3.4. ANAPHYLACTIC AND ALLERGIC REACTION

(Adapted from the evidence-based guideline developed using the National Evidence-Based Medicine Guideline Development Process Model).

Related Names

Anaphylactic shock.

Purpose of assistance

1. Conduct timely therapy for life-threatening reactions to known or suspected allergens, and prevent shock and collapse.
2. Conduct symptomatic treatment to reduce symptoms caused by known or suspected allergens.

Patient description

Inclusion criteria

Patients of all age groups with suspected allergic reaction and/or anaphylaxis

Exclusion criteria

There are no recommendations.

Patient Management

Condition assessment

1. Assess airway patency and presence of oral edema.

2. Auscultate the chest to detect whistling sounds and evaluate breathing efforts.

3. Assess the adequacy of perfusion.

4. Assess for signs of anaphylaxis.

4.1. Anaphylaxis is a complication that is characterized by an acute manifestation in the form of:

a) irritation of the skin (urticaria) and/or mucous membrane with simultaneous violation of breathing or decrease in blood pressure (blood pressure) or the appearance of signs of dysfunction of the target organ;

OR

b) hypotension in patients after exposure to a known allergen:

• • • • adults: systolic pressure less than 90;
      • Children: Pathological vital signs (see. Appendix 4);

OR

c) two or more of the above symptoms occur immediately after exposure to a potential allergen:

• • • • skin and/or mucous membrane irritation (hives, itching, swelling of the tongue/lips), skin irritation is absent in 40% of cases of anaphylaxis;
      • respiratory disorders (dyspnea, whistling, stridor, hypoxemia);
      • persistent symptoms in the gastrointestinal tract (vomiting, abdominal pain, diarrhea);
      • hypotension or associated symptoms (loss of consciousness, hypotension, urinary incontinence).

Signs affect only one organ system (for example, localized angioedema that does not violate airway patency or is not associated with vomiting; rash only).

Treatment and intervention

1. If there are signs of an allergic reaction without any signs of anaphylaxis, go to step 4.

2. If there are signs of anaphylaxis, administer epinephrine (1 mg/mL) at the following dose and route:

a) adults (25 kg or more) 0.3 mg w/w into the upper-outer thigh;
b) children (less than 25 kg): 0.15 mg in the upper-outer thigh;
c) 1 mg/mL epinephrine can be administered via ampoule kit or automatic syringe (if available).

3. With hives or itching, enter diphenhydramine 1 mg/kg, the maximum dose is 50 mg IV/m, IV, orally:

a) IV use is recommended in the presence of severe shock;
b) to enhance the action of diphenhydramine in hives, antihistamines (N2 blockers, histamine receptors (for example – famotidine, cimetidine), routes of administration – IV, orally in combination with diphenhydramine can be administered simultaneously.

4. In the presence of impaired breathing with characteristic whistling sounds, you can enter:

a) salbutamol 2.5-5 mg through a nebulizer;

AND/OR

b) epinephrine 1 mg/ml, 5 ml via nebulizer.

5. In the presence of stridor, epinephrine can be administered 1 mg/ml, 5 ml through a nebulizer.

6. If signs of anaphylaxis and hypoperfusion continue after the first dose of epinephrine, additional epinephrine administration (IV) can be performed every 5-15 minutes using the above doses.

7. If there are signs of hypoperfusion, also enter 20 ml/kg of isotonic solution (physiological saline or a combined drug with a composition of sodium chloride + potassium chloride + sodium lactate + calcium chloride) for 15 minutes IV or IV, repeat the procedure if necessary if there are signs of hypoperfusion.

8. In vascular collapse, inject epinephrine IV by dropper (0.5 μg/kg/minute) (hypotension accompanied by a change in consciousness, pale skin, excessive sweating and/or delayed capillary filling), despite repeated IV doses of epinephrine in combination with boluses of isotonic fluids with a dose of at least 60 ml/kg

9. Transport the patient immediately, conducting ongoing assessment and monitoring of the condition in parallel. Monitoring of heart rhythms is not mandatory, however, it may be necessary if there is a history of heart disease or the patient has already been administered several doses of epinephrine.

Patient safety

1. Time to epinephrine administration.
2. Epinephrine concentration relative to route of administration.
3. The dosage of drugs should be based on the weight of the patient.

Useful information for training

Key points

1. Allergic reaction and anaphylaxis are a serious problem and can be life threatening. This is the body’s response to the penetration of a foreign protein (for example, food, medicines, pollen, insect sting or any substance consumed or inhaled). A local allergic reaction (for example, hives or Quincke’s edema, which does not block the respiratory tract) can be treated with the introduction of antihistamines. If anaphylaxis is suspected, EMF workers should use epinephrine as a first-line treatment. Cardiovascular collapse can occur simultaneously without prior manifestation of skin and respiratory symptoms. Continuous monitoring of the patient’s airways and breathing is important.

2. Despite the widespread belief that each case of anaphylactic shock is accompanied by such skin manifestations as swelling of the mucous membrane or redness of the skin, a large number of similar cases of anaphylaxis pass without the manifestation of similar symptoms in the first stages. Moreover, most fatal reactions due to anaphylaxis caused by eating in children were not associated with the presence of symptoms on the patient’s skin.

3. A detailed assessment and a high level of suspicion are necessary in all potential allergic patients – consider:

a) history of allergic manifestations:

• • • • start and localization;
      • bite or stinging by an insect;
      • Allergy to food;
      • Allergy to clothing, detergents;
      • history of the last reaction;
      • medical history;
      • b) signs and symptoms:

b) signs and symptoms:

• • • • itching or redness;
      • coughing, breathing with a whistle, or impaired breathing;
      • chest discomfort or swelling of the throat;
      • hypotension or shock;
      • persistent gastrointestinal manifestations (vomiting, nausea, diarrhea);
      • disturbance of consciousness;

c) other important details:

• • • • angioedema (caused by the use of drugs);
      • aspiration/airway obstruction;
      • loss of consciousness;
      • asthma or chronic obstructive pulmonary disease;
      • heart failure.

4. Manifestations from the gastrointestinal tract are most often associated with anaphylaxis due to food intake, but can be caused by other substances:

a) itching in the oral cavity is often the first symptom observed in patients with anaphylaxis caused by eating;
b) abdominal cramps are also a typical symptom, nausea, vomiting and diarrhea are also often present.

5. Patients with asthma have a high risk of a severe allergic reaction.

6. There is insufficient evidence of the effectiveness of steroid medications to control allergic reactions and/or anaphylaxis.

7. There are contradictions among experts with evidence of poor quality regarding the use of epinephrine IV to control the condition after the action of a known allergen on a patient who had a history of anaphylactic shock.

Relevant evaluation results

1. Presence/absence of angioedema.
2. Presence/absence of respiratory disturbance.
3. Presence/absence of circulatory disorders.
4. Generalized or localized hives.
5. Response to treatment.

Key elements of documentation

1. Drugs administered.
2. Dose and concentration of epinephrine administered.
3. Route of administration of epinephrine.
4. Epinephrine administration time.
5. Signs and symptoms in the patient.

Criteria for the effectiveness of care

1. Percentage of patients with anaphylaxis who were administered epinephrine for anaphylaxis:

a) IV (compared to other routes of administration);
b) IV into the upper anterior thigh (compared to other sites for administration).

2. Percentage of patients with anaphylaxis who were injected:

a) epinephrine within the first 10 minutes after the arrival of EMF employees;
b) correctly selected (based on the patient’s weight) dose of epinephrine.

3. Percentage of patients requiring airway control at pre-hospital (and/or emergency department).