Anaphylaxis

Introduction
Rapid onset of allergic manifestations in
response to an allergen that has
sensitised the immune system previously
Anaphylactoid reactions are clinically
indiscernible but do not have an immunemediated underlying mechanism.

Pathophysiology
Most common cause is drugs, insect bites and
stings, and food
An IgE mediated release of preformed
vasoactive substances including histamine and
leukotrienes occurs, resulting in clinical
manifestations.
Thereafter, vasodilation, increased capillary
permeabilty, increased mucous production and
bronchoconstriction

Clinical
Typically of sudden onset, important features:
Respiratory
Upper: oropharyngeal oedema, rhinorrhea, layngeal
spasm or oedema
Lower: cough, dyspnoea, bronchospasm and
respiratory distress
Cardiovascular
Hypotension, tachycardia or syncope
Cutaneous
Erythema, urticaria, or angio-oedema with pruritus
Gastrointestinal
Abdominal pain, vomiting or diarrhoea

Adult Guidelines
Investigations:
- Majority of cases nil investigations required
- Severe cases may require standard pathology
studies, CXR and ECG

Treatment
Basic measures
- Triage to appropriate area of ED
- Attend to immediate life threat- ABCs
- Remove or cease administration of causative
agent
- IV access and fluids
- Monitoring vital signs, ECG and O2 saturation

First line treatment

O2 to maintain adequate saturation >92%
Adrenaline- drug of choice in all serious
cases
- If stable (0.5mg IM of 1:1000) Rpt every 5 minutes as required
according to BP/Pulse/Respiratory function
- If unstable initial IV bolus 0.75-1.5mcg/kg, then 10-20mcg IV
increments
- If predominantly upper airway manifestations or bronchospasm5mg of 1:1000 solution via nebuliser

- IV Fluids

Second line treatment

Antihistamines
-

H1 blockers- Promethazine 10-25mg IV, IM or oral

H2 blockers- Ranitidine 50mg IV, or 300mg orally

Steroids
-

Prednisolone 25-50mg orally

Hydrocortisone 100-250mg IV
Dexamethasone 4-8mg IV, IM

Glucagon
-

Has a place when patient is on Beta Blockers and relatively resistant to

Adrenaline, or severe refractory anaphylaxis. 1mg IV repeated 5 minutely or by
infusion

Disposition
95% of patients have a uniphasic presentation, and will require 48hrs observation prior discharge
Small amount of people will develop delayed recurrent
symptoms, hence the time frame for observation
If severe cases might require ICU admission
Most cases can be discharged on antihistmines +/- steroids for 23 days with GP follow up
If cause not known for anaphylaxis, will require further
investigations by allergist or immunologist as outpatient
Need to educate all patients how to manage this in a repeat
episode and should be discharged and educated on an epipen

Guidelines
Australian Prescriber Guidelines
http://www.australianprescriber.com/
Update 2011