Statement PaperEmergency treatment of anaphylactic reactions—Guidelines for healthcare providers☆
Introduction
The UK incidence of anaphylactic reactions is rising.1 Despite previous guidelines, there is confusion about the diagnosis, treatment, investigation and follow-up of patients who have an anaphylactic reaction.2, 3, 4
This guideline replaces the previous guidance from the Resuscitation Council UK.5 The full version of this guideline and supplementary information is available on the Resuscitation Council UK website (www.resus.org.uk).
There are no randomised controlled clinical trials in humans providing unequivocal evidence for the treatment of anaphylactic reactions. Nonetheless, there is a wealth of experience and systematic reviews of the limited evidence that can be used as a resource.6
This guideline gives:
- 1.
An updated consensus about the recognition and treatment of anaphylactic reactions.
- 2.
A greater focus on the treatments that a patient having an anaphylactic reaction should receive. There is less emphasis on specifying treatments according to which specific groups of healthcare providers should give them.
- 3.
Recommendations for treatment that are simple to learn and easy to implement, and that will be appropriate for most anaphylactic reactions.
This guideline is for healthcare providers who are expected to deal with an anaphylactic reaction during their usual clinical role (e.g., doctors, nurses, paramedics) working in the hospital or out-of-hospital setting. There is considerable variation and overlap between the skills and knowledge of different healthcare providers who are expected to treat an anaphylactic reaction. We have therefore deliberately not developed guidelines for specific groups of healthcare provider.
The Association of Anaesthetists of Great Britain & Ireland and the British Society for Allergy and Clinical Immunology have published specific guidance for the treatment of anaphylactic reactions associated with anaesthesia (www.aagbi.org and www.bsaci.org).
There is also specific guidance for managing medicines in schools, nurseries and similar settings (www.allergyinschools.org.uk and www.medicalconditionsatschool.org.uk).7, 8
The key treatment of a patient having an anaphylactic reaction in any setting is the same for children9 and adults. Any differences will be highlighted.
Organisations involved in the previous guideline nominated individuals for the Working Group. The co-chairs (appointed by the Executive Committee of the Resuscitation Council UK) identified the key issues based on review of the previous guidelines and a database of frequently asked questions. The group met in January and November 2007. Drafts of this guideline were discussed by email. A draft guideline was made available for comment on the Resuscitation Council UK website between 25th September and 4th November 2007. The document was accessed 15,432 times in this period. The feedback was reviewed at the November working group meeting and the document updated. The final guideline was made available on the Resuscitation Council UK website in January 2008. The review date for the guideline is January 2013 or earlier if necessary.
Section snippets
Definition of anaphylaxis
A precise definition of anaphylaxis is not important for the emergency treatment of an anaphylactic reaction. There is no universally agreed definition. The European Academy of Allergology and Clinical Immunology Nomenclature Committee proposed the following broad definition10:
Epidemiology
Anaphylaxis is not always recognised, so studies may
Recognition of an anaphylactic reaction
Anaphylactic reaction is the likely diagnosis if a patient who is exposed to a trigger (allergen) develops a sudden illness (usually within minutes) with rapidly developing life-threatening airway and, or breathing and, or circulation problems usually associated with skin and mucosal changes. The reaction is usually unexpected.
The lack of any consistent clinical manifestation and a range of possible presentations cause diagnostic difficulty. Many patients with a genuine anaphylactic reaction
Treatment of an anaphylactic reaction
As the diagnosis of anaphylaxis is not always obvious, all those who treat anaphylaxis must have a systematic approach to the sick patient. In general, the clinical signs of critical illness are similar whatever the underlying process because they reflect failing respiratory, cardiovascular, and neurological systems, i.e., ABCDE problems. Use an ABCDE approach to recognise and treat an anaphylactic reaction. Treat life-threatening problems as you find them. The basic principles of treatment are
Adrenaline (epinephrine)
Adrenaline is the most important drug for the treatment of an anaphylactic reaction.38 Although there are no randomised controlled trials, adrenaline is a logical treatment31 and there is consistent anecdotal evidence supporting its use to ease breathing and circulation problems associated with anaphylaxis. As an alpha-receptor agonist, it reverses peripheral vasodilation and reduces oedema. Its beta-receptor activity dilates the bronchial airways, increases the force of myocardial contraction,
Investigations
Undertake the usual investigations appropriate for a medical emergency, e.g., arterial blood gases, 12-lead ECG, chest X-ray, urea and electrolytes, etc.
Discharge from hospital
Patients who have had a suspected anaphylactic reaction (i.e., an airway, breathing or circulation (ABC) problem) should be treated and then observed for at least 6 h in a clinical area with facilities for treating life-threatening ABC problems.64 They should then be reviewed by a senior clinician and a decision made about the need for further treatment or a longer period of observation. Patients with a good response to initial treatment should be warned of the possibility of an early recurrence
Conflict of interest
Dr Jasmeet Soar (Co-Chair), Consultant in Anaesthetics & Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, no conflict of interest.
Dr Richard Pumphrey (Co-Chair), Honorary Consultant in Clinical Immunology, Central Manchester & Manchester Children's Hospitals, Manchester M13 9WL, no conflict of interest.
Professor Andrew Cant, Consultant in Paediatric Immunology, Ward 23, Newcastle General Hospital, Westgate Rd, Newcastle upon Tyne, NE4 6BE, no conflict of
References (72)
- 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) - 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) - et al.
Epidemiology of anaphylaxis in Olmsted County: a population-based study
J Allergy Clin Immunol
(1999) - et al.
Emergency department anaphylaxis: a review of 142 patients in a single year
J Allergy Clin Immunol
(2001) - et al.
Epidemiology of anaphylaxis among children and adolescents enrolled in a health maintenance organization
J Allergy Clin Immunol
(2004) - et al.
Further fatal allergic reactions to food in the United Kingdom, 1999–2006
J Allergy Clin Immunol
(2007) Clinical features and severity grading of anaphylaxis
J Allergy Clin Immunol
(2004)- et al.
Food allergy as a risk factor for life-threatening asthma in childhood: a case-controlled study
J Allergy Clin Immunol
(2003) Fatal posture in anaphylactic shock
J Allergy Clin Immunol
(2003)- 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)
European Resuscitation Council guidelines for resuscitation 2005. Section 7. Cardiac arrest in special circumstances
Resuscitation
Removing bee stings
Lancet
European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support
Resuscitation
European Resuscitation Council guidelines for resuscitation 2005. Section 6. Paediatric life support
Resuscitation
Epinephrine absorption in adults: intramuscular versus subcutaneous injection
J Allergy Clin Immunol
Adequacy of the epinephrine autoinjector needle length in delivering epinephrine to the intramuscular tissues
Ann Allergy Asthma Immunol
Epinephrine absorption in children with a history of anaphylaxis
J Allergy Clin Immunol
Epinephrine for the out-of-hospital (first-aid) treatment of anaphylaxis in infants: is the ampule/syringe/needle method practical?
J Allergy Clin Immunol
Epidemiology of anesthetic anaphylactoid reactions. Fourth multicenter survey (July 1994–December 1996)
Ann Fr Anesth Reanim
Five-year experience in prehospital intraosseous infusions in children and adults
Ann Emerg Med
Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists
Ann Emerg Med
Diagnostic value of tryptase in anaphylaxis and mastocytosis
Immunol Allergy Clin North Am
Biphasic anaphylactic reactions
Ann Allergy Asthma Immunol
Best evidence topic reports. Oral corticosteroids in acute urticaria
Emerg Med J
First aid anaphylaxis management in children who were prescribed an epinephrine autoinjector device (EpiPen)
J Allergy Clin Immunol
Action plans for the long-term management of anaphylaxis: systematic review of effectiveness
Clin Exp Allergy
Proposed use of adrenaline (epinephrine) in anaphylaxis and related conditions: a study of senior house officers starting accident and emergency posts
Postgrad Med J
Adrenaline given outside the context of life threatening allergic reactions
BMJ
Survey of the use of epinephrine (adrenaline) for anaphylaxis by junior hospital doctors
Postgrad Med J
Emergency medical treatment of anaphylactic reactions. Project Team of The Resuscitation Council (UK)
Resuscitation
Evidence-based management of anaphylaxis
Allergy
Management of children with potential anaphylactic reactions in the community: a training package and proposal for good practice
Clin Exp Allergy
Topical application of luteolin inhibits scratching behavior associated with allergic cutaneous reaction in mice
Planta Med
The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology
Allergy
Cited by (0)
- ☆
A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.02.001.
- 1
See Appendix A.