Airway Remove any obvious cause of anaphylaxis – IV antibiotics / Nuts / etc Is the patient able to talk? - if so the airway is patent Noisy breathing suggests airway compromise Perform Head tilt, Chin lift If noisy breathing persists try a Jaw Thrust If airway still appears compromised use an airway adjunct Insert an Oropharyngeal Airway (Guedel) only if unconscious (as otherwise may gag & aspirate) Or alternatively use a Nasopharyngeal airway (better tolerated if patient is partially conscious) Breathing Give High Flow Oxygen via a Non-rebreathe mask – 15 Litres – 100% Assess Respiratory rate – a falling respiratory rate in the context of hypoxia is a life threatening sign Oxygen saturation – aim to keep as high as possible (94-98%) – if <92% this is life threatening Air entry - reduced air entry suggests significant airway compromise & need for critical care input Give nebulised bronchodilators if wheeze present: Salbutamol 5mg Nebulised Ipratropium Bromide 500mcg Nebulised Circulation Give IM Adrenaline - 0.5mg 1:1000 – repeat every 5 minutes if needed – guided by BP, Pulse & RR¹ Assess BP – often severely hypotensive due to leaky blood vessels causing fluid shift Capillary Refill Time - central (as may be peripherally shut down) – should be <2 seconds Pulse Gain IV access – large bore cannula – e.g. 14 Gauge Give Chlorphenamine - 10mg IV – stabilises mast cells, reducing histamine release¹ Hydrocortisone – 200mg IV – prevents rebound of inflammation over next few hours¹ Fluids (stat) – Normal Saline – up to 2L may be needed – titrate to BP¹ Take blood samples – FBC, U&E, LFT, Clotting, CRP Perform ABG - check PaO2 & pH – Hypoxia & Acidosis indicate need for ITU support (CPAP) If Patient Remains Hypotensive, Admit to ITU! Intravenous infusion of adrenaline Intravenous aminophylline Disability Assess AVPU - rough assessment of level of consciousness Assess Pupils - constricted in opiate overdose, dilated in TCA overdose, blown in brain pathology Exposure Expose patients entire body looking for Rash – seen in anaphylaxis, meningococcal septicaemia Hidden sources of bleeding Other secondary injuries Hot swollen calf may suggest DVT – important if PE suspected Reassess ABCDE Important to keep reassessing ABCDE Allows you to recognise if the treatment you have initiated is working Also allows fast recognition that the patient is not responding to treatment & is deteriorating If patient continues to deteriorate, seniors need to be involved sooner rather than later Further management Once the patient is stabilised they will need admitting to a ward They will require regular observations, ECG monitoring, etc Continue Chlorphenamine 4mg/6hrs PO if itching¹ Arrange for a medic alert bracelet to be put on patients wrist, identifying allergen Document the patients allergy clearly & thoroughly in the notes Arrange follow up to discuss self-injected adrenaline (Epipen) Perform skin-prick tests to identify potential allergens to avoid in the future Source
