Anaphylaxis

Question 1

List the examples of possible allergens provided under this guideline.

Answer 1

Food, bites/stings, medications or unknown allergen.

Question 2

What is the ideal site for IM Adrenaline administration?

Answer 2

Anterolateral mid-thigh due to improved absorption.

Question 3

What note is made about IM vs. IV Adrenaline?

Answer 3

All patients should receive initial IM Adrenaline regardless of presentation, with IV Adrenaline being reserved for impending cardiac arrest/extremely poorly perfused patients.

Question 4

Which patients may be persistently unresponsive to IM Adrenaline? What alternative treatment pathway can be considered for them?

Answer 4

Patients on beta blockers.

Consult for 1-2 IU of IM or IV Glucagon.

Question 5

Deaths from anaphylaxis are far more likely to be associated with…?

Answer 5

Delay in treatment than inadvertent Adrenaline administration.

Question 6

What must be done for all anaphylaxis patients?

Answer 6

Transport to hospital, irrespective of symptom resolution or severity. Monitoring for 4 hours is recommended following treatment.

Question 7

What supplementary inhaled therapies may also benefit in anaphylaxis?

Answer 7

Salbutamol - for persistent bronchospasm

Nebulised Adrenaline - for persistent upper airway oedema and stridor

Question 8

If pt has self-injected EpiPen and symptoms have corrected prior to paramedic arrival, do they require transport?

Answer 8

Yes.

Question 9

Outline the R.A.S.H criteria.

Answer 9

Sudden onset of symptoms (minutes to hours)
AND
R - respiratory distress (SOB, wheeze, stridor, cough)
A - abdominal symptoms (N or V, cramps, diarrhoea)
S - Skin/mucosal symptoms (hives, itch, flush, swelling)
H - Hypotension or altered conscious state
OR
Isolated hypotension of <90 following exposure to a known antigen.

Question 10

If a patient refuses Tx post-anaphylaxis, what steps must be taken?

Answer 10

1. Strongly encouraged to consent to transport
2. Advised of the risk and consequences (incl. death)
3. Left with a responsible third party
4. Given clear instructions on when to call back
5. Advised to follow up with their LMO

Question 11

If RASH criteria not met, what is the management?

Answer 11

1. BLS
2. Continually re-assess
3. Consider Tx for observation and further Mx

Question 12

If RASH criteria met and Anaphylaxis/Severe Allergic Reaction confirmed, outline the management.

Answer 12

1. Monitor cardiac rhythm
2. Do not allow pt to stand or walk
3. Adrenaline
   - 500mcg IM, rpt at 5 min intervals
   - 300mcg IM, rpt at 5 min intervals
   Until satisfactory results or side effects occur
4. 10-15L/min of O2
5. Salbutamol 10mg via neb. mask (if bronchospasm)
6. Adrenaline 5mg via neb. mask (if U.A oedema)
7. Normal Saline up to 40ml/kg titrated to pt response, consult for further fluids/ or admin further 20ml/kg if no consult available (only if less than adequate perfusion)

Question 13

What is the indication for Normal Saline under this guideline and what is the administration?

Answer 13

Less than adequate perfusion.

Up to 40ml/kg, consult for further or if no consult available, admin further 20ml/kg (max 60ml/kg).

Titrate to pt response.

Question 14

What is purpose of an early MICA request in these patients?

Answer 14

IV Adrenaline, possible intubation.

Question 15

Irrespective of symptom resolution, what is the further management?

Answer 15

1. Tx
2. Reassess en route
3. Monitor for recurring symptoms