and anaphylactic reaction to anything ingested, injected, inhaled and administered to patients unless alternate treatment has been otherwise specified.

4.1 Anaphylaxis is likely when ONE or more of the following occurs:-

1. Sudden onset and rapid progression of symptoms3

- The patient will feel and look unwell - Most reactions occur over several minutes (but may take hours) - An intravenous trigger will cause a more rapid onset than orally ingested triggers - The patient is generally anxious and can experience a “sense of impending doom”

2. Life-threatening Airway and/or Breathing and /or Circulation problems3

Using the ABCDE approach to assess signs and symptoms for recognition

AIRWAY - Hoarse voice - Stridor - Pharyngeal/laryngeal oedema (Medical emergency)

BREATHING - Shortness of breathing (SOB) with an increased respiratory rate (RR) - Wheeze - Patient becomes tired - increased work of breathing - Confusion caused by hypoxia (usually a late sign) - Respiratory arrest

CIRCULATION - Tachycardia (or late sign bradycardia) - Hypotension - Pale and clammy – signs of shock - Decreased level of consciousness (LOC) - Ischaemic changes on ECG (even in people with normal coronary arteries) - Cardiac arrest

DISABILITY - Agitation, dizziness, headache, disorientated - Confusion due to hypoxia - Change in patient’s neurological status due to decreased cerebral perfusion - Loss of consciousness

3. Skin and/or mucosal changes (flushing, urticarial, angioedema, tingling mouth, abdominal) 3

EXPOSURE

- Skin reactions are a common first sign, but skin reactions without life-threatening ABC does not signify anaphylaxis. Skin reactions can be subtle or dramatic and causing itching

- There may be ‘only’ skin, or ‘only’ mucosal or both skin and mucosal changes - Erythema – patchy or generalised red rash - Urticaria – hives, nettle rash or welts - Angioedema – swelling of deeper tissue most commonly seen in the eyelids and lips - Abdominal or pelvic pain, nausea, vomiting or/and diarrhoea

Skin changes without life threatening airway, breathing or circulation problems do not signify anaphylaxis

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4.2 Classification of allergen reactions: Hypersensitivity to allergens is graded into 4 classifications, by severity of symptoms. The signs and symptoms for each grade are found in TABLE 1. The management for each grade is found in APPENDIX 1 – 5. (See index for links to table and appendix).

Grade 1: Mild Grade 2: Moderate Grade 3: Life-Threatening Grade 4: Cardiac Arrest

4.3 Use of medications in the treatment of anaphylaxis 2

The use of adrenaline in moderate and life-threatening anaphylaxis is paramount and should not be withheld due to risk of adverse reaction or contraindications. 3 6 10 (Adults and Children >12yr dose using 1:1,000 is 0.5mg / 0.5mLs adrenaline, given IMI. See Table 3)

When treating moderate to life threatening anaphylaxis, adrenaline should be administered IM (anterolateral thigh) while the patient remains in a conscious state. IV adrenaline should only be administered if the patient lapses into a state of unconsciousness, is deemed refractory or condition progresses to cardiac arrest.3 6 10

The use of IV adrenaline bolus or infusion should ONLY be given under the direction of emergency or critical care specialists, as this may increase the risk of cardiac arrhythmia or cardiac infarction5. (Guidelines for administration of Adrenaline in TABLE 3 and appendix 5 for use of medications in the presence of refractory anaphylaxis1 (see index for links).

The use of medications to treat hypersensitivity reactions and anaphylaxis is tabled at the back of this document in TABLE 2 (see index for link).

The use of oral antihistamines may be appropriate for mild allergic reaction or hypersensitivity. These may take up to 2-3 hours to have effect. Less sedating antihistamines are preferred.4 10

Injectable promethazine should not be used in anaphylaxis, as it can worsen hypotension, has a sedating effect and when given IM can cause muscle necrosis 5 10

The use of nebulised adrenaline is advantageous to counteract bronchospasm or for patients experiencing respiratory distress (wheezing or stridor).4

The use of corticosteroids are not recommended as first line treatments, due to their delayed effect and should not take precedence over treatment with adrenaline. 4 7 8

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4.4 Investigations and follow-up:

4.4.1 Blood tests

If the diagnosis of anaphylaxis is uncertain, consider a serum mast cell tryptase blood test. This is an insensitive marker of anaphylaxis, although serial measurements improve specificity and sensitivity, a normal result does not exclude anaphylaxis.

If tests are taken:- 1. Take blood samples for mast cell tryptase, as soon as possible and within 7 hours of the

event. A brown top tube (serum gel) is used for the specimen.

2. An additional sample can be taken if the patient is still in the hospital at 24 hours, or prior to discharge. Alternatively, the need for a repeat or baseline tryptase should be communicated to the patient’s usual GP.

4.4.2. Patients who have had (Grade 2) Moderate, (Grade 3) Life-Threatening and (Grade 4) Cardiac Arrest caused by anaphylaxis, should be referred to an allergy specialist / immunologist for investigation.

4.4.3 Documentation in medical records

The suspected allergen and the nature of the hypersensitivity reaction is to be documented in eMR of the patient. Details of the reaction are to be included in the Discharge Summary and the patient advised to seek specific follow-up of the reaction by the GP. Provide an Event Record. (Event record is included in the Anaphylaxis packs)

4.4.4 Period of observation

GRADES 3 & 4: All patients who have life-threatening and cardiac arrest anaphylaxis should be considered for admission to intensive care unit (ICU) or high dependency unit. GRADE 2: Moderate anaphylaxis reaction. The patient should be observed for a minimum of 4-6 hours and then reassessed before discharge. Reactions can be biphasic in time and can occur up to 24hrs after initial reaction. If the patient is discharged after observation period, they need to be discharged into the care of a responsible adult. They should be provided with:- An advice / information sheet to re-present to hospital ED if their condition deteriorates.

(ASCIA Action plan for Anaphylaxis, included in Anaphylaxis packs)

Discharge letter to GP for follow up supply of adrenaline and to seek referral to an immunology specialist

Note: For hospitals with an After Hours supply of EpiPens, these may be provided for high risk patients, if there is a delay anticipated in accessing this medication after discharge.

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Section 4: Guideline Content Section 5: Documentation & Related Documents


4.5 Accreditation for community staff who administer medicines without a Medical Officer 4.5.1 Staff in Hospital in the Home and Chest Clinic who administer medications to patients without the attendance of a Medical Officer, are to be annually accredited to administer medications for the management of allergic reactions. These staff are to follow standing orders for the administration of an oral antihistamine for mild hypersensitivity reactions or IM adrenaline in the event of moderate or life-threating anaphylaxis. 4.5.2 Ambulatory and Primary Health Care staff are to call 000 in the case of a suspected allergic reaction or anaphylaxis. These staff do not carry anaphylaxis mobile kits and do not require accreditation.

4.6 Anaphylaxis Kits

Anaphylaxis kits are sealed pre-packaged kits containing emergency medications and equipment used for the immediate treatment of moderate and life-threatening anaphylaxis for patients in hospital departments. They are prepared in Pharmacy and kept on the emergency trolley in high risk areas. After use, the kit is returned to Pharmacy for replacement. The contents of the kits are in TABLE 4 (see index for link).

Off-Site based services such as Community and District Health Services carry a mobile anaphylaxis emergency pack with their equipment. The packs are prepared in Pharmacy and must be replaced when opened or after use. The contents carried in this mobile anaphylaxis pack are documented in TABLE 5 (see index for link).

SECTION 5: DOCUMENTATION AND RELATED DOCUMENTS

eMR Emergency Event Audit IIMS report (Public Health & Community Based Services)

ASCIA Action plan for Anaphylaxis (included in Anaphylaxis pack and link below) https://www.allergy.org.au/images/stories/anaphylaxis/2016/Anaphylaxis_Epipen_Personal_Action_Plan_2016_WEB.pdf

ASCIA Event Record for Allergic Reactions (included in Anaphylaxis pack and link below) https://www.allergy.org.au/images/pcc/ASCIA_event_record_allergic_reactions_2015.pdf

Related Documents

Standing order for the management of mild hypersensitivity and moderate anaphylaxis (Community and District Services)

https://www.allergy.org.au/images/stories/anaphylaxis/2016/Anaphylaxis_Epipen_Personal_Action_Plan_2016_WEB.pdf

https://www.allergy.org.au/images/stories/anaphylaxis/2016/Anaphylaxis_Epipen_Personal_Action_Plan_2016_WEB.pdf

https://www.allergy.org.au/images/pcc/ASCIA_event_record_allergic_reactions_2015.pdf

Section 4: Guideline Content Section 5: Documentation & Related Documents


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Section 6: References


SECTION 6: REFERENCES

1. Australian & New Zealand Anaesthetic Allergy Group. Perioperative Anaphylaxis

Management Guidelines: Appendix 5 Differential Diagnosis Card. 2016 Date cited 30th May 2016. Available from: http://www.anzaag.com/Docs/PDF/Management%20Guidelines/differential_Diagnosis_Card_2016.pdf

2. Australian prescriber, Emergency management for health professionals. Australian

prescriber, 2011. 34(4). 3. ANZCOR. Advanced Life Support. Level 2. Handbook. Australian 3rd Edition. 2016. Ch.12

Pages145 -150. Resuscitation in special circumstances. Anaphylaxis.

4. Journal. eMedicine. Medscape. On-line issue: May 2016. Article 135065. Treatment & Management of anaphylaxis.

5. Australasian Society of Clinical Immunology and Allergy. (ASCIA) Acute management of anaphylaxis guidelines. 2016

6. Australasian Society of Clinical Immunology and Allergy. (ASCIA) Adrenaline for severe allergies. 2015

7. The Australian Immunisation Handbook. 10th Edition. Published 2013. Updated July 2015

8. Australian Technical Advisory Group on Immunisation. Canberra: Australian Government Department of Health and Ageing: July 2015

9. Australian Society of Clinical Immunology and Allergy. (ASCIA). Article 2016. Choose Wisely Australia. 5 Things clinicians and consumers should question.

10. APLS Anaphylaxis Management algorithm. These algorithms were created for the Australia and New Zealand Edition of ‘Advanced Paediatric Life Support: The Practical Approach 5th Edition’, March 2012.

11. Epinephrine for First-aid Management of Anaphylaxis Scott H., Sicherer, F. Estelle R. Simons and SECTION ON ALLERGY AND IMMUNOLOGY Pediatrics; Originally published online February 13, 2017;DOI: 10.1542/peds.2016-4006 (For the purpose of this guideline, the

Paediatric component has been removed from the information used from this reference)

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http://www.anzaag.com/Docs/PDF/Management%20Guidelines/differential_Diagnosis_Card_2016.pdf

http://www.anzaag.com/Docs/PDF/Management%20Guidelines/differential_Diagnosis_Card_2016.pdf

Section 7: Revision & Approval History

Revision: 1 Trim No: DT17/82698 Date: July 2019 Page 12 of 21

SECTION 7: REVISION & APPROVAL HISTORY

Date Revision No. Author and Approval

June 2017 June 2017

0 Adam Purdon. ICU Staff Specialist. Chair ISLHD CERS Committee

Margaret Jordan. Senior pharmacist

Gabrielle Vereker. CPR/Resuscitation Educator

Ruchit Agrawal. Advanced Trainee. Emergency Department. WH

Clinical Associate Professor E. Grant Simmons, Senior Intensive Care Consultant, ISLHD.

Approved by: ISLHD CERS Committee

ISLHD Drug & Therapeutics Committee

July 2019 1 Author: Margaret Jordan – Senior Pharmacist Updated to reflect clear the responsibilities of the staff working in community. Ambulatory and Primary Health are not accredited or responsible to manage anaphylaxis in the home and are to immediately call 000 in the event of an emergency.

Approval: ISLHD Drug & Therapeutics Committee

TABLE 1 Classification of allergen reactions and anaphylaxis

Revision: 1 Trim No: DT17/82698 Date: July 2019 Page 13 of 21

GRADE 1

MILD

GRADE 2

MODERATE

GRADE 3

LIFE-THREATENING

GRADE 4

CARDIAC ARREST

Generalised skin and mucocutaneous signs:

EARLY stage anaphylaxis Multi-organ involvement, including:

LATE stage anaphylaxis Multi-organ - ABCDE Compromised

SUDDEN DEATH

Airway & Breathing

No effects

Airway & Breathing Difficulty in breathing Noisy breathing or wheezing Dysphagia Change in voice or cry in infant Persistent cough or/and

bronchospasm

Airway & Breathing Swelling / hoarseness / stridor Dysphagia Rapid respiratory rate Bronchospasm Hypoxia (SaO2 <92%)

Advanced airway assistance ASAP

Airway & Breathing Partial or total obstruction Apnoeic

Immediate assistance in breathing (BVM) & intubation

Cardiovascular

No effects

Cardiovascular

Hypotension Tachycardia or palpitations

If available attach to defibrillator monitor ASAP

Cardiovascular

Cardiovascular collapse (signs of shock) Profound hypotension Bradycardia Arrhythmia’s

Attach to defibrillator monitor ASAP

Cardiovascular

Cardiac arrest Pulseless electrical activity VF / Pulseless VT

Follow ARC or APLS algorithm for cardiac arrest

Disability – Neurological

No effects

Disability - Neurological Usually not effected but may have headache, feel light headed or dizzy

Disability - Neurological

Confusion or altered state of consciousness

Disability – Neurological

Unresponsive / unconscious

Exposure – Skin Erythema Urticaria Itchy lips / mouth Itchy / watering eyes

Exposure - Gastrointestinal & Skin

Mucocutaneous signs & angioedema Nausea & vomiting Diarrhoea Abdominal or pelvic pain

Exposure – Gastrointestinal & Skin

Mucocutaneous signs & angioedema may be present or absent

Incontinent Abdominal or pelvic pain

Exposure - Gastrointestinal & Skin

Mucocutaneous & angioedema signs may be present or absent

Incontinent

Absence of tachycardia or cutaneous signs does not exclude anaphylaxis. Anaphylaxis is usually rapid in onset but is occasionally delayed 3

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APPENDIX 1

GRADE 1

Management of mild hypersensitivity

Revision: 0 Trim No: DT17/82698 Date: June 2017 Page 14 of 21

Hospital staff are to notify patient Home team (PACE Tier 1)

District Health Services are to notify Medical Officer or

follow Standing Order

STOP TRIGGER

If ABC threatened consider anaphylaxis

and move to Grade 2 or 3 Assess ABCDE

District Health Services

CALL Ambulance - 000

Hospital Staff

CALL PACE Tier 2 Consider

Anaphylaxis

MILD Hypersensitivity

Sign & Symptoms Skin or mucous membrane reaction

Observe closely and may consider loratadine 10mg orally orally

Continue to monitor ABCDE for 20-30 minutes If condition worsens involving Altered neurological state Respiratory and/or cardiovascular systems Gastrointestinal systems

ESCALATE Management of Moderate Anaphylaxis

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APPENDIX 2

GRADE 2

Management of moderate anaphylaxis


Give Adrenaline 1:1,000 500microg IM (0.5mls) NOW

If ABC threatened consider life–threatening anaphylaxis

and move to Grade 3

District Health Services Call Ambulance - 000

CALL HELP

Hospital Staff Call Cardiac Arrest

ESCALATE Management of Life – Threatening Anaphylaxis

MODERATE ANAPHYLAXIS

Multi-organ manifestation may include Bronchospasm, cough, wheeze, difficulty breathing, hypotension, tachycardia,

gastro systems, angioedema, mucocutaneous signs

Adrenaline (1:1,000) 500microg IM may repeat

every 3-5 minutes if required.

Oxygen – High flow 15L via NRM

Adrenaline 1:1,000 nebulised (5mg/5mL) undiluted

Consider IV fluid if hypotensive

Monitor patient on defibrillator monitor

Continue to monitor ABCDE If condition worsens such as Severe bronchospasm or airway oedema

Gross hypotension & tachycardia

Altered neurological state

Severe gastrointestinal symptoms

Transfer to ICU or acute care

ED/Outpatients should be observed for at least 4 to

6hrs before discharge

STOP TRIGGER

Assess ABCDE

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APPENDIX 3

GRADE 3

Management of life-threatening anaphylaxis


Must be monitored for 24hours before discharge

Transfer to ICU or acute care

STOP TRIGGER

Assess ABCDE

Give Adrenaline 1:1,000 500microg IM (0.5mL) NOW

LIFE – THREATENING ANAPHYLAXIS

ESCALATE Management of Cardiac Arrest

ESCALATE Management of Refractory Anaphylaxis

Multi-organ compromise requiring immediate treatment Airway obstruction / stridor, severe bronchospasm and/or airway oedema/swelling, gross hypotension /

shock, bradycardia or tachycardia, neurological impairment, may or may not have gastro or skin reaction

No signs of life

Loss of consciousness

Not breathing normally

Un-recordable manual BP

Adrenaline (1:1,000) 500microg IM may repeat

every 3-5 minutes if required.

Oxygen – High flow 15L via NRM

Adrenaline 1:1,000 nebulised (5mg/5mL) undiluted

IV Fluid challenge (N/S 0.9% 500-1000mL)

Monitor Patient on defibrillator monitor

Not responding to treatment

Impaired LOC (but still

conscious)

Gross cardiovascular /

respiratory compromise

CALL HELP

If condition worsens

Continue to monitor ABCDE



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APPENDIX 4

GRADE 4

Management of cardiac arrest - anaphylaxis


ADULT - CARDIAC ARREST - ANAPHYLAXIS

Unconscious, unresponsive and not breathing normally



Shockable Non-Shockable

Shock VF / Pulseless VT

Return of spontaneous

circulation (ROSC)

Adrenaline 1mg IV after 2nd shock then every 2nd loop

Amiodarone 300mg after 3rd shock

CPR 2 minutes

CPR 2 minutes Post Resuscitation Care

Modified version of Australian Resuscitation Council – Adult ALS Algorithm – January 2016

Assess Rhythm

Attach Defibrillator / Monitor

Start CPR 30 compressions : 2 breaths

STOP TRIGGER

CALL HELP

Adrenaline 1mg IV immediately then every 2nd loop

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APPENDIX 5

Management of refractory anaphylaxis


Management of Refractory Anaphylaxis

REQUEST MORE HELP Call Emergency Team

May require assistance with fluid resusitation

TRIGGERS REMOVED? Chlorhexidine – including impregnated CVC; colloid or

drugs. Disconnect and remove

MONITORING Consider arterial line / Consider TOE/TTE

RESISTANT HYPOTENSION

Commence adrenaline

infusion

Additional IV fluid bolus

50mL/kg

Add second vasopressor

Consider CVC

Cardiac bypass/ECMO if

available

Adult recommendations:

Adrenaline infusion. 1 microgram / minute. 6mg diluted in 100mL N/S 0.9%. Commence infusion at 1mL / hr or follow hospital / department protocol

Noradrenaline infusion 3 – 40 microgram / minute (0.05 – 0.5 microgram/kg/min) and/or

Vasopressin 1 – 2 units (0.1 to 0.2mL) IV bolus then IV infusion at 2units/hour

If neither are available or central line is not available for noradrenaline or vasopressin use: Metaraminol or phenylephrine infusion Glucagon 1 – 2mg IV every 5 minutes until response

(to counteract any beta-blockade).

Consider glucagon infusion at 5-15microgram/minute, titrated to response, due to short half-life.

RESISTANT BRONCHOSPASM

continue adrenaline infusion

consider tension

pneumothorax (decompress)

additional bronchodilator

Adult recommendations:

Adrenaline nebulised: 5mg in 5mL undiluted (use 1:1,000 adrenaline ampoules for nebulising)

Salbutamol Nebulised 5mg/2mL undiluted IV bolus 100 – 200microgram (0.2mL to 0.4mL)

+/- infusion 5 – 25microg / minute Magnesium 10mmol over 20 minutes

PREGNANCY Manual left uterine displacement Caesarean within 4 minutes if arrest or peri-arrest

CONSIDER OTHER DIAGNOSIS

Modified version from Australian & New Zealand Anaesthetic Allergy Group. May 2016 (Reference 1)

Refractory anaphylaxis occurs when patient is not responsive to conventional recommended treatments

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TABLE 2

TABLE 3


TABLE 2: Medications used to treat hypersensitivity reactions and anaphylaxis

GRADE DRUG DOSE ROUTE FREQUENCY GRADE 1

Mild

Loratadine

(Available Department imprest)

10mg Oral Once only

(May be required over 2 – 3 days if symptoms persist)

GRADE 2

Moderate

Adrenaline (1:1,000) Adrenaline (1:1,000) (5mg/5ml for nebulising)

500microg (0.5mg in 0.5mL)

5mg in 5mL undiluted

IM (Anterolateral thigh preferred site)

Nebuliser with oxygen

If Patient does not improve Repeat dose and escalate to grade 3 (Life-threatening) Continuous as required

GRADE 3

Life-threatening

Adrenaline (1:1,000) Adrenaline for nebulising (1:1,000) (5mg/5mL for nebulising)

500microg (0.5mg in 0.5mL)

5mg in 5mL undiluted

IM (Anterolateral thigh preferred site)

Nebuliser with oxygen

If Patient continues to deteriorate, repeat dose every 3-5 minutes until emergency team / services arrives. (Escalate to refractory) Continuous as required

GRADE 4

Cardiac Arrest

Adrenaline (1:10,000)

1mg (1mg in 10mls)

IV Follow ANZCOR ALS Algorithm. (See recommended dose

below for adrenaline)

Refractory anaphylaxis

See APPENDIX 5

TABLE 3: Use of adrenaline and dose for anaphylaxis for adult

Type of patient Administration Site

Ampoule concentration

Volume Dose

Adult IM 1: 1,000 0.5mg in 0.5mL 500 micrograms Repeat every 5min as required

Adult IV (Given by SMO only)

1:10,000 1mg in 10mL 1mg Repeat every 4min as required

Adult IV Infusion 1: 1,000

Prepare Infusion Add 6mg (6 ampoules) to 100mL normal saline (or as per site protocol)

Commence infusion at 1mL/ hr Infusion rate = 1microg / min (or as per site protocol)

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TABLE 4

TABLE 5


TABLE 4

Contents of anaphylaxis pack (In-Hospital departments)

DRUG / EQUIPMENT STRENGTH QUANTITY Adrenaline 1:1,000 10 amps (2 x packs)

Sodium Chloride 0.9% in 10 mL 5 amps

Sodium Chloride 0.9% in 500mL 1 bags

3mL Syringe 5

18g Needle (Blunt drawing up needle) 2

23g Needle 5

Alcohol Swabs 5

Blood Infusion Pump Set 1

Nebuliser mask 1

ASCIA Event Record and ASCIA Action Plan

2

Anaphylaxis flip cards (Flow charts and

standing orders)

1 (Flip card to remain in

pack when taken back to pharmacy for replacement stock)

Note: Drugs required for cardiac arrest are in the drug pack on every emergency trolley and in the mobile arrest bag carried by ICU Nurse on the adult emergency team

TABLE 5

Contents of ‘mobile anaphylaxis pack’ (Off-Site Services)

DRUG / EQUIPMENT STRENGTH QUANTITY Loratadine 10mg 2 tablets

Adrenaline 1:1,000 5 ampoules

3mL syringe 5

18g Needle (Blunt drawing up needle) 2

23g Needle 5

Alcohol Swabs 5

Pocket mask 1 size only 1

Guedels airway Size 3 1

Patient information and education sheet ASCIA Event Record

2

Allergic reaction / anaphylaxis chart & standing order chart

1 (Card to remain in pack when

taken back to pharmacy for replacement stock)

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