Icu Guidelines Australia
Aureo Harvey
Cancer Council Australia develops and publishes clinical practice guidelines with scientifically-valid recommendations to inform health professional's clinical practice and ultimately improve cancer management in Australia.
This document has been developed by ASCIA, the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand. ASCIA information is based on published literature and expert review, is not influenced by commercial organisations and is not intended to replace medical advice. For patient or carer support contact Allergy & Anaphylaxis Australia or Allergy New Zealand.
ASCIA guidelines for the acute management of severe allergic reactions (anaphylaxis) are intended for medical practitioners, nurses and other health professionals who provide first responder emergency care. Appendix A includes additional information for health professionals working in emergency departments, ambulance services, and rural or regional areas, who provide emergency care.
The ASCIA definition is consistent with the following criteria published in the World Allergy Organisation Anaphylaxis Guidance Position Paper 2020.
Anaphylaxis is highly likely when any one of the following two criteria are fulfilled:
Criteria 1.
Acute onset of an illness (minutes to several hours) with simultaneous involvement of the skin, mucosal tissue, or both (e.g. generalized hives, pruritus or flushing, swollen lips-tongue-uvula), and at least one of the following:
a) Respiratory compromise (e.g. dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
b) Reduced blood pressure or associated symptoms of end-organ dysfunction (e.g. hypotonia [collapse], syncope, incontinence).
c) Severe gastrointestinal symptoms (e.g. severe crampy abdominal pain, repetitive vomiting), especially after exposure to non-food allergens.
Criteria 2.
Acute onset of hypotension or bronchospasm or laryngeal involvement after exposure to a known or highly probable allergen for that patient (minutes to several hours), even in the absence of typical skin involvement.
ALWAYS give adrenaline FIRST, then asthma reliever if someone with known asthma and allergy to food, insects or medication has SUDDEN BREATHING DIFFICULTY (including wheeze, persistent cough or hoarse voice) even if there are no skin symptoms.
The most common triggers of anaphylaxis are foods, insect stings and drugs (medications). Less common triggers include latex, tick bites, exercise (with or without food), cold temperatures, radiocontrast agents, immunisation (rare) and unidentified (idiopathic).
Anaphylaxis usually occurs within one to two hours of ingestion in food allergy. The onset of a reaction may occur rapidly (within 30 minutes) or may be delayed several hours (for example, in mammalian meat allergy and food dependent exercise induced anaphylaxis, where symptoms usually occur during exercise).
Anaphylaxis to stings and injected medications (including radiocontrast agents and vaccines) usually occurs within 5-30 minutes but may be delayed. Anaphylaxis to oral medications can also occur but is less common than to injected medications.
Adrenaline is the first line treatment for anaphylaxis and acts to reduce airway mucosal oedema, induce bronchodilation, induce vasoconstriction and increase strength of cardiac contraction.
The adrenaline injector devices listed above are available in Australia and listed on the Pharmaceutical Benefits Scheme (PBS). EpiPen and EpiPen Jr are available in New Zealand (Pharmac listed since 2023).
Management of anaphylaxis in pregnant women is the same as for non-pregnant women. Adrenaline should be the first line treatment for anaphylaxis in pregnancy, and prompt administration of adrenaline (1:1,000 IM adrenaline 0.01mg per kg up to 0.5mg per dose) should not be withheld due to a fear of causing reduced placental perfusion. The left lateral position is recommended, as shown below. For more information go to www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-in-pregnancy
Whilst 10-20kg was the previous weight guide for a 150 microgram adrenaline injector device, a 150 microgram device may now also be prescribed for an infant weighting 7.5-10 kg by health professionals who have made a considered assessment. Use of a 150 microgram device for treatment of infants weighing 7.5 kg or more poses less risk, particularly when used without medical training, than use of an adrenaline ampoule and syringe.
Infants with anaphylaxis may retain pallor despite 2-3 doses of adrenaline, and this can resolve without further doses. More than 2-3 doses of adrenaline in infants may cause hypertension and tachycardia, which is often misinterpreted as an ongoing cardiovascular compromise or anaphylaxis. Blood pressure measurement can provide a guide to the effectiveness of treatment, to check if additional doses of adrenaline are required. The correct way to hold an infant is flat, as shown below.
The left lateral (recovery) position is recommended for patients who are pregnant (see image above). This reduces the risk of compression of the inferior vena cava by the pregnant uterus and improves venous return to the heart.
Patients with mostly respiratory symptoms may prefer to sit with their legs outstretched in front of them (see image above), which may help support breathing and improve ventilation. They should not sit on a chair as this may trigger hypotension. Monitor closely and immediately lay the patient flat if there is any alteration in conscious state or drop in blood pressure.
If there is an inadequate response after 2-3 adrenaline doses, or deterioration of the patient, start IV adrenaline infusion, given by staff trained in its use or in liaison with an emergency specialist.
Antihistamines have no role in treating or preventing respiratory or cardiovascular symptoms of anaphylaxis. Do not use oral sedating antihistamines as side effects (drowsiness or lethargy) may mimic some signs of anaphylaxis. Injectable promethazine should not be used in anaphylaxis as it can worsen hypotension and cause muscle necrosis.
If there is a risk of re-exposure to allergens such as stings or foods, or if the cause of anaphylaxis is unknown (idiopathic) then prescribe and if possible dispense an adrenaline injector before discharge, pending specialist review. It is important to teach the patient how to use the adrenaline injector using a trainer device and provide them with an ASCIA Action Plan for Anaphylaxis which can be completed online and printed from the ASCIA website www.allergy.org.au/hp/anaphylaxis
Patients should be advised to document episodes of anaphylaxis, and the ASCIA allergic reactions event record can be used to collect this information. www.allergy.org.au/hp/anaphylaxis/anaphylaxis-event-record
If there is not an established protocol for your centre, two protocols for IV adrenaline infusion are provided, one for pre-hospital settings and a second for emergency departments/tertiary hospital settings only.
If there is inadequate response to IMI adrenaline or deterioration, start an intravenous adrenaline infusion. IV adrenaline infusions should only be given by, or in liaison with, an emergency medicine/critical care specialist.
If unable to maintain an airway and the patient's oxygen saturations are falling, further approaches to the airway (e.g. cricothyrotomy) should be considered in accordance with established difficult airway management protocols. Specific training is required to perform these procedures.
Acute Anaphylaxis Clinical Care Standard 2021, developed by Australian Commission on Safety and Quality in Health Care, in consultation with the Australasian Society of Clinical Immunology and Allergy (ASCIA), Allergy & Anaphylaxis Australia (A&AA), and the National Allergy Strategy (NAS). safetyandquality.gov.au/standards/clinical-care-standards/acute-anaphylaxis-clinical-care-standard
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The guidelines have been developed to specifically support improved infection prevention and control in acute health settings. While some of the principles and recommendations described in the guidelines may be applicable to other health settings, all healthcare facilities should consider the risk of transmission of infection in their setting and implement the guidelines and its recommendations according to their specific setting and circumstances.
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