CP01 Emergency Treatment of Anaphylactic Reactions - Devon ...

Protocol for the Emergency Treatment of 

Anaphylactic Reactions 

Clinical Protocol CP01 

Protocol Summary 

Anaphylactic reactions may follow exposure to numerous agents such as insect 

stings, medication and foodstuffs. 

All clinical staff must be aware of this protocol, and must be familiar with the 

emergency management of this potentially fatal reaction. 

This protocol supports adherence to NICE Clinical Guideline CG134 and the 

Resuscitation Council (UK) Emergency Treatment of anaphylactic reactions- 

Guidelines for Healthcare Workers and includes a description of the recognition, 

assessment and management of an anaphylactic reaction 

A Trust eLearning package on the identification and management of anaphylactic 

reactions is available to support clinicians in the delivery of this protocol into 

practice. 

CP 01 - Protocol for the Emergency Treatment of Anaphylactic Reactions 

Approved by Drugs and Therapeutics Committee: March 2014 

Review Date: March 2016 Page 1 of 8

Document Control 

Version Date Issued Author Name / Job Title / Email 

1.0 September 2009 Amanda Gulbranson 

Clinical Effectiveness Lead - Medicine Management 

amanda.gulbranson@nhs.net 

2.0 March 2011 Deborah Marriott 

Lead Clinical network Pharmacist (Exeter, East and Mid) 

Deborah.marriott@nhs.net 

Kelly Smith 

Prescribing Information Analyst 

Kelly.smith8@nhs.net 

3.0 May 2012 Amanda Gulbranson 

4.0 March 2013 Clinical Effectiveness Lead - Medicine Management 

5.0 March 2014 amanda.gulbranson@nhs.net 

Target audience / staff groups: 

Ratifying Group: 

Date ratified: March 2014 

Implementation date: March 2014 

Review date: March 2016 

Clinical staff: All inpatient units and staff responsible for the 

administration of vaccines 

Medicines Management Governance Group 

Document History 

Version Start End date Author History 

date 

1.0 September 

2009 

AG New Protocol signed off. Replaces PGDs for adrenaline for 

treatment of anaphylaxis 

1.1 05.01.11 05.01.11 KS Added reference and hyperlink to Anaphylaxis eLearning 

package 

1.2 05.01.11 01.03.11 DM/KS Appendix 1 now includes the following: 

- To call 999 

- Record time adrenaline administered 

- Administer oxygen only if difficulty in breathing 

Add that Anaphylaxis pack to be stored in Treatment Room 

with other emergency equipment (not locked away). 

Add that the person should not be left alone until emergency 

services arrive. 

2.0 22.03.11 22.03.11 KS Document signed off. 

2.1 May 12 AG Review of protocol to reflect Clinical Guidance issued by 

NICE (CG134) December 2011 

Sections 3.11, 4.2 bullet point 2 & 4.4 added 

3.0 May 12 KS Version 3 signed off. 

3.1 Mar 13 21.03.13 AG Contents of anaphylactic packs reviewed 

Anaphylaxis pack to be stored in emergency Equipment bag 

Information contained in algorithm (Appendix 1) minimised. 

Section added regarding patient’s own adrenaline autoinjector 

devices. 

4.0 Apr13 KS Version 4 signed off 

4.1 Feb14 Mar14 AG Anaphylaxis pack & contents reviewed in order to comply 

with EU Council Directive 2010/32/EU and availability of 

500microgram adrenaline auto-injector device. 

5.0 Mar14 KS Document ratified at DTC and signed off. 




1. Introduction 

1.1 This protocol covers the recognition, assessment and treatment of anaphylactic reactions 

and is intended to be read in conjunction with the Resuscitation Council (UK) Guidelines for 

the Emergency Treatment of Anaphylactic Reactions. 

1.2 Anaphylaxis can be defined as ‘a severe, life-threatening, generalised or systemic 

hypersensitivity reaction’. Anaphylaxis is characterised by rapidly developing lifethreatening 

airway, breathing and /or circulation problems, usually associated with skin and 

mucosal changes. 

1.3 Anaphylactic reactions may follow exposure to a variety of agents, with insect stings, drugs 

(e.g. antibiotics, non-steroidal anti-inflammatory drugs, parenteral vitamins such as 

Pabrinex ® ) and some foods being the most common. 

Peanut and tree nut allergy now accounts for a significant incidence of anaphylaxis. 

Beta blockers may increase the severity of an anaphylactic reaction and antagonise the 

response to adrenaline (the decision to prescribe a beta-blocker to a patient at increased 

risk of an anaphylactic reaction should only be made after assessment by an allergist and 

cardiologist). 

1.4 A low rate of anaphylaxis has been observed following vaccination based on reports to the 

Vaccine Adverse Event Reporting System (VAERS) with an estimated incidence of 1 case in 

600,000 vaccine doses distributed. None of the reported cases were fatal, however 

anaphylaxis can be fatal and vaccinations can (in very rare instances) cause a lifethreatening 

hypersensitivity reaction in certain individuals. Further administration of vaccines 

or specific medication is contraindicated in people with a history of anaphylaxis after a 

previous dose 

1.5 The lack of any consistent clinical manifestation makes the diagnosis of anaphylaxis difficult. 

All clinicians who treat anaphylaxis should be aware of possible differential diagnoses (i.e. 

vasovagal attacks or panic attacks) 

2 Emergency Medication 

2.1 The following medication will be stocked for the emergency management of anaphylaxis in 

accordance with this protocol; 

o 3 x Adrenaline (1:1000) auto-injector 

devices (500micrograms/ 0.5mls) 

Brand may vary 

NB. Anti-histamines (chlorphenamine) and corticosteroids (hydrocortisone) NOT included. These are 

second-line treatments, and will be administered by paramedics or acute trust clinicians if indicated. 

2.2 Emergency medication for the management of anaphylaxis will be held as stock on 

All inpatient units 

Community teams where vaccination programmes are offered (i.e. substance misuse 

services) and where individual workers administer vaccinations in the course of their 

work 

Note: Community psychiatric nurses solely administering antipsychotic depot injections need 

not carry an anaphylaxis treatment pack. Refer to section 4.3.2 of this document and Trust 

guidelines for the administration of antipsychotic depot injections. 

2.3 The emergency medication will be stored with the unit’s Emergency Resuscitation 

Equipment in the central (tamper-evident) section of the Emergency Equipment Bag (Fig 

1) OR on the Resuscitation/Crash team trolley (co-located wards only) 




Fig. 1 

A flow chart for the emergency treatment of an anaphylactic 

reaction (Appendix 1) will be located in the front pocket of the bag. 

The pack must be easily accessible in an emergency- under no 

circumstances will the pack be locked away in a drug cupboard or 

trolley. 

The ward manager / clinical team leader is responsible for ensuring 

that all clinical staff are aware of the agreed location of the 

Anaphylaxis Pack on their ward / unit and all new staff must be 

informed of this on their first day of employment. 

2.4 The Resuscitation Link Practitioner (or other designated registered nurse) will be 

responsible for checking and recording the expiry date of the emergency medication held on 

the ward and ensure the timely reordering of replacement stock. 

Good Practice Recommendation: 

Record the expiry date of all emergency medication held on the ward next to the medicine listed on 

the ward stock profile (Emergency Medication section). 

The registered nurse completing the weekly medication stock order will check the expiry date on 

the profile and re-order if the expiry date less than 2 weeks from the current date. 

2.5 Emergency medication will be re-ordered as necessary from the pharmacy department in 

accordance with Standard Operating Procedure MM27 (Ordering ward stock from profiles) 

3. Patient’s Own Medication (Adrenaline auto-injector devices) 

3.1 Auto-injectors devices (e.g. Epipen ® ) are prescribed on an individual basis, by a specialist in 

allergy, for self- administration by people who are at risk of an anaphylactic reaction. 

3.2 If a person on an inpatient unit experiences an anaphylactic reaction, intramuscular 

adrenaline (500micrograms) will be administered in accordance with this protocol (see 

section 2.1 and Appendix 1). However, if access to the emergency medication is delayed, it 

would be appropriate for a healthcare professional to use the person’s own adrenaline autoinjector 

(NB this may deliver a dose of 300miccrograms or 500micrograms depending on the 

product prescribed), for the management of an anaphylactic reaction to ensure timely 

administration of treatment. 

3.3 For individuals prescribed an adrenaline auto-injector by a specialist or their GP, the product 

should be prescribed in the ‘when required’ section of the Trust inpatient prescription and 

administration chart to ensure clinicians are aware the person is prescribed, and usually 

carries, emergency medication for self- treatment of an anaphylactic reaction. 

3.4 Individuals prescribed an adrenaline auto-injector should carry this with them during periods 

of leave away from the unit and staff must also ensure that the person’s own adrenaline 

auto-injector device is returned to them at the time of discharge. (Refer to procedure MM08) 

4. Recognition and diagnosis of anaphylaxis 

4.1 When recognising (and treating) any acutely ill patient, a rational ABCDE approach must be 

followed (see 4.2) and life-threatening problems treated as they are recognised. 

4.2 A diagnosis of anaphylaxis is likely if a patient who is exposed to a trigger (allergen) also 

presents with the following; 

• Sudden onset and rapid progression of symptoms 

• Life-threatening Airway and/or Breathing and/or Circulation problems 

• Skin and/or mucosal changes (flushing, urticaria, angioedema) 




Presenting signs and symptoms may include; 

Airway 

Airway swelling (throat & tongue), difficulty breathing and swallowing, sensation of 

throat closing up, hoarse voice, stridor (loud, harsh, high-pitched breathing) 

Breathing problems 

Shortness of breath (increased respiratory rate), wheeze, fatigue, confusion caused 

by hypoxia, cyanosis (blue-tinge to the skin), respiratory arrest. 

Some patients may die from acute irreversible asthma or laryngeal oedema with few 

more generalised manifestations present. 

Circulation 

Signs of shock (pale, clammy), tachycardia, hypotension, dizziness, collapse, 

reduced or loss of consciousness and faint carotid pulse. 

Disability 

Airway, breathing and circulatory problems can all alter neurological status causing 

confusion, agitation and loss of consciousness. 

Continued….. 

Exposure (Skin and/or mucosal changes) 

Urticaria can appear anywhere on the body. Wheals may be pale, pink or red and 

may look like a nettle sting. They can be different shapes & sizes, often surrounded 

by a red flare and usually itchy. 

Angioedema most commonly affects eyelids and lips and sometimes the mouth and 

throat. 

Skin or mucosal changes alone are not a sign of an anaphylactic reaction and can 

be subtle or absent in up to 20% of reactions. 

Other 

Gastrointestinal (vomiting, abdominal pain, incontinence), rhinitis and conjunctivitis. 

4.3 Differential Diagnosis: 

Non-life threatening conditions which can be confused with anaphylaxis include: 

4.3.1 Panic attacks 

Individuals who have previously experienced an anaphylactic reaction may be particularly 

prone to panic attacks if they think they have been re-exposed to the causative allergen. 

The sense of impending doom and breathlessness leading to hyperventilation may resemble 

anaphylaxis, however there is no hypotension, pallor, wheeze, or urticarial rash/swelling. An 

erythematous rash associated with anxiety may complicate diagnosis, whereas overbreathing, 

tingling around the lips and muscle spasms in the fingers are usually associated 

with panic attacks. 

4.3.2 Vasovagal Attacks 

Vasovagal attacks (vagal overactivity producing bradycardia and a fall in blood pressure) 

can occur following vaccination and administration of intra-muscular injections (i.e. 

antipsychotic depot injections) and can be misdiagnosed as anaphylaxis. However, the 

absence of rash, breathing difficulties, and swelling is a useful distinguishing feature as is 

the slow pulse and normal blood pressure (compared with the rapid pulse and 

low/undetectable blood pressure of a severe anaphylactic episode). 

5. Treatment 

5.1 Treatment of an anaphylactic reaction should be based on general life support principals: 

Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) 

5.2 In all cases of suspected anaphylactic reactions, immediately shout for assistance and an 

anaphylaxis pack. Medical help must be urgently sought by calling 999 from an outside line. 

5.3 The person should NOT be left unattended. From when the reaction is identified until the 

emergency services arrive, the person must not be left alone. 




5.4 Treatment must not be delayed while waiting for an ambulance to arrive. 

5.5 Reassure the patient. 

5.6 Place the patient in a comfortable position taking into account the following factors: 

If the person has low blood pressure and / or reports feeling faint- lie the patient down 

flat, with or without leg elevation. If the person reports feeling faint, do not sit or stand 

them up (this can cause a cardiac arrest) 

A person with breathing difficulties may prefer to sit up to make breathing easier 

If the person is breathing but unconscious, place them on their side in the recovery 

position (NB pregnant patients should lie on their LEFT side to prevent caval 

compression). 

5.7 Remove the trigger allergen if possible (i.e. stop the administration of a medication, remove 

the stinger from a bee sting). If food is the suspected trigger, DO NOT attempt to induce 

vomiting. Treatment must NOT be delayed if the removal of the trigger is not feasible. 

5.8 Early administration of intramuscular adrenaline (epinephrine) is the treatment of choice in 

the management of anaphylactic shock. 

Use ADRENALINE (epinephrine) injection 1:1000 (1mg/ml) 

The dose for adults and children over 12 years is 500micrograms 

(0.5ml of Adrenaline 1:1000) 

Administer intramuscularly into the anterolateral aspect of the middle third of the thigh. 

(Refer to SOP MM28 Safer Use of Injectables) 

Administer the intramuscular injection with the needle at a 90º angle to the skin. The skin 

should be stretched not bunched 

Record the TIME that the dose was administered in the clinical notes 

In the absence of clinical improvement, repeat every 5 minutes (until paramedics arrive). 

For further information, consult a Summary of Product Characteristics for an adrenaline 

injection at www.medicines.org.uk/emc/ 

5.9 Oxygen should be administered as soon as it is available. Oxygen should be administered 

using a mask with an oxygen reservoir using high flow oxygen (10 to15 litres/minute) to 

prevent the collapse of the reservoir during inspiration. (In life-threatening emergencies a 

prescription for oxygen is not necessary when acting in accordance with this protocol, but 

subsequently documented of treatment administered must be recorded). 

5.10 Patients who have been administered adrenaline (epinephrine) as first line treatment must 

be transferred to an acute Trust hospital as soon as possible where monitoring and further 

treatment (if appropriate) can be provided by paramedics and Accident and Emergency 

clinicians. 

5.11 Clearly document the following information the patient’s electronic medical records: 

Presenting acute clinical features of suspected anaphylactic reaction 

The time of onset of the reaction 

The circumstances immediately before the onset of symptoms to help identify the 

possible trigger 




6. Follow up 

6.1 Following an anaphylactic reaction all patients should be taken by ambulance to the accident 

and emergency (A&E) department of the local acute trust hospital for observation, 

assessment and further treatment where necessary. Individuals must be advised to go to 

A&E even where symptoms subside following immediate treatment, as delayed or rebound 

reactions may occur. 

6.2 Details of the incident should accompany the patient, to include: 

Probable cause of anaphylactic reaction (if known) 

Presenting clinical features of suspected anaphylactic reaction, time of onset and 

circumstances leading up to event ( as stated in 5.11) 

List of medications the patient is known to be taking, including over-the counter 

medicines and vitamin or mineral supplements if available. 

Action taken (i.e. doses of adrenaline given and the times of administration). 

6.3 All cases, where a medicine was suspected in causing an anaphylactic reaction, should be 

reported to the Medicines and Healthcare products Regulatory Agency (MHRA) using the 

Yellowcard ® system (found in the back of the BNF, or via the MHRA web-site: 

www.yellowcard.gov.uk). 

6.4 Following assessment and treatment by acute Trust emergency and / or medical services, 

ensure that details of any known / suspected allergies are updated in the patient’s medical 

records (and communicated to the GP on discharge) where applicable. 

7. Further Training 

7.1 There is an Anaphylactic Shock eLearning module available to promote the following: 

Recognition of anaphylaxis 

Common triggers of anaphylaxis 

Actions required if anaphylactic reaction occurs 

Treatment of anaphylaxis 

7.2 This module is required learning for all Trust clinical (nursing and medical) staff working on 

inpatient units, and for all clinical staff responsible for administering vaccines. The module 

must be completed once every year. 

7.3 Click here to access the module via the Trust’s Online Course Programme. 

8. References 

Emergency Treatment of Anaphylactic Reactions, Working Group of the Resuscitation 

Council (UK), January 2008 

Immunisation against infectious disease (The Green Book), Department of Health London 

HMSO, 2006 

British National Formulary Edition 57, British Medical Association and Royal Pharmaceutical 

Society of Great Britain, March 2009 

Should Community mental health nurses be trained in recognising and treating anaphylaxis, 

Mental Health Practice 2(10) 18-20, Paton C and Morrison P (1999) 

National Institute for Health and Clinical Excellence (2011) Clinical Guidelines CG134- 

Anaphylaxis 




Appendix 1

CP01 Emergency Treatment of Anaphylactic Reactions - Devon ...

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