Hailey Tran
Anaphylaxis is a severe allergic reaction that requires immediate medical attention and treatment with adrenaline. If left untreated, it can be fatal. The Australasian Society of Clinical Immunology and Allergy (ASCIA) provides guidelines for the acute management of anaphylaxis, which include administering an intramuscular injection of adrenaline into the outer mid-thigh without delay and calling for emergency services. Patients experiencing anaphylaxis should be transferred to a hospital for observation, and those with a risk of re-exposure should be prescribed an adrenaline autoinjector prior to discharge. This article will explore the steps to deal with anaphylaxis in a hospital setting, including patient care, treatment protocols, and discharge procedures.
| Characteristics | Values |
|---|---|
| Treatment | Adrenaline (epinephrine) is the first line of treatment for anaphylaxis. |
| Treatment Time | Adrenaline should be administered without delay. |
| Treatment Location | An intramuscular injection (IMI) of adrenaline should be given into the outer mid-thigh. |
| Oxygen | Give oxygen if available. |
| Ambulance | Call an ambulance to transport the patient to the hospital if not already in a hospital setting. |
| Patient Position | Lay the patient flat. Do not allow them to stand or walk. |
| Unconscious or Pregnant Patient Position | Place the patient in the recovery position on their left side if they are unconscious or pregnant. |
| Breathing Difficulties | If the patient is having difficulty breathing, allow them to sit with their legs outstretched. |
| CPR | Commence CPR if the patient is unresponsive and not breathing normally. |
| Adrenaline Toxicity | If the patient is nauseous, shaky, vomiting, or tachycardic but has a normal or elevated SBP, consider adrenaline toxicity rather than worsening anaphylaxis. |
| IV Adrenaline Infusion | IV adrenaline infusions should only be given by, or in liaison with, an emergency medicine/critical care specialist. |
| Adrenaline Autoinjector | Adrenaline autoinjectors (EpiPen) are available from the hospital pharmacy. |
| Allergen Avoidance | Before discharge, advise the patient about the suspected allergen and allergen avoidance strategies. |
| Post-discharge Care | Provide the patient with a discharge care plan that includes details of the suspected allergen, the appropriate ASCIA Action Plan, and the need for a follow-up appointment with a general practitioner and clinical immunology/allergy specialist. |
| Adrenaline Injector Prescription | If there is a risk of re-exposure, prescribe a personal adrenaline injector and train the patient in its use. |
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What You'll Learn
Administering adrenaline
Adrenaline, also known as epinephrine, is the first-line treatment for anaphylaxis. It is a medical emergency and requires immediate treatment. If treatment with adrenaline is delayed, it can result in fatal anaphylaxis.
If a patient presents with anaphylaxis, they should be laid flat and not allowed to stand or walk. If unconscious or pregnant, place them in the recovery position on their left side. If breathing is difficult, allow them to sit with their legs outstretched.
Give an intramuscular injection (IMI) of adrenaline into the outer mid-thigh without delay. This can be done using an adrenaline autoinjector (such as an EpiPen) if available, or an adrenaline ampoule/syringe. If there is a risk of re-exposure to the allergen, the patient should be prescribed an autoinjector prior to discharge and trained in its use.
If there are no skin symptoms but there is sudden breathing difficulty, such as wheezing, persistent coughing, or a hoarse voice, give IM adrenaline before an asthma reliever. Adrenaline auto-injectors are expensive without a pharmaceutical benefits scheme subsidy, so consider providing one from the hospital pharmacy prior to discharge.
IV adrenaline infusions should only be given by, or in liaison with, an emergency medicine/critical care specialist. If your centre has a protocol for IV adrenaline infusion, this should be utilised and titrated to response with close cardio-respiratory monitoring. If there is no established protocol, there are two separate protocols for pre-hospital settings and emergency departments/tertiary hospital settings. It is vital that IV adrenaline infusions are used with dedicated line equipment wherever possible.
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Laying the patient down
When dealing with a patient experiencing anaphylaxis, it is crucial to act quickly and lay the patient flat on their back. Do not allow them to stand or walk, as this can worsen the reaction and delay treatment. Place the patient in a comfortable position, ensuring their airway remains unobstructed. If the patient is unconscious or pregnant, place them in the recovery position on their left side. This position helps maintain an open airway and promotes blood flow to the developing fetus in pregnant individuals.
If the patient is experiencing breathing difficulties, allow them to sit with their legs outstretched. This position can help improve airflow and make breathing easier. It is important to ensure that the patient's upper body is slightly elevated to facilitate breathing and prevent further complications. Keep the patient calm and reassured while administering treatment.
In the event of vomiting, immediately place the patient in the left lateral position, also known as the recovery position. This position helps prevent aspiration and keeps the airway clear. If the patient is unconscious, this position can also help prevent choking. Ensure that any vomit is cleared from the patient's mouth and airway to reduce the risk of aspiration pneumonia.
During the treatment process, closely monitor the patient's breathing and vital signs. Be prepared to administer oxygen if necessary. If the patient's breathing becomes compromised or difficult, adjust their position accordingly, ensuring their comfort and safety. It is imperative to keep the patient under clinical observation for at least four hours after their last dose of adrenaline to ensure their condition stabilizes.
These instructions provide a comprehensive guide for healthcare providers on how to properly lay a patient down during anaphylaxis, ensuring their safety and well-being throughout the treatment process.
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Removing the allergen
Anaphylaxis is a severe allergic reaction that should be treated as a medical emergency. If a patient presents with allergy symptoms, it is important to promptly recognise any progression to anaphylaxis. If a patient is experiencing anaphylaxis, the first step is to remove the allergen if it is still present. This could include insect stings, foods, or unknown allergens.
If an individual is experiencing anaphylaxis, it is important to act quickly. Remove the allergen if it is still in contact with the patient. For example, if the patient has been stung by an insect, remove the stinger if possible. If the patient has been in contact with an unknown allergen, remove any potential allergens from the patient's environment. This may include removing foods, medications, or other potential triggers.
If the patient is wearing jewellery that is suspected to be causing the reaction, remove it immediately. If the patient is wearing contact lenses, remove them as well, as they may be irritating the eyes and contributing to the reaction.
It is also important to stay with the patient, call for assistance, and locate an adrenaline injector (e.g. EpiPen). If an adrenaline injector is available, administer it into the outer mid-thigh without delay. If there is no injector available, prepare to administer an injection using an adrenaline ampoule or syringe. If the patient is unconscious or pregnant, place them in the recovery position on their left side. If their breathing is difficult, allow them to sit with their legs outstretched.
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Referring the patient to a specialist
Identify the Need for a Specialist Referral
All patients who present with anaphylaxis should be referred for a specialist review. Anaphylaxis is a severe allergic reaction that requires immediate medical attention and follow-up care. A specialist referral ensures proper management of the patient's allergy and helps reduce the risk of future anaphylaxis episodes.
Timing of the Referral
Ideally, the referral process should begin before the patient is discharged from the hospital. This allows for continuity of care and timely management of the patient's condition.
Information to Provide to the Specialist
When referring a patient to a clinical immunology/allergy specialist, it is essential to provide detailed information about the patient's experience. This includes documentation of the specific allergen identified, the patient's reaction, and the treatment provided. It is also important to communicate any discharge care arrangements, including any prescribed medications or devices, such as an adrenaline injector (EpiPen).
Educating the Patient
During the discharge process, it is crucial to educate the patient about their allergic trigger and provide strategies for allergen avoidance. Patients should be instructed to keep their adrenaline injector close by and easily accessible, even while in a healthcare setting. They should also be advised to arrange a follow-up appointment with their general practitioner (GP) within a specified timeframe, typically within one week.
Specialist Follow-up
The role of the specialist is to provide ongoing care and management of the patient's allergy. During the patient's first visit with the specialist, the cause of the anaphylaxis will be confirmed, and comprehensive advice will be provided on managing their allergy. This may include guidance on allergen avoidance, the use of any prescribed devices or medications, and any necessary lifestyle adjustments.
In summary, referring a patient who has experienced anaphylaxis to a specialist involves a comprehensive process that begins during their hospital stay and extends into their ongoing care. Proper referral and follow-up ensure that patients receive the necessary education, treatment, and support to manage their allergy effectively and reduce the risk of future anaphylaxis episodes.
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Providing an adrenaline autoinjector
Adrenaline (epinephrine) is the first-line treatment for anaphylaxis and should be administered without delay. If an adrenaline autoinjector is available, it should be used to give an intramuscular injection (IMI) of adrenaline into the outer mid-thigh.
If a patient presents with anaphylaxis, they should be referred for a specialist review. If there is a risk of re-exposure to the allergen, the patient should be prescribed an adrenaline autoinjector prior to discharge or provided with one from the hospital pharmacy. It is important to teach the patient how to use the autoinjector and ensure they understand the need for prompt follow-up with a healthcare professional.
Patients who are admitted to the hospital and have their own adrenaline injector should keep it at their bedside for themselves or staff to use if necessary. They should inform their healthcare team about the injector and arrange to keep it near them during their care.
If a patient experiences symptoms of an allergic reaction, such as breathing difficulties, faintness, swelling of the tongue, or tightness in the throat, they should lie down (or sit with their legs outstretched if breathing is difficult), use their adrenaline injector as soon as possible, and alert a staff member immediately. After the administration of adrenaline, the patient should remain under clinical observation for at least four hours or overnight.
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Frequently asked questions
Lay the patient flat and do not allow them to stand or walk. If unconscious or pregnant, place them in the recovery position on their left side. If breathing is difficult, allow them to sit with legs outstretched. Give an intramuscular injection (IMI) of adrenaline into the outer mid-thigh without delay, using an adrenaline autoinjector if available.
Anaphylaxis is characterised by a sudden onset of symptoms, including skin features such as urticaria rash, erythema/flushing, and/or angioedema. It may also involve respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms. Other signs include abdominal pain, vomiting, wheezing, persistent cough, and tightness in the throat.
If the patient is in a hospital setting, transfer them for at least 4 hours of observation. If they are not in a hospital, phone an ambulance to transport them. Commence CPR at any time if the person is unresponsive and not breathing normally.
Before discharge, patients should receive information about their allergic trigger (allergen) and allergen avoidance strategies. They should also be provided with an ASCIA Action Plan, which includes details on recognising allergic reaction symptoms and using their prescribed adrenaline injector. Patients should be advised to see a general practitioner within one week and refer to a clinical immunology/allergy specialist for follow-up care.
If there is a risk of re-exposure, prescribe an adrenaline autoinjector (EpiPen) prior to discharge and teach the patient how to use it.
