1. Anaphylaxis theory To complete this training you must also complete the short MCQ and score 100%. You can retake the MCQ as required to achieve this.

2. Objectives:
By the end of this sessions you will understand the following
What is anaphylaxis
What can cause it
Who gets anaphylaxis
How to recognise and treat it

3. What is anaphylaxis?
Anaphylaxis is a severe, life threatening, generalised or systemic hypersensitivity reaction
It is characterised by rapidly developing, life threatening, problems with airway, breathing, circulation (may have any or all of these)
Often with skin and/or mucosal changes

4. Who gets anaphylaxis Incidence seems to be increasing
Mainly in children and young women
Commoner in females
People with inflammatory response conditions (eg asthma, eczema) may be more at risk

5. What causes anaphylaxis
Stings and nuts remain the most common “trigger” for anaphylaxis, drugs remain relatively low, however in hospital we expose many patients to many kinds of drugs

6. Time to cardiac arrest
Note that when drugs are injected (IV or IM) you are most likely to suffer cardiac arrest in less than 20 minutes from exposure. With food or oral medications this time will be delayed as the substance has reach the gut before it is absorbed

7. How to recognise anaphylaxis
The diagnosis may not always be obvious however is highly likely when the following 3 criteria are applied:
Symptoms are sudden in onset and progress rapidly
Patient has life threatening airway, breathing, circulation problems (some or all)
There are skin and/or mucosal changes
It may be that the patient tells us they have had anaphylaxis to the “trigger” previously

8. Prognosis Overall prognosis is good, less than 1% fatality
Most fatal cases occur in asthmatics
1 in 12 patients will suffer a further episode
75% of the patients who die from anaphylaxis die from respiratory problems, the remaining 25% die from shock

9. ABCDE assessment
We use an ABCDE assessment approach to identify and treat life threatening problems, reassessing response to interventions as we progress . This approach is used as we identify symptoms and support systems in order of priority ie: if the patient doesn’t have a clear airway they won’t be able to breathe. Without breathing for a period of time, they will suffer cardiac arrest

10. Additionally:
Skin or mucosal changes alone are not a sign of an anaphlyactic reaction
Skin or mucosal changes can be subtle or absent in up 20% of reactions, this is one of the most commonly recognised signs of anaphylaxis
There may be gastrointestinal symptoms such as abdominal pain, vomiting which are less commonly recognised signs

11. Airway – signs to look for
Swelling of upper airway, including
throat, tongue and lips. This may
be noted as you hear speech changing
as lips/tongue swell
Patient may clutch at their throat and
tell you that their throat is “closing up”
The patient may develop a stridor,
wheeze or hoarse voice, indicative of
upper airway swelling (normal breathing
through a clear airway should be relatively
quiet)

12. Breathing – signs to look for
Shortness of breath
Use of accessory muscles
Raised respiratory rate
Drop in SpO2
Wheeze
Tiredness/exhaustion
Confusion or agitation due to hypoxia
Cyanosis – NB a late sign
May progress to respiratory arrest

13. Circulation – signs to look for
Visibly looking shocked, eg pale,
clammy
Flushing is common
Tachycardia
Hypotension
Light headedness
Decreased level of conciousness
May progress to cardiac arrest
NB DO NOT STAND THE PATIENT UP- THIS MAY CAUSE THEIR BP TO DROP FURTHER AND CAUSE CARDIAC ARREST ( flat with feet up is recommended where possible)

14. Disabilty (neurological status)
Decreased level of conciousness in view of airway, breathing, circulation problems
May be anxious, agitated
Sense of “impending doom”

15. Exposure
Look for the following to support the diagnosis of anaphylaxis:
Skin changes are often and early
feature and are present in over 80%
of anaphylactic reactions
Mucosal changes, angioedema
Urticarial rash (is it localised or
widespread)
It’s worth looking for a trigger that
can be removed eg medication
patch, sting etc

16. What may anaphylaxis be mistaken for?
Life threatening:
Asthma – similar symptoms, particularly in children
Septic shock – hypotension with petechial/purpuric rash
Non life threatening:
Panic attach
Idiopathic(non-allergic) urticaria or angioedema
Vasovagal episode or faint (NB these will respond quickly to reassurance, repositioning)

17. What to do now? If you’re unsure of the diagnosis seek help
If you think this is anaphylaxis call for help and treat
Anaphylaxis is potentially life threatening so call 2222 stating “medical emergency team and anaesthetic team” followed by your location (no need to call anaesthetic team separately at BGH site)
If outside of the hospital call 999 to summon ambulance

18. What to do now?

19. First line treatment
First line treatment is adrenaline given IM and repeated at intervals of 5 – 15 minutes if no response
Does in an adult is 500 mcg or 0.5 mls of 1:1000 concentration (note that this is not the concentration kept in the cardiac arrest drugs box so this cannot be used)
Adrenaline autoinjectors devices willl give a dose of 300mcg or 0.3mls, so may be used for first dose, ideally second dose will be from an ampoule at 500mcg or 0.5mls
Adrenaline is given as a vasoconstrictor (aids return of blood to major vessels) and a bronchodilator (opens airways)

20. Adrenaline auto injector pens
If you expect to use an auto injector device, take time to familiarise yourself with it before you have to use it. Most need to be held to the skin for up to 10 seconds to allow the driver system to deliver the drug

21. IM adrenaline Early use associated with improved outcomes
May reduce development of biphasic reaction
1:3 patients require more than 1 dose
61% patients require 2nd dose within 5 mins of 1st
Time to maximum concentration:
IM=8mins SC=34mins
Actions:
Dilates the bronchiole
Constricts blood vessels
Increases heart rate
In life threatening emergency has no contraindications

22. First line treatment (continued)
High flow oxygen, 15 litres via non-rebreather mask
Gain IV access or intraosseous if necessary and give fluid challenge of preferably crystalloid solution (avoid colloid if thought to have caused reaction)
Second line treatments
Hydrocortisone 10mgs IM/IV
Chlorphenamine 10 mgs IM/IV
Nebulisers if wheezy

23. If the patient improves
Continue to observe and reassess regularly, patient may have a secondary reaction
Continue to treat as necessary as per reassessments
Patient should have bloods taken for mast cell tryptase testing (identifies anaphylaxis) at the following times
As soon as possible after initial resuscitation started
1-2 hours after onset of symtoms
24 hours or at follow up
If a drugs reaction, this must be reported to pharmacy who will support you in documentation and reporting of this event
Complete DATIX as record of event in addition to clinical notes

24. If the patient deteriorates further
Should the patient progress to cardiac arrest follow current resuscitation guidelines (stop treating with IM adrenaline and move to cardiac arrest management drug protocols)
Administer IV fluids
Resuscitation will often be prolonged, as we know what has caused this (hypoxia and hypovolaemia)
High quality CPR essential
Complete DATIX as record of event in addition to clinical notes

25. What drugs can I give?
A healthcare professional can give adrenaline for anaphylaxis if the purpose is to save a life, even in the absence of a prescription or Patient Group Direction (PGD), it would be incorrect to think you are not “covered” for this. A PGD guides local practice in this scenario By calling for further help immediately, you will have quick access to other HCPs who can prescribe and administer second line drugs that you may not be able to prescribe yourself

26. Will I recognise anaphylaxis?:
One of the most common concerns raised by staff is would they recognise anaphylaxis. Watch the short film (link below) of a man who has a severe peanut allergy who films his reaction after accidental ingestion of peanuts in a food substance. Imagine this is a patient to whom you have just administered an IM injection and decide at what point you would call for help and give IM adrenaline if necessary

27. In summary
Anaphylaxis may be life threatening. Prompt recognition and treatment maximises chance of survival
Assess using ABCDE approach
If anaphylaxis call for help and commence treatment
Record events clearly post event