Advertisement

Emergency treatment of anaphylactic reactions—Guidelines for healthcare providers

      Summary

      • The UK incidence of anaphylactic reactions is increasing.
      • Patients who have an anaphylactic reaction have life-threatening airway and, or breathing and, or circulation problems usually associated with skin or mucosal changes.
      • Patients having an anaphylactic reaction should be treated using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach.
      • Anaphylactic reactions are not easy to study with randomised controlled trials. There are, however, systematic reviews of the available evidence and a wealth of clinical experience to help formulate guidelines.
      • The exact treatment will depend on the patient's location, the equipment and drugs available, and the skills of those treating the anaphylactic reaction.
      • Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction.
      • Despite previous guidelines, there is still confusion about the indications, dose and route of adrenaline.
      • Intravenous adrenaline must only be used in certain specialist settings and only by those skilled and experienced in its use.
      • All those who are suspected of having had an anaphylactic reaction should be referred to a specialist in allergy.
      • Individuals who are at high risk of an anaphylactic reaction should carry an adrenaline auto-injector and receive training and support in its use.
      • There is a need for further research about the diagnosis, treatment and prevention of anaphylactic reactions.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Resuscitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. Department of Health E. A review of services for allergy. The epidemiology, demand for, and provision of treatment and effectiveness of clinical interventions. Department of Health; 2006.

        • Gompels L.L.
        • Bethune C.
        • Johnston S.L.
        • Gompels M.M.
        Proposed use of adrenaline (epinephrine) in anaphylaxis and related conditions: a study of senior house officers starting accident and emergency posts.
        Postgrad Med J. 2002; 78: 416-418
        • Johnston S.L.
        • Unsworth J.
        • Gompels M.M.
        Adrenaline given outside the context of life threatening allergic reactions.
        BMJ. 2003; 326: 589-590
        • Jose R.
        • Clesham G.J.
        Survey of the use of epinephrine (adrenaline) for anaphylaxis by junior hospital doctors.
        Postgrad Med J. 2007; 83: 610-611
      2. Emergency medical treatment of anaphylactic reactions. Project Team of The Resuscitation Council (UK).
        Resuscitation. 1999; 41: 93-99
        • Simons F.E.
        • Sheikh A.
        Evidence-based management of anaphylaxis.
        Allergy. 2007; 62: 827-829
        • Vickers D.W.
        • Maynard L.
        • Ewan P.W.
        Management of children with potential anaphylactic reactions in the community: a training package and proposal for good practice.
        Clin Exp Allergy. 1997; 27: 898-903
        • Baolin L.
        • Weiwei W.
        • Ning T.
        Topical application of luteolin inhibits scratching behavior associated with allergic cutaneous reaction in mice.
        Planta Med. 2005; 71: 424-428
        • Muraro A.
        • Roberts G.
        • Clark A.
        • et al.
        The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology.
        Allergy. 2007; 62: 857-871
        • Johansson S.G.
        • Bieber T.
        • Dahl R.
        • et al.
        Revised nomenclature for allergy for global use: report of the Nomenclature Review Committee of the World Allergy Organization, October 2003.
        J Allergy Clin Immunol. 2004; 113: 832-836
        • Lieberman P.
        • Camargo Jr., C.A.
        • Bohlke K.
        • et al.
        Epidemiology of anaphylaxis: findings of the American College of Allergy. Asthma and Immunology Epidemiology of Anaphylaxis Working Group.
        Ann Allergy Asthma Immunol. 2006; 97: 596-602
      3. Sheikh A H-CJ, Newton J, Fenty J. Trends in national incidence, lifetime prevalence and adrenaline prescribing for anaphylaxis in England. J R Soc Med, 2008, in press.

        • Stewart A.G.
        • Ewan P.W.
        The incidence, aetiology and management of anaphylaxis presenting to an accident and emergency department.
        QJM. 1996; 89: 859-864
        • Pumphrey R.S.
        Fatal anaphylaxis in the UK, 1992–2001.
        Novartis Found Symp. 2004; 257 ([discussion 128–32, 157–60, 276–85]): 116-128
        • Alves B.
        • Sheikh A.
        Age specific aetiology of anaphylaxis.
        Arch Dis Child. 2001; 85: 348
        • Ewan P.W.
        Anaphylaxis.
        BMJ. 1998; 316: 1442-1445
        • Yocum M.W.
        • Butterfield J.H.
        • Klein J.S.
        • Volcheck G.W.
        • Schroeder D.R.
        • Silverstein M.D.
        Epidemiology of anaphylaxis in Olmsted County: a population-based study.
        J Allergy Clin Immunol. 1999; 104: 452-456
        • Brown A.F.
        • McKinnon D.
        • Chu K.
        Emergency department anaphylaxis: a review of 142 patients in a single year.
        J Allergy Clin Immunol. 2001; 108: 861-866
        • Bohlke K.
        • Davis R.L.
        • DeStefano F.
        • Marcy S.M.
        • Braun M.M.
        • Thompson R.S.
        Epidemiology of anaphylaxis among children and adolescents enrolled in a health maintenance organization.
        J Allergy Clin Immunol. 2004; 113: 536-542
        • Pumphrey R.S.
        • Gowland M.H.
        Further fatal allergic reactions to food in the United Kingdom, 1999–2006.
        J Allergy Clin Immunol. 2007; 119: 1018-1019
        • Gupta R.
        • Sheikh A.
        • Strachan D.P.
        • Anderson H.R.
        Burden of allergic disease in the UK: secondary analyses of national databases.
        Clin Exp Allergy. 2004; 34: 520-526
        • Mullins R.J.
        Anaphylaxis: risk factors for recurrence.
        Clin Exp Allergy. 2003; 33: 1033-1040
        • Gupta R.
        • Sheikh A.
        • Strachan D.P.
        • Anderson H.R.
        Time trends in allergic disorders in the UK.
        Thorax. 2007; 62: 91-96
        • Pumphrey R.S.
        Lessons for management of anaphylaxis from a study of fatal reactions.
        Clin Exp Allergy. 2000; 30: 1144-1150
        • Haymore B.R.
        • Carr W.W.
        • Frank W.T.
        Anaphylaxis and epinephrine prescribing patterns in a military hospital: underutilization of the intramuscular route.
        Allergy Asthma Proc. 2005; 26: 361-365
        • Brown S.G.
        Clinical features and severity grading of anaphylaxis.
        J Allergy Clin Immunol. 2004; 114: 371-376
        • Schmidt-Traub S.
        • Bamler K.J.
        The psychoimmunological association of panic disorder and allergic reaction.
        Br J Clin Psychol. 1997; 36: 51-62
        • Roberts G.
        • Patel N.
        • Levi-Schaffer F.
        • Habibi P.
        • Lack G.
        Food allergy as a risk factor for life-threatening asthma in childhood: a case-controlled study.
        J Allergy Clin Immunol. 2003; 112: 168-174
        • Pumphrey R.S.
        Fatal posture in anaphylactic shock.
        J Allergy Clin Immunol. 2003; 112: 451-452
        • Gikas A.
        • Lazaros G.
        • Kontou-Fili K.
        Acute ST-segment elevation myocardial infarction after amoxycillin-induced anaphylactic shock in a young adult with normal coronary arteries: a case report.
        BMC Cardiovasc Disord. 2005; 5: 6
        • Brown S.G.
        Cardiovascular aspects of anaphylaxis: implications for treatment and diagnosis.
        Curr Opin Allergy Clin Immunol. 2005; 5: 359-364
        • Sampson H.A.
        • Munoz-Furlong A.
        • Campbell R.L.
        • et al.
        Second symposium on the definition and management of anaphylaxis: summary report–second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium.
        Ann Emerg Med. 2006; 47: 373-380
      4. National Minimum Standards for Immunisation Training. Health Protection Agency; 2005.

        • Soar J.
        • Deakin C.D.
        • Nolan J.P.
        • et al.
        European Resuscitation Council guidelines for resuscitation 2005. Section 7. Cardiac arrest in special circumstances.
        Resuscitation. 2005; 67: S135-S170
        • Visscher P.K.
        • Vetter R.S.
        • Camazine S.
        Removing bee stings.
        Lancet. 1996; 348: 301-302
        • Nolan J.P.
        • Deakin C.D.
        • Soar J.
        • Bottiger B.W.
        • Smith G.
        European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support.
        Resuscitation. 2005; 67: S39-S86
        • Biarent D.
        • Bingham R.
        • Richmond S.
        • et al.
        European Resuscitation Council guidelines for resuscitation 2005. Section 6. Paediatric life support.
        Resuscitation. 2005; 67: S97-S133
        • McLean-Tooke A.P.
        • Bethune C.A.
        • Fay A.C.
        • Spickett G.P.
        Adrenaline in the treatment of anaphylaxis: what is the evidence?.
        BMJ. 2003; 327: 1332-1335
        • Kay L.J.
        • Peachell P.T.
        Mast cell beta2-adrenoceptors.
        Chem Immunol Allergy. 2005; 87: 145-153
        • Chong L.K.
        • Morice A.H.
        • Yeo W.W.
        • Schleimer R.P.
        • Peachell P.T.
        Functional desensitization of beta agonist responses in human lung mast cells.
        Am J Respir Cell Mol Biol. 1995; 13: 540-546
        • Bautista E.
        • Simons F.E.
        • Simons K.J.
        • et al.
        Epinephrine fails to hasten hemodynamic recovery in fully developed canine anaphylactic shock.
        Int Arch Allergy Immunol. 2002; 128: 151-164
        • Simons F.E.
        • Gu X.
        • Simons K.J.
        Epinephrine absorption in adults: intramuscular versus subcutaneous injection.
        J Allergy Clin Immunol. 2001; 108: 871-873
        • Song T.T.
        • Nelson M.R.
        • Chang J.H.
        • Engler R.J.
        • Chowdhury B.A.
        Adequacy of the epinephrine autoinjector needle length in delivering epinephrine to the intramuscular tissues.
        Ann Allergy Asthma Immunol. 2005; 94: 539-542
        • Simons F.E.
        • Roberts J.R.
        • Gu X.
        • Simons K.J.
        Epinephrine absorption in children with a history of anaphylaxis.
        J Allergy Clin Immunol. 1998; 101: 33-37
        • Simons F.E.
        • Gu X.
        • Johnston L.M.
        • Simons K.J.
        Can epinephrine inhalations be substituted for epinephrine injection in children at risk for systemic anaphylaxis?.
        Pediatrics. 2000; 106: 1040-1044
        • Simons F.E.
        • Chan E.S.
        • Gu X.
        • Simons K.J.
        Epinephrine for the out-of-hospital (first-aid) treatment of anaphylaxis in infants: is the ampule/syringe/needle method practical?.
        J Allergy Clin Immunol. 2001; 108: 1040-1044
        • Brown S.G.
        • Blackman K.E.
        • Stenlake V.
        • Heddle R.J.
        Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation.
        Emerg Med J. 2004; 21: 149-154
        • Laxenaire M.C.
        Epidemiology of anesthetic anaphylactoid reactions. Fourth multicenter survey (July 1994–December 1996).
        Ann Fr Anesth Reanim. 1999; 18: 796-809
        • Ewan P.W.
        Adverse reactions to colloids.
        Anaesthesia. 2001; 56: 771-772
        • Glaeser P.W.
        • Hellmich T.R.
        • Szewczuga D.
        • Losek J.D.
        • Smith D.S.
        Five-year experience in prehospital intraosseous infusions in children and adults.
        Ann Emerg Med. 1993; 22: 1119-1124
        • Sheikh A.
        • Ten Broek V.
        • Brown S.G.
        • Simons F.E.
        H(1)-antihistamines for the treatment of anaphylaxis: Cochrane systematic review.
        Allergy. 2007; 62: 830-837
        • Lin R.Y.
        • Curry A.
        • Pesola G.R.
        • et al.
        Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists.
        Ann Emerg Med. 2000; 36: 462-468
        • Rowe B.H.
        • Spooner C.
        • Ducharme F.M.
        • Bretzlaff J.A.
        • Bota G.W.
        Early emergency department treatment of acute asthma with systemic corticosteroids.
        Cochrane Database Syst Rev. 2001; : CD002178
        • Smith M.
        • Iqbal S.
        • Elliott T.M.
        • Everard M.
        • Rowe B.H.
        Corticosteroids for hospitalised children with acute asthma.
        Cochrane Database Syst Rev. 2003; : CD002886
        • Manser R.
        • Reid D.
        • Abramson M.
        Corticosteroids for acute severe asthma in hospitalised patients.
        Cochrane Database Syst Rev. 2001; : CD001740
        • Dewachter P.
        • Raeth-Fries I.
        • Jouan-Hureaux V.
        • et al.
        A comparison of epinephrine only, arginine vasopressin only, and epinephrine followed by arginine vasopressin on the survival rate in a rat model of anaphylactic shock.
        Anesthesiology. 2007; 106: 977-983
        • Higgins D.J.
        • Gayatri P.
        Methoxamine in the management of severe anaphylaxis.
        Anaesthesia. 1999; 54: 1126
        • Heytman M.
        • Rainbird A.
        Use of alpha-agonists for management of anaphylaxis occurring under anaesthesia: case studies and review.
        Anaesthesia. 2004; 59: 1210-1215
        • Kill C.
        • Wranze E.
        • Wulf H.
        Successful treatment of severe anaphylactic shock with vasopressin. Two case reports.
        Int Arch Allergy Immunol. 2004; 134: 260-261
        • Schummer W.
        • Schummer C.
        • Wippermann J.
        • Fuchs J.
        Anaphylactic shock: is vasopressin the drug of choice?.
        Anesthesiology. 2004; 101: 1025-1027
        • Thomas M.
        • Crawford I.
        Best evidence topic report. Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers.
        Emerg Med J. 2005; 22: 272-273
        • Schwartz L.B.
        Diagnostic value of tryptase in anaphylaxis and mastocytosis.
        Immunol Allergy Clin North Am. 2006; 26: 451-463
        • Brown S.G.
        • Blackman K.E.
        • Heddle R.J.
        Can serum mast cell tryptase help diagnose anaphylaxis?.
        Emerg Med Australas. 2004; 16: 120-124
        • Brown A.F.
        Therapeutic controversies in the management of acute anaphylaxis.
        J Accid Emerg Med. 1998; 15: 89-95
        • Lieberman P.
        Biphasic anaphylactic reactions.
        Ann Allergy Asthma Immunol. 2005; 95: 217-226
      5. quiz 226, 258
        • Tole J.W.
        • Lieberman P.
        Biphasic anaphylaxis: review of incidence, clinical predictors, and observation recommendations.
        Immunol Allergy Clin North Am. 2007; 27 (viii): 309-326
        • Poon M.
        • Reid C.
        Best evidence topic reports. Oral corticosteroids in acute urticaria.
        Emerg Med J. 2004; 21: 76-77
        • Zull D.N.
        Preventing fatalities from anaphylaxis: an emergency medicine physician's perspective.
        Allergy Proc. 1995; 16: 113-114
        • Sicherer S.H.
        • Simons F.E.
        Quandaries in prescribing an emergency action plan and self-injectable epinephrine for first-aid management of anaphylaxis in the community.
        J Allergy Clin Immunol. 2005; 115: 575-583
        • Gold M.S.
        • Sainsbury R.
        First aid anaphylaxis management in children who were prescribed an epinephrine autoinjector device (EpiPen).
        J Allergy Clin Immunol. 2000; 106: 171-176
        • Choo K.
        • Sheikh A.
        Action plans for the long-term management of anaphylaxis: systematic review of effectiveness.
        Clin Exp Allergy. 2007; 37: 1090-1094
        • Ewan P.W.
        • Clark A.T.
        Efficacy of a management plan based on severity assessment in longitudinal and case-controlled studies of 747 children with nut allergy: proposal for good practice.
        Clin Exp Allergy. 2005; 35: 751-756