Questionnaire/history: Anaphylaxis?

1. Felt and looked unwell within several minutes?

2. Life-threatening problems:

Airway (A)

Throat swelling?

Tongue swelling?

Hoarse voice?

High-pitched noise when breathing in (stridor)?

Difficulty in swallowing?

Breathing (B)

Rapid breathing?

Shortness of breath/difficulty in breathing?

Wheeze?

Persistent cough?

Tiredness, confusion or agitation (caused by hypoxia)?

Cyanosis?

SpO2 < 94%

Respiratory arrest?

Circulation?

Pale?

Clammy?

Increased pulse rate?

Arrhythmia?

Hypotension?

Feeling dizzy, faint or collapse?

Decreased level or loss of consciousness?

Cardiac arrect?

3. Skin and/or mucosal changes?

Flushing?

Erythema (patchy or generalised)?

(Itchy) well defined white or red patches (hives, weals, nettle rash) on the surface of the skin (urticaria)?

- Site?

(More tender/painful than itchy) less well defined skin coloured or red swellings below the surface of the skin (angio-oedema)?

- Site (eg lips, tongue, eyelids, genitalia, hands and feet)?

Gastrointestinal symptoms (eg cramps or pain, vomiting, incontinence)?

When did the symptoms start and for how long were they present?

Biphasic reaction?

Exposure to a known allergen?

- Certain foods (eg nuts, shellfish, milk, eggs)?

- Drugs (eg penicillin, cephalosporine, ACEI, NSAIDs, aspirin)?

- Insect bites and sting?

- Latex?

Idiopathic?

Past medical history (eg angio-oedema, autoimmune disorder)?

Family history (eg (hereditary) angio-oedema (HAE))?

Current medication?

Antihistamines?

Drug allergies?

Examination:

Facial oedema?

Oral oedema?

Laryngeal oedema?

Diagnosis:

Anaphylaxis

Angio-oedema with urticaria

- Allergic cause (angio-oedema transient (hours or days) and occurs within 1-2 hours

of exposure to a known allergen

- Idiopathic (recurrent episodes of angio-oedema and urticaria and an allergic cause

cannot be identified)

Angio-oedema without urticaria (non-allergic cause likely)

- Non-allergic drug reaction

- Hereditary angio-oedema (HAE)

- Acquired angio-oedema (AAE)

Management: Anaphylaxis with or without angio-oedema

Ambulance called, stated ‘anaphylaxis’?

Supine (with legs raised if primarily hypotensive)?

Semi-recumbent if primarily respiratory distress (eg wheezy and short of breath)?

Lied on left side if pregnant to prevent aortocaval compression?

IM Adrenaline given in anterolateral aspect of middle third of thigh every 5 minutes until adequate response?

Adrenaline (epinephrine) 1 mg/ml (1:000)?

- < 6 months: 100-150 mcg (0.1-0.15 ml)

- 6 months -6 years: 150 mcg (0.15 ml)

- 6 – 12 years: 300 mcg (0.3 ml)

> 12 years: 500 mcg (0.5 ml)

Nebulised adrenaline (5 ml of 1:1000 solution) as an adjunct to IM adrenaline if

laryngeal oedema (hoarse voice, stridor)?

High-flow oxygen given?

Oxygen driven nebulised salbutamol and ipratropium given as wheezy?

Fluid challenge (if possible) as hypotensive after 5 minutes?

- 10 ml/kg in child

- 500-1000 ml adult (can take 1-3 litres of IV fluids)?

Monitored blood pressure, heart rate and oxygen saturation?

ECG?

Bloods?

- Initial sample as soon as possible?

- Second sample at 1-2 hours (but no later than 4 hours) from the onset of symptoms

(if possible, take 5-10 ml extra for serum store to facilitate further investigations)?

- Convalescent sample at least 24 hour after complete resolution (eg at follow-up at allergy clinic) to provide a baseline tryptase value?

Reported suspected drug/vaccine-induced adverse drug reaction (ADR) via the MHRA’s Yellow Card scheme

Referral to allergy clinic?

Angio-oedema without anaphylaxis

Reference(s): DermNet NZ: Angioedema NICE CKS: Angio-oedema and anaphylaxis