Starship Childrens Health Clinical Guideline

Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

ANAPHYLAXIS

Introduction
Differential Diagnosis
Management
Treatment of Anaphylaxis
(Flow Chart)

Disposition from Emergency Department

Adrenaline Autoinjectors
Action Plan
Adrenaline Autoinjector Information Sheet

Introduction
Anaphylaxis is a systemic immediate hypersensitivity reaction to an allergen, which may be
ingested, inhaled or injected (including bites/stings as well as medical treatment). Symptoms
typically occur within 30 minutes of exposure (usually within 5 minutes). Onset can be fulminant
and life threatening. Classic anaphylaxis results from IgE mediated mast cell degranulation
releasing histamine and other mediators. Anaphylaxis has also been described following exercise
or sudden cold exposure. Many cases are idiopathic. Non IgE mediated reactions (previously
referred to as "anaphylactoid") can be clinically identical and result from direct mast cell
stimulation.
Anaphylaxis is a multisystem allergic reaction with respiratory and / or cardiovascular involvement.
Other organ systems are often involved such as skin (itch, rash, flushing, angioedema) and the GI
tract (vomiting, diarrhoea, tummy pain). Signs and symptoms that an allergic reaction is
anaphylaxis include:
Respiratory:
Difficulty/noisy breathing
Swelling of tongue
Swelling/tightness in throat
Difficulty talking and/or hoarse voice
Wheeze or persistent cough
Cardiovascular:
Loss of consciousness
Collapse
Palor and floppiness (in young children)
Hypotension

Differential Diagnosis
Anaphylaxis is sometimes confused with vasovagal syncope. Syncope produces pallor and
bradycardia in contrast to the flushing and tachycardia of anaphylaxis. Hyperventilation may
occasionally be interpreted erroneously as the early phase of anaphylaxis.
Anaphylaxis may evolve to being life threatening even if severe symptoms are not initially present.
Other causes of hypovolaemic shock and airway obstruction should be considered in severe
cases.

Author:
Editor:

Dr Jan Sinclair
Dr Raewyn Gavin

Service:
Date Reviewed:

Anaphylaxis

Page:

1 of 6

Starship Allergy & Immunology.

March 2010

Starship Childrens Health Clinical Guideline

Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

ANAPHYLAXIS
Management
See Flow chart below.
First line treatment of anaphylaxis is the administration of adrenaline. Adrenaline should be given
immediately for any allergic reaction with respiratory or cardiovascular involvement. Many deaths
from anaphylaxis are associated with delayed administration of adrenaline.
Adrenaline 0.01 ml per kg of 1:1000 (1mg/1ml) intramuscularly.
Minimum dose 0.1 ml
Maximum dose 0.5 ml
It is important to remember that:
Adrenaline should be given IM not subcutaneously
Antihistamines and steroids are second line therapies in anaphylaxis.
Adrenaline is not indicated for simple generalised urticaria with no other system involved.

Author:
Editor:

Dr Jan Sinclair
Dr Raewyn Gavin

Service:
Date Reviewed:

Anaphylaxis

Page:

2 of 6

Starship Allergy & Immunology.

March 2010

Starship Childrens Health Clinical Guideline

Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

ANAPHYLAXIS
Treatment of Anaphylaxis
History consistent with
anaphylaxis?

Consider other causes of shock, collapse, respiratory

distress or obstruction

No

(see above)

Yes
Attend to immediate issues of basic life support:
Airway
Breathing
Circulation
And call for help as necessary (phone 777)
See also CPR guideline

If possible, interrupt further

absorption of antigen: e.g. stop IV
injection, remove sting

Adrenaline is first line treatment.

Administer 0.01 ml/kg of 1:1000 (1mg/ml) solution intramuscularly

Minimum dose 0.1 ml
Maximum dose 0.5 ml
Intravenous adrenaline may be needed for the most severe cases (starting dose 0.1 ml/kg of 1:10,000) but do not
delay IM adrenaline while awaiting venous access

- Move child to resuscitation area

- Attach monitors
- Ensure sufficient staff attend
- In areas other than PICU and
CED always initiate a 777 team
call out

Upper airway
obstruction?

Yes

No
Poor perfusion,
tachycardia,
hypotension?

Yes

No
If possible obtain blood sample for
tryptase within 1-2 hours from onset
of symptoms. This may help to
confirm an uncertain diagnosis (in
retrospect)

- Sit child upright

- Face mask oxygen
- Nebulised adrenaline
(1:1000 solution, 0.5ml/kg, max
dose 6ml. Dilute to min volume 4ml)
- Prepare for possible intubation

Bronchospasm?

No

Yes

- Obtain IV access
- Give 20ml/kg 0.9% NaCl
- Repeat boluses as necessary, preferably
changing to colloid such as haemacell or
4% albumin.
- May require multiple doses of IV
adrenaline or inotrope infusion if failing to
respond

- Give nebulised salbutamol (5mg in 4ml,

running with wall oxygen at 8l/min)
- Repeat as necessary
- Lower airway obstruction may be severe
and require continuous nebulisers, IV
salbutamol, and/or intubation & ventilation

Other drugs
1. Hydrocortisone 4mg/kg IV q6h to reduce delayed/recurrent symptoms. An oral steroid such as prednisone or
prednisolone can be used in less severe cases.
2. Non-sedating antihistamine H1-blocking antihistamines (e.g. loratadine or cetirizine) may be useful for itch or
angioedema
3. Oral ranitidine 1-2 mg/kg max 150mg (H2-blocking antihistamines) may work synergistically with H1-blocking
antihistamines in severe reactions.
Observation
All children should be carefully observed for a minimum of 4 hours after onset. Children who require more treatment than
a single dose of IM adrenaline must be admitted for 24 hours.

IM adrenaline may need to be repeated after 10-15 minutes if symptoms are ongoing or recurring

Author:
Editor:

Dr Jan Sinclair
Dr Raewyn Gavin

Service:
Date Reviewed:

Anaphylaxis

Page:

3 of 6

Starship Allergy & Immunology.

March 2010

Starship Childrens Health Clinical Guideline

Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

ANAPHYLAXIS
Disposition from Emergency Department
Children requiring treatment with adrenaline should be observed for at least 4-6 hours as lifethreatening manifestations can appear after apparent remission. All children who require more than
a single dose of adrenaline should be admitted because of the possibility of recurrent symptoms.
24 hours.
Children with less severe disease, good family supervision, transport and telephone can be
discharged after 4-6 hours observation with oral antihistamine. They should be instructed to return
immediately if there are any recurrent symptoms.
For those patients who have had anaphylaxis:
Follow up should be arranged with the Paediatric Allergy/Immunology Service. Provide the family
with an emergency action plan and Adrenaline autoinjector ordering information before leaving the
emergency department (see below).

Adrenaline Autoinjectors
Ensure that the family obtains and is instructed in the use of an autoinjector. There are 2 devices
available in NZ. EpiPen and AnaPen.
The autoinjector teaching kit is in a box in the right hand side cupboard under the fax machine in
the doctors work station. Follow the check list on the lid of the box. Autoinjectors are not funded.
See Page 5 & 6 for Autoinjector ordering information
Be mindful that EpiPen comes in different doses.
Suggestions below from ASCIA (Australasian Society for Clinical Immunology & Allergy):
EpiPen Adult for children >20kg (package insert says over 30kg)
Epipen Jnr for children 10-20kg (package insert says 15-30kg)
Recommendation of an EpiPen to a child weighing <10kg should be discussed with senior
medical staff
An adrenaline autoinjector is appropriate for those:
with anaphylaxis to non-avoidable triggers e.g. Beestings and most food
with less severe allergic reaction (i.e. not anaphylaxis) but with other risk factors for
anaphylaxis (e.g.asthma, living in remote locations, peanut allergy). This decision can
usually be made at Outpatient Clinic.

Please complete an ACC form, this may assist the family with ambulance and autoinjector costs.
Patients with urticaria without an identifiable trigger do not necessarily need referral (see Urticaria
guideline).

Action Plan
You can print an action plan form from the ASCIA website
http://www.allergy.org.au/content/view/10/3/. There is a separate insect sting version, as well as a
non adrenaline version.
Author:
Editor:

Dr Jan Sinclair
Dr Raewyn Gavin

Service:
Date Reviewed:

Anaphylaxis

Page:

4 of 6

Starship Allergy & Immunology.

March 2010

Starship Childrens Health Clinical Guideline

Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

ANAPHYLAXIS
Adrenaline Autoinjector Information Sheet

Patient information re adrenaline

autoinjector ordering
EpiPen and AnaPen are both adrenaline auotinjector devices. Neither device is funded by
PHARMAC. A comparison of the devices is on the other side of this page.
You can obtain your EpiPen or AnaPen from:
Your GP:

Some GPs are happy to order the device direct to their practise from the
distributor. You will need to check with your GP whether they will assist with
this.

Pharmacy:

It is worth shopping around to check the costs as this will vary by pharmacy.
Some pharmacies have little/no mark up on EpiPen or AnaPen (such as
Quay Park Pharmacy in central Auckland, or
http://www.allergypharmacy.co.nz. Allergy Pharmacy also has trainer pens
available for purchase).

If you need to use your adrenaline autoinjector to treat an allergic reaction make sure the doctor
you see fills out an ACC form, as ACC will cover the replacement cost of the pen.
Please keep the receipt for the purchase of your device as this may be required for an ACC claim.
When your EpiPen or AnaPen has expired it is a good idea to practice with it by injecting in to a
pillow or mattress. The device will then need to be discarded in a sharps box (such as at your GP).
A free access on line e-learning course is available at
http://www.allergy.org.au/content/view/366/325/ for review of recognition and management of
anaphylactic reactions.
Make sure you and other caregivers review your action plan and how to use your EpiPen or
AnaPen regularly.

Author:
Editor:

Dr Jan Sinclair
Dr Raewyn Gavin

Service:
Date Reviewed:

Anaphylaxis

Page:

5 of 6

Starship Allergy & Immunology.

March 2010

Starship Childrens Health Clinical Guideline

Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

ANAPHYLAXIS

Doses

Expiry

Costs

Club

AnaPen

EpiPen

Junior: 0.15mg (for 10-20kg)

Adult: 0.3mg (for >20kg)

Junior: 0.15mg (for 10-20kg)

Adult: 0.3mg (for >20kg)

NB Once your child is over 20kg

ASCIA suggest changing from a junior
to adult pen when your device is due to
be replaced, though package insert
suggests 30kg

NB Once your child is over 20kg

ASCIA suggest changing from a junior
to adult pen when your device is due to
be replaced, though package insert
suggests 30kg

20 months at manufacture
Variable at dispensing check
before purchase

20 months at manufacture
Variable at dispensing check
before purchase

Varies by pharmacy
$125 (allergypharmacy march 11)
$120 (Quay Park Pharmacy, Beach
Rd, Ph 919 2320, March 11)

Varies by pharmacy
$149 (allergypharmacy March 11)
$145 (Quay Park Pharmacy, Beach
Rd, Ph 919 2320, March 11)

www.anapen.co.nz
On registering your device you can get
a free trainer pen plus reminders of
expiry date

www.epiclub.com.au/
On registering your device you can get
a free trainer pen plus reminders of
expiry date

Other useful web sites:

Australasian Society of Clinical Immunology and Allergy (ASCIA)
http://www.allergy.org.au/
Allergy New Zealand
www.allergy.org.nz

Author:
Editor:

Dr Jan Sinclair
Dr Raewyn Gavin

Service:
Date Reviewed:

Anaphylaxis

Page:

6 of 6

Starship Allergy & Immunology.

March 2010