Sponsor: Clinical Board
Name: Anaphylaxis Policy
ORGANISATIONAL
POLICY:
ANAPHYLAXIS POLICY
Immediate management plan for a patient suffering from an anaphylactic reaction
AUTHOR:
Resuscitation Coordinator
AUTHORITATIVE SOURCES:
New Zealand Resuscitation Council
United Kingdom Resuscitation Council
Tairawhiti District Health (TDH) Resuscitation Committee
Clinical Board
PURPOSE:

To ensure all patients who are experiencing an anaphylactic reaction are cared
for using a standardised management plan based on contemporary best practice
guidelines

To enable the healthcare professional to treat immediately to prevent further
deterioration in the patients condition

To highlight the differences in the resuscitation management of a patient who
has arrested due to anaphylaxis
SCOPE OF POLICY:
The following policy applies to all staff of TDH who administer or use substances
likely to cause an allergic reaction or who are responsible for caring with those with
an anaphylactic reaction during their usual clinical role.
POLICY STATEMENTS:
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TDH will regard an anaphylactic reaction as a medical emergency and will treat it
with the same urgency as a cardiac arrest
TDH will adopt the current recommended management principles and guidelines
of the New Zealand Resuscitation Council in regard to treating patients
experiencing anaphylaxis.
TDH acknowledge that individuals will work within their scope of practice as
health professionals
TDH recognise that the exact treatment will depend on the severity of the
patients condition, their location and the expertise, equipment and drugs
available
Author: Resuscitation Co-ordinator
Authorised By: Chief Executive
Date of first approval: November 2008
Date last review completed: November 2008
Page:1 of 9
Sponsor: Clinical Board
Name: Anaphylaxis Policy
DEFINITIONS:
Anaphylaxis: ‘Anaphylaxis is a severe life threatening generalised, systemic
hypersensitivity reaction that involves an abnormal/antibody response to a trigger. It
is characterised by rapidly developing life-threatening airway and/or breathing and/or
circulation problems usually associated with skin and mucosal change’ – World
Health Organisation 2003(1)
Severe anaphylaxis may lead to respiratory arrest due to bronchoconstriction.
Anaphylaxis can cause cardiac arrest within minutes of initial reaction, where PEA
(Pulseless Electrical Activity) rapidly deteriorates into asystole due to severe
hypovolaemia and hypoxia.
Causes: Common precipitating agents are stings, food, antibiotics, contrast media,
thrombolytics, non steroidal anti-inflammatory drugs and anaesthetic agents
Influencing Factors: Conditions such as asthma, pre-existing hypovolaemia, heart
failure and coronary disease predispose the patient to increasing levels of severity
and potentially fatal complications.
Some drugs also emphasise the anaphylaxis or the effects of adrenalin, for e.g.
betablockers, tricyclic anti depressants, MAOI
For the purpose of this document, the following definitions apply:
Hypotension: systolic blood pressure below 90mmHg
Hypovolaemia: decrease in the volume of circulating blood
Bronchospasm: constriction of small airways
Angioedema - swelling of deeper tissues. Most commonly in the eyelids and lips,
and sometimes in the mouth and throat
Erythema – a patchy or generalised red rash
Urticaria – also known as hives, weals or welts. Pale pink or red nettle sting type
rash. Can be different shapes and sizes. Usually itchy
Trigger/ Allergen - the substance that is the cause of the reaction – for example
drug, sting, food type
Cardiovascular collapse - A sudden loss of effective blood flow due to cardiac
and/or peripheral vascular factors
PEA - Pulseless Electrical Activity - Cardiac arrest in the presence of ECG
complexes but no palpable pulse
Author: Resuscitation Co-ordinator
Authorised By: Chief Executive
Date of first approval: November 2008
Date last review completed: November 2008
Page:2 of 9
Sponsor: Clinical Board
Name: Anaphylaxis Policy
Differential diagnosis – other potential causes for signs and symptoms
AVPU – a tool used for assessing conscious levels. (Alert, Voice, Pain,
Unresponsive)
DRS ABC – the systematic approach used when dealing with a collapse. (Dangers?
Response? Send for help, Airway? Breathing? Circulation?)
Diagnosing Anaphylaxis
Anaphylaxis is likely when the following criteria are met:

Sudden onset and rapid progression of symptoms

Life-threatening Airway and/or Breathing and/or Circulation problems
 +/- Skin and/or mucosal changes (flushing, urticaria, angioedema)
The following supports the diagnosis:

Exposure to a known allergen for the patient
Remember
 Skin or mucosal changes alone are not a sign of an anaphylactic reaction
 Skin and mucosal changes can be subtle or absent in up to 20% of
reactions (some patients can have only a decrease in blood
pressure, i.e. a Circulation problem)
 There can also be gastrointestinal symptoms (e.g. vomiting, abdominal pain,
incontinence)
Management Principles
The exact treatment will depend on the severity of the patient’s condition, their
location and the expertise, equipment and drugs available- but the main stays of
the treatment are administration of
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Adrenaline
Fluid therapy
Antihistamines
Corticosteroids
Author: Resuscitation Co-ordinator
Authorised By: Chief Executive
Date of first approval: November 2008
Date last review completed: November 2008
Page:3 of 9
Sponsor: Clinical Board
Name: Anaphylaxis Policy
Management guidelines
Due to the potential rapidity of patient deterioration it is essential to adopt a rational
systematic approach –‘DRS’ A B C D E’ and it is necessary to treat life threatening
problems as they are recognized
For staff working in the community setting the emphasis is on removal of the
allergen, early call for help by dialling 111, laying the patient flat, administration of IM
Adrenaline and continual reassessment of the patient’s airway, breathing and
circulation until help arrives
If the diagnosis of anaphylaxis seems most likely:
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Stop the administration of any intravenous drug or remove the direct exposure to
the allergen. (For e.g. if latex suspected wash out wound/skin that had contact,
or removal of the bee sting)
Call for help and activate the 777 alarm.
Lie the patient flat
Give high flow oxygen as soon as it becomes available and monitor oxygen
saturations
Assess the degree of Angioedema (A) - presence of hoarse voice, stridor,
feeling of throat closing over
Assess the degree of Bronchospasm (B) – signs of breathing difficulty, wheeze
and respiratory distress
Attach patient to a cardiac monitor. Assess the degree of Cardiovascular
collapse (C) –evidence of tachycardia, hypotension, pallor, clamminess.
Disability (D) - Assess patients conscious level by using the AVPU scale
Exposure (E) – Check the patient for any signs of rash or mucosal swelling
Exclude other life threatening and non life threatening differential diagnoses: e.g.
asthma, meningococcal sepsis, heart failure, tension pneumothorax, panic
attacks.
If the patient shows signs of angioedema, bronchospasm or cardiovascular
collapse immediately:
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Administer IM Adrenalin 0.5mg (or 0.5ml) of 1:1000 into the thigh muscle
If hypotensive, tilt the patients bed so that legs are raised
Attempt to insert a large size 14 gauge cannula, into the antecubital fossa or
other available large vein, if this is difficult any size cannula is better than no
cannula at all. If this is not possible – IO access is a viable option in children and
adults
Commence rapid intravenous fluid infusion of either colloid, preferably Starquin,
or normal saline. Adjust the following fluid requirements according to patient’s
needs – aim for systolic BP above 90 mmhg. Between 1-3 litres of saline and
500-1500ml of colloid is usually needed
Author: Resuscitation Co-ordinator
Authorised By: Chief Executive
Date of first approval: November 2008
Date last review completed: November 2008
Page:4 of 9
Sponsor: Clinical Board

Name: Anaphylaxis Policy
If time allows go ahead and administer the antihistamine – IV Promethazine
25mg by slow intravenous injection and the corticosteroid – IV Hydrocortisone
250mg (both can be given IM/IO if IV access unavailable)
NB IV promethazine and IV hydrocortisone will not affect the haemodynamic or the
respiratory state of critical condition- so although important do not let them delay
other lifesaving treatments, for e.g IV fluids, if they have not been commenced or
second dose of Adrenaline if 5 minutes have already passed since the first dose
Reassess after 5 minutes of first dose of Adrenaline and if continuing signs of
angioedema, bronchospasm and cardiovascular collapse:

Commence titration of IV Adrenaline if the expertise is available (see box below).
Intra osseus Adrenaline can also be used if the equipment is obtainable. If not
repeat IM Adrenaline 0.5mg (or 0.5ml) of 1:1000 into the thigh muscle
IV Adrenaline Titration –
If expertise and facilities allow, careful titration of IV Adrenaline can be considered
as an alternative route to IM adrenaline.
Before administration, IV access must be secured, ECG monitoring attached and
continual BP monitoring in situ. If the systolic BP is less than 80mmhg then IV
titration can begin.
Using a 1:10,000 solution, administer small increments of 1ml (100mcg) every
one minute and observe the response. Do not give as a bolus but as a slow
infusion using the hand held syringe. If BP does not respond to this after 3
minutes double the dose to 2ml (200mcg) every one minute. Continue until BP
above 90 mmHg. Thereafter small 0.5ml doses may be needed to maintain BP
above 90. Further dilution to 1:100 000 may be useful to allow finer increments
doses.
NB If adrenaline is causing any ventricular arrhythmias, chest pain or severe
tachycardia >150 bpm or if the heart rate is above 150 bpm prior to adrenaline
administration consider using the alpha agonist, IV Metaraminol 1mg – dilute the
10mg in 1ml ampoule with 9mls of water. It can be then be given in 1mg /1ml
increments every 2 minutes until the blood pressure rises above 90 mmHg
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If angioedema (A) persists consider nebulised adrenaline 1mg, i.e. 1ml of
1:1000 mixed with 5ml Normal Saline. If no improvement consider early
intubation by a skilled practitioner – it may be useful to use an ET tube that is 2
sizes smaller due to obstructive swelling
If bronchospasm (B) is still persisting, administer salbutamol 5mg nebulizer
and monitor heart rate - treat as an asthmatic emergency
Continue to assess cardiovascular collapse (C) – IV adrenalin should be being
titrated but if resources do not allow, i.e. a community setting a third IM dose of
Author: Resuscitation Co-ordinator
Authorised By: Chief Executive
Date of first approval: November 2008
Date last review completed: November 2008
Page:5 of 9
Sponsor: Clinical Board

Name: Anaphylaxis Policy
IM Adrenalin 0.5mg (or 0.5ml) of 1:1000 may be repeated after 5 minutes from
previous dose
If hypotension continues administer an H2 antihistamine – IV Ranitidine 50mg
slowly.
The patient’s condition can deteriorate rapidly into P.E.A cardiac arrest.
There can be a delay in recognizing this as the cardiac monitor will still
show electrical activity. The patient however will have no output and no
pulse, and be in cardiac arrest.
If patient becomes unresponsive, commence standard NZRC collapse
guidelines using the ABCDE approach. If patient is unresponsive, with
no breathing and no circulation commence CPR – 30 chest
compressions/ 2 ventilations
If cardiac arrest occurs:
In addition to standard guidelines
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Elevate the legs
Give early escalating doses of IV adrenaline. Give 1mg of Adrenaline
initially and then double every 3 minutes until 4mg reached and
continue – 1mg, 2mg, 4mg, 4mg…
Insert 2 large bore cannulae and administer 2-4 litres of Normal Saline or
2 litres of colloid
Give H1 and H2 antihistamines IV
Give extended CPR - so that correction of hypovolaemia and vasodilation
can be achieved
If not responding to adrenaline consider boluses of Noradrenaline 4mg (2
x 2mg/2ml ampoules) to improve vasoconstriction
LEGISLATION, STANDARDS AND POLICIES:

New Zealand Resuscitation Council Guidelines 2006

TDH Cardiopulmonary Resuscitation policy

TDH Safe use of Medicine policy
Author: Resuscitation Co-ordinator
Authorised By: Chief Executive
Date of first approval: November 2008
Date last review completed: November 2008
Page:6 of 9
Sponsor: Clinical Board
Name: Anaphylaxis Policy
TRAINING:
1. Staff of TDH completing their CORE level 5–7 will update their knowledge of
anaphylaxis every two years.
2. Independent learning sessions on anaphylaxis will be arranged at managers
request
OUTCOME STANDARDS:
Staff of TDH will be able to deliver high standard of care, using current best practice
guidelines while caring for patients experiencing anaphylaxis.
EVALUATION METHOD:
1. All incidents resulting in an unexpected patient outcome will be reported using
the TDH incident reporting mechanism and adherence / variance to this policy
will be audited
2. Resuscitation audit forms will be completed for patients suffering severe
reactions and sent to the Resuscitation Coordinator. These will be further
considered by the Resuscitation Committees to be able to review practice
Authorised By
Date of Approval: November 2008
Next Review Date: November 2010
References:
1. Johansen SG et al – Report of the Nomenclature Review Committee of the
World Allergy Organization, October 2003. Journal of Allergy and Clinical
Immunology
2. New Zealand Resuscitation Council – Advanced Resuscitation for Health
Professionals, February 2007
3. UK Resuscitation Council – Emergency treatment of Anaphylactic Reactions –
Guidelines for health providers, January 2008
Author: Resuscitation Co-ordinator
Authorised By: Chief Executive
Date of first approval: November 2008
Date last review completed: November 2008
Page:7 of 9
Sponsor: Clinical Board
Author: Resuscitation Co-ordinator
Authorised By: Chief Executive
Name: Anaphylaxis Policy
Date of first approval: November 2008
Date last review completed: November 2008
Page:8 of 9
Sponsor: Clinical Board
Author: Resuscitation Co-ordinator
Authorised By: Chief Executive
Name: Anaphylaxis Policy
Date of first approval: November 2008
Date last review completed: November 2008
Page:9 of 9