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Anaphylaxis

Assessment and Referral after Emergency Treatment

 

Introduction

Anaphylaxis is an acute severe systemic reaction which is most often allergic (but can be non-allergic, previously called anaphylactoid).

Patients with a history of anaphylaxis should be referred to a specialist allergy clinic6.
 

In Scope            Assessment and referral of anaphylaxis in adults (16 years and over) after
                           emergency treatment


Not in Scope     
In those patients who present with an absence of systemic features, please
                           see the Urticaria and Angioedema guideline

                           Any other allergic reaction

                           Emergency treatment of acute life threatening anaphylaxis


 

Red flag Features

Any features of anaphylaxis needs emergency treatment

Anaphylaxis is characterised by one or more of2:

  • Airway – tongue/throat swelling, difficulty talking/hoarse voice
  • Breathing – shortness of breath, wheeze, persistent cough
  • Circulation – persistent dizziness or collapse, loss of consciousness
  • Neurological – sense of impending doom, visual changes
  • Skin changes

*This list is not exhaustive


 

Investigations required prior to referral

No investigations in primary care are required prior to referral

If anaphylaxis has been recurrent with no clear trigger, a baseline mast cell tryptase

(MCT) would be helpful.

  • No special conditions for taking and transporting sample. Gold top tube required. Only one single sample required when outside of the acute setting


 

Management Optimisation

Anaphylaxis is a medical emergency. It should be treated immediately and the patient urgently transferred to the Emergency Department. .

During follow up after the emergency episode, adopt a shared decision-making approach with the patient and their caregivers where appropriate.

  • Identify any potential triggers (e.g. foods, drugs, stings, exercise) in the 4 hours before the reaction
  • Advise avoidance of potential identified triggers pending further investigations.

 If a suspected trigger has been tolerated since the reaction it is excluded as a cause

  • Self-injectable adrenaline guidance:


     
    • All patients prescribed self-injectable adrenaline must have appropriate training in their use. Please consider the following:
      • i) Adrenaline should be co-prescribed with caution for patients with cardiovascular disease on betablockers and/or ACE inhibitors
         
      • ii) Asthma care should be optimised4

      • iii) Any patient with a tendency to angioedema should avoid ACE-I7
    • All patients should be provided with an emergency plan due to the difficulty in ensuring complete avoidance of potential trigger.
    • Drug reactions are not an indication for self-injectable adrenaline, as drugs can usually be avoided unless there is altered consciousness3, and or uncertainty about whether another likely allergen was responsible. Ensure the Primary Care record is updated with the drug allergy, and advise the patient to carry a medical alert

  • The use of alternative methods of diagnosis (e.g. naturopathy, hair analysis food-specific IgG testing, vega testing, kinesiology, pulse testing) or treatment (e.g. homeopathy, acupuncture, reflexology, chiropractic therapy) is not advised.


 

Advice and Guidance

No formal advice and guidance pathway is available


 

Referral

Referral instructions

There is a referral form available, which would help to minimise returned referrals. Only

the relevant section needs to be completed. GPs have the right to refer via referral letter

in the usual way.

 

Referral Criteria

  • Refer all adults (16 years and over) who have had an episode of suspected anaphylaxis
     
  • Please include details of index reaction with copy of appropriate correspondence (e.g. ED discharge summary) and suspected triggers


 

Supporting Information

For patients

For professionals

References

  1. https://www.nice.org.uk/Guidance/CG134
  2. https://cks.nice.org.uk/topics/angio-oedema-anaphylaxis/diagnosis/diagnosis-of-anaphylaxis/
  3. Ewan P, Brathwaite N, Leech S, et al. BSACI guideline: prescribing an adrenaline auto-injector. Clin Exp Allergy. 2016; 46(10): 1258-1280
  4. https://www.anaphylaxis.org.uk/fact-sheet/adrenaline/
  5. BSACI guideline: prescribing an adrenaline auto-injector. Pamela Ewan, Nicola Brathwaite, Susan Leech, David Luyt, Richard Powell, Stephen Till, Shuaib Nasser, Andrew Clark. First published: 29 September 2016https://onlinelibrary.wiley.com/doi/10.1111/cea.12788
  6. [ARCHIVED CONTENT] Specialised Services National Definition Set: 17 Specialised services for allergy (all ages) : Department of Health - Managing your organisation
  7. Scenario: Angio-oedema without anaphylaxis | Management | Angio-oedema and anaphylaxis | CKS | NICE

 

 

 

Review date:                            12 Feb 2025

Next review date:                    12 Feb 2027

Speciality Lead GP                  Dr Kate Northridge

Contributors                             Dr Catherine Elliott, Specialist Doctor in Allergy, University Hospital Plymouth