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
-
i) Adrenaline should be co-prescribed with caution for patients with cardiovascular disease on betablockers and/or ACE inhibitors
- 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
-
All patients prescribed self-injectable adrenaline must have appropriate training in their use. Please consider the following:
- 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
- Adrenaline Auto-Injector training video | University Hospitals Plymouth NHS Trust
- Anaphylaxis action plan WITHOUT adrenaline.pdf
- Anaphylaxis Action Plan with Adrenaline
- MedicAlert | Medical ID | Jewellery & Services
- Anaphylaxis UK | Supporting people with serious allergies | Anaphylaxis UK
For professionals
- Emergency treatment of anaphylactic reactions: Guidelines for healthcare providers | Resuscitation Council UK
- Anaphylaxis algorithm 2021.pdf
- Overview | Anaphylaxis: assessment and referral after emergency treatment Guidance | NICE
- [ARCHIVED CONTENT] Specialised Services National Definition Set: 17 Specialised services for allergy (all ages) : Department of Health - Managing your organisation
References
- https://www.nice.org.uk/Guidance/CG134
- https://cks.nice.org.uk/topics/angio-oedema-anaphylaxis/diagnosis/diagnosis-of-anaphylaxis/
- Ewan P, Brathwaite N, Leech S, et al. BSACI guideline: prescribing an adrenaline auto-injector. Clin Exp Allergy. 2016; 46(10): 1258-1280
- https://www.anaphylaxis.org.uk/fact-sheet/adrenaline/
- 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
- [ARCHIVED CONTENT] Specialised Services National Definition Set: 17 Specialised services for allergy (all ages) : Department of Health - Managing your organisation
- 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