Anaphylaxis and allergy - Queensland Ambulance Service

Clinical Practice Guidelines:
Medical/Anaphylaxis and allergy
Disclaimer and copyright
©2016 Queensland Government
All rights reserved. Without limiting the reservation of copyright, no person shall reproduce, store in a
retrieval system or transmit in any form, or by any means, part or the whole of the Queensland Ambulance
Service (‘QAS’) Clinical practice manual (‘CPM’) without the priorwritten permission of the Commissioner.
The QAS accepts no responsibility for any modification, redistribution or use of the CPM or any part
thereof. The CPM is expressly intended for use by QAS paramedics whenperforming duties and delivering
ambulance services for, and on behalf of, the QAS.
Under no circumstances will the QAS, its employees or agents, be liable for any loss, injury, claim, liability
or damages of any kind resulting from the unauthorised use of, or reliance upon the CPM or its contents.
While effort has been made to contact all copyright owners this has not always been possible. The QAS
would welcome notification from any copyright holder who has been omitted or incorrectly acknowledged.
All feedback and suggestions are welcome, please forward to:
[email protected]
Date
April, 2016
Purpose
Scope
To ensure consistent management of patients with Anaphylaxis and allergy.
Applies to all QAS clinical staff.
Author
Clinical Quality & Patient Safety Unit, QAS
Review date
April, 2018
URL
https://ambulance.qld.gov.au/clinical.html
This work is licensed under the Creative Commons
Attribution-NonCommercial-NoDerivatives 4.0
International License. To view a copy of this license,
visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Anaphylaxis and allergy
April, 2016
Anaphylaxis is a life-threatening condition requiring urgent treatment. The Australasian Society of Clinical Immunology and Allergy (ASCIA) defines anaphylaxis as:
Clinical features
UNCONTROLLED WHEN PRINTED
Any acute onset illness with typical skin features (urticarial rash or erythema/flushing and/or angioedema), plus involvement of respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms OR any acute onset of hypotension or bronchospasm or upper airway
Often there is a history of a trigger (e.g. an animal sting, food ingestion, or drug reaction).
The physical presentation may be localised or
generalised, mild to severe and have a gradual or rapid onset.
Signs and symptoms may include:
UNCONTROLLED WHEN PRINTED
obstruction where anaphylaxis is considered possible, even if typical skin features are not present.[1]
• Skin:
- urticaria
- angioedema
- erythema
An allergic reaction usually only involves the skin. Occasionally, patients can get isolated swelling of the face, lips and tongue
(angioedema) due to drug reactions. Although appearing dramatic,
these cases rarely progress to anaphylaxis.[2]
• Respiratory:
UNCONTROLLED WHEN PRINTED
- itchiness or lump in throat
- hoarse voice
- inspiratory stridor
- bronchospasm
- respiratory distress
UNCONTROLLED WHEN PRINTED
• Cardiovascular:
- tachycardia
- hypotension
- vasodilation with warm flushed skin
Figure 2.18
QUEENSLAND AMBULANCE SERVICE
83
Clinical features (cont.)
e
• Gastrointestinal:
- abdominal pain/cramping
Additional information
• The aggressiveness of therapy should match the seriousness of the allergic reaction.
UNCONTROLLED WHEN PRINTED
- nausea and/or vomiting
- diarrhoea.
Different patients will have different reactions. Some may only present with hypotension.[3]
• Nebulised adrenaline (epinephrine) may be administered for isolated facial and/or tongue swelling thought to be
allergic in origin – if stridor is present, parenteral (IM or IV)
adrenaline (epinephrine) must be administered.
• The use of adrenaline may lead to hypertension, stroke, ACS or dysrhythmias. Adrenaline (epinephrine) is only to be administered to patients suffering anaphylaxis
or a severe allergic reaction and not for simple localised reactions such as a rash, itching, or redness.
UNCONTROLLED WHEN PRINTED
Risk Assessment
• Acute anaphylaxis may occur without urticaria
• Urticaria, erythema and angioedema may be transient.
• Patients may present with CVS symptoms only.
• Be aware that some patients relapse hours after an apparent recovery (biphasic response).[4] All patients
should be transported to hospital.
UNCONTROLLED WHEN PRINTED
• Risk factors for fatal anaphylaxis include:
- asthma
• Promethazine should not be administered for anaphylaxis or severe allergic reaction.
- age (teenagers/older adults)
- initial misdiagnosis
- delay to, or no adrenaline (epinephrine) administration
UNCONTROLLED WHEN PRINTED
QUEENSLAND AMBULANCE SERVICE
84
CPG: Paramedic Safety
CPG: Standard Cares
Note: Officers are only to perform
procedures for which they have
received specific training and authorisation by the QAS.
Remove allergen
(if present)
UNCONTROLLED WHEN PRINTED
Anaphylaxis OR Severe
allergic reaction?
UNCONTROLLED WHEN PRINTED
N
Y
Consider:
•
•
•
•
Oxygen
Salbutamol Neb
Ipratropium bromide Neb
Promethazine (symptomatic urticaria)
UNCONTROLLED WHEN PRINTED
Consider:
•
•
•
•
Adrenaline (epinephrine)
Oxygen
IV fluid
Hydrocortisone
N
Improvement in symptoms?
UNCONTROLLED WHEN PRINTED
Y
Transport to hospital
Pre-notify as appropriate
Transport to hospital
Pre-notify as appropriate
85