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Practice Nurse

Anaphylaxis

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Have improved knowledge of the differential diagnosis and investigation of anaphylaxis.

Have better knowledge of the emergency treatment of patients presenting with anaphylaxis according to current guidance.

Have a better understanding of the appropriate care pathways for patients presenting to the general clinician with anaphylaxis.

Have improved knowledge of the education of patients with anaphylaxis, including avoidance and self-management using devices such as the adrenaline auto-injector.

http://www.resus.org.uk/pages/reaction.pdf

http://www.resus.org.uk/pages/anaalgo2.pdf

Knowledge of the differential diagnosis, diagnosis and investigation of anaphylaxis.

Knowledge of the emergency treatment of patients presenting with anaphylaxis according to current guidance.

Appropriate care pathways for patients presenting to the general clinician with anaphylaxis.

Education of patients with anaphylaxis regarding avoidance and self-management using devices such as the adrenaline auto-injector.

You attend a 12 year old boy who has developed facial swelling, light-headedness and difficulty breathing following exposure to food suspected to have nut content. On immediate assessment you note that he has swelling of the lips and eyes with a widespread red blotchy rash. He is particularly wheezy, with a respiratory rate of 28/min, a pulse of 110bpm and a supine blood pressure of 100/70 mmHg.Which of the following would be the most appropriate immediate treatment for this patient?

This patient has developed a severe allergic reaction to nuts causing the swelling and rash but more worryingly he also has features of anaphylaxis, with difficulty breathing and wheeze. He requires urgent treatment and the acknowledged first line treatment for anaphylaxis is IM adrenaline. The dose varies according to age and in a child of this age the recommended dose should be 0.5mls of 1:1000 adrenaline (with the prefered site being the outer upper thigh). The injection can be repeated every 5-10 minutes until the patient's condition stabilises. Adjuvant therapies can be given, these include high flow oxygen , IV fluids, nebulised bronchodilators, corticosteroids and antihistamines (such as chlorphenamine) . IV adrenaline is not recommended as a first line and should only be given by experienced specialists.

http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5139

What is the evidence for the use of IM adrenaline as the mainstay of treatment?

Why is IV adrenaline only reserved for specialists with experience?

Question 1

Which of the following might indicate that someone is having an anaphylactic reaction?

All of the symptoms described can be seen with an anaphylactic reaction. In childhood most (around 90%) of anaphylactic reactions are caused by exposure to foodstuffs, especially nuts, shellfish, eggs and milk. Other causes are insect stings, and allergens such as latex, penicillins and exercise. A proportion of reactions are idiopathic. Other symptoms can also include

Gastrointestinal symptoms such as cramps and vomiting

Anaphylaxis is highly likely when the following criteria are met:

Acute onset of an illness (this means minutes to several hours) with skin and/or mucosal tissue involvement PLUS one or both of respiratory compromise and cardiovascular compromise.

Acute onset (minutes to several hours) after exposure to a known allergen for the patient of two or more of the following: skin or mucosal tissue involvement, cardiovascular compromise,, respiratory compromise and gastrointestinal symptoms [adapted from Sampson HA et al. J Allergy Clin Immunol 2006]


Patients at risk of anaphylaxis should be prescribed an epipen to carry with them at all times, in case of an emergency.



If in doubt it is best to assume anaphylaxis and to treat as an emergency with IM adrenaline.

Child suffering from an anaphylactic reaction showing pronounced oedema round the eyes and lips and hives to the face and upper abdomen.

http://www.netdoctor.co.uk/allergy-and-asthma/medicines/epipen.html

http://www.nhs.uk/conditions/Anaphylaxis/Pages/Introduction.aspx

What differentiates anaphylaxis from an allergic reaction?

What investigations may be useful in confirming a diagnosis of suspected anaphylaxis?

Question 2

A 13 year old girl was admitted to hospital and treated for a first episode of anaphylaxis. There was no known precipitant of this reaction. She was observed overnight and discharged the following morning. With which of the following should she have been provided with and trained to use prior to discharge from hospital?

It is recommended that all patients who are admitted with diagnosed anaphylaxis should be provided with an adrenaline auto-injector and trained on its use prior to discharge. Patients should be advised to keep the auto-injector with them at all times and should also be referred to a specialist allergy clinic for follow up where this is available. Patients should also be supplied with a written emergency management plan where possible.

Emergency treatment of anaphylactic reactions

What is your local access to the training of your patients on adrenaline autoinjectors?

Are staff appropriately trained on the use of the auto-injector?

Is there adequate and immediate access to adrenaline devices in your practice?

Question 3

A 4 year old girl is discharged from hospital following successful treatment of anaphylaxis after first exposure to shellfish. She is prescribed an Epipen Junior and she and her parents are trained on using the device. Regarding her further outpatient management, which of the following should be undertaken for this patient?

According to the Resuscitation Council guidance, all patients admitted and treated for anaphylaxis should be referred to a specialist allergy clinic for review. This will involve determining the cause of the anaphylaxis after the diagnosis has been confirmed and training and advice will be given on how to manage any future occurrence and how to reduce the likelihood of future attacks. Consult the British Society of Allergy and Clinical Immunology website at 

 to find out the location of the nearest allergy clinic. Referral to a dietician may also be considered as a component of the Allergy Clinic referral, particularly if the patient and family needs help avoiding the allergen.

Do you have adequate access to allergy clinics for your patients?

What is the evidence for the benefit of a referral to an allergy clinic rather than a general clinic?

Question 4

Which of the following is the approximate incidence of anaphylaxis in children?

The true incidence of anaphylaxis is not entirely clear partly because of inconsistencies between definitions used by different investigators and partly because of a lack of studies, especially in paediatric cases. However, data reveal that the incidence of anaphylaxis does not vary greatly from one country to another and most estimates have the actual incidence at somewhere between 1-3 sufferers per 10,000 population. In the UK hospital admission data shows a seven-fold increase in the prevalence of anaphylaxis between 1990/91 and 2003/04 with the highest rate in school-age children.

 - Muraro et al. Allergy 2007, Kemp SF and Palmer GW

Question 5

A 13 year old boy is admitted following an anaphylactic reaction and is treated with IM adrenaline using his Epipen. He makes an extremely good response and is discharged the following day. His parents enquire as to how many Epipens he should have at home as currently they have none.How many Epipens should this patient receive?

Guidance from the European Academy of Allergology and Clinical Immunology (Muraro et al. Allergy, 2007) states that a patient should have 2 pens available at all times as, in some cases, a second injection is required if administration of the first dose does not adequately control symptoms. If required, this second dose should be administered 5 - 10 minutes after the first. For a young school age child this means that he should have at least two autoinjectors at least for home use plus a further 2 should be available at school.

What is the evidence to support the prescription of the adrenaline autoinjector in patients who have had anaphylaxis?

How often is a second dose of adrenaline required?

Question 6

An 11 year old boy is admitted and treated for his first episode of anaphylaxis. On discharge he and his parents are educated on the use of the Epipen and also are referred to a specialist allergy clinic. His parents are concerned regarding the possibility of a further anaphylactic reaction. Which of the following most appropriately describes the approximate annual risk of a further anaphylactic reaction?

Patients who have had an anaphylactic reaction have a high likelihood of having another one, the estimate being there is a 1 in 12 chance of another attack 

. This emphasises the critical importance of specialist advice on managing future episodes plus training and advice on how to adopt preventive strategies.

Gupta R, Sheikh A, Strachan DP, Anderson HR. Burden of allergic diseasein the UK: secondary analyses of national databases. Clin Exp Allergy2004;34(4):520-6.

What are the main precipitants of anaphylaxis in children?

What is the mortality associated with anaphylaxis and is this changing over the decades?

Question 7

You are called to see a 10 year old boy who has developed what appears to be an anaphylactic reaction after eating his lunch. You are informed that he is known to have allergies and on this occasion had a couple of mouthfuls of food and became unwell.
On inspection, he appears rather pale, has puffy watery eyes and swollen lips, has a pulse of 120 bpm and has a respiratory rate of 30/min. He has been administered IM adrenaline by his Epipen approximately 5 minutes ago and you are awaiting an ambulance.
Which of the following would be most appropriate for this patient?

If there is no improvement following the initial IM adrenaline injection, the recommendation is to administer further doses every 5-10 minutes until symptoms are under control. There are no absolute contraindications for the use of adrenaline in children as they do not normally suffer from any co-morbidities such as coronary heart disease. Once the initial symptoms are under control, other adjuvant treatments such as inhaled beta-2-agonists, high flow oxygen and volume support can be administered.

What other treatments should be used and when should these be employed in the treatment of anaphylaxis after the initial use of the adrenaline autoinjector?

What are some of the potential adverse events attributable to the use of adrenaline?

Question 8

A 13 year old girl develops anaphylaxis after a wasp sting. She makes a good recovery, and her and her family receive an emergency management plan together with the prescription and training upon an adrenaline auto-injector. Together with her outpatient appointment to the allergy clinic, which of the following should she also receive?

Together with the prescription of the autoinjector and an emergency management plan, the patient should have a MedicAlert bracelet. Medic Alert items are available at the patients expense but should be recommended as a potentially useful device in alerting immediate carers in the event of anaphylaxis. More information can be found at the following website:

How should an anaphylactic reaction to a potential drug be reported?

How many of your patients actually use a medicalert item?

Question 9

An 8 year old boy develops a severe allergic reaction resulting in hospital admission. Which of the following is the most common cause of anaphylactic reactions in children in the UK?

All of the above factors can cause anaphylaxis, but by far the most common cause in childhood is allergy to food. It is estimated that around 90% of all anaphylactic reactions are caused by foodstuffs with the following being the most common:

http://www.health.wa.gov.au/anaphylaxis/about/causes.cfm

Which is the commonest food precipitant of anaphylaxis?

Have there been any changes regarding the incidence of anaphylaxis with foods over the years?

How common is anaphylaxis to drugs or venoms?

Question 10

Which of the following best describes the current mortality rate associated with anaphylaxis?

Fatalities associated with anaphylaxis are rare with a reported rate of between 0.65 - 2% causing 1-3 deaths per million people annually. In the UK half of all deaths due to anaphylaxis have a iatrogenic cause, for example anaesthetics or antibiotics. A quarter have a food allergen cause and a quarter are due to insect stings. Death can occur quickly with one US study showing the average time between initial onset to death being 25-35 minutes for food related anaphylaxis and 10-15 minutes for insect stings. It has been shown that in 90% of deaths caused by anaphylaxis, an adrenaline auto-injector has not been used prior to cardiac arrest.

http://emedicine.medscape.com/article/135065-overview

Has the modern management of anaphylaxis had an impact on mortality?

What is the main cause of mortality associated with anaphylaxis?

Is there a worse prognosis associated with different precipitants of anaphylaxis?

Anaphylaxis

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