Elsevier

Resuscitation

Volume 77, Issue 2, May 2008, Pages 157-169
Resuscitation

Statement Paper
Emergency treatment of anaphylactic reactions—Guidelines for healthcare providers

https://doi.org/10.1016/j.resuscitation.2008.02.001Get rights and content

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.

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

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    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.

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