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Drugs. Some medications can cause anaphylaxis. To summarise, a diagnosis of anaphylaxis is likely
Although more common in adults, it is important if a child has been exposed to a known trigger and
to recognise that the most common problems are unexpectedly - usually in minutes - has rapid skin
the beta-iactam antibiotics, for example peniciiiins, changes, life-threatening airway or breathing problems,
cephaiosporins, and muscie relaxants, for example and/cr circulation problems.
suxamethonium and vecuronium) (Simons 2010). Now do time out 2.
Now do time out 1.
1 ^ June
June 2011 | Volume 23 i Number 5 NURSING CHILDREN AND YOUNG PEOPLE
Investigations
There is no diagnostic test for anaphylaxis. Blood
tests can look at tryptase or histamine levels, however
both have to be taken soon after the onset of the
anaphylactic episode as levels return to normal quickly.
It has also been shown that the serum tryptase level
is seldom increased when anaphylaxis is triggered by
food (Sampson ef al 1992). Skin-prick testing or serum
Diagnosis - look for:
specific IgE blood tests can help identify allergens, thus
Acute onset of illness.
enabling families to identify possible triggers and help in
Life-threatening Airway and/or Breathing and/or
avoiding allergen exposure.
Circulation problems'.
And usually, skin changes.
Risk factors
Risk factors to help practitioners identify those children
and young people who are at risk if exposed to a known
trigger include;
Call for help. 1
Lie patient flat.
Patients who have had an anaphylactic reaction have Raise patient's legs.
a strong likelihood of having another one (Pumphrey
and Stanworth 1996, Mullins 2003).
A strong link has been identified between poor
Adrenaline^.
asthma control and fatal anaphylaxis in children with
food allergy (Sampson ef al 1992, Pumphrey 2000,
2004). When skills and equipment available:
Adolescents who take less care avoiding known Establish airway.
triggers, particularly in foods, or fail to carry their High flow oxygen. Monitor:
AAls (Greenhavirt ef al 2009). IV fluid challenge^. Pulse oximetry.
Treatment in hospital. Chlorphenamine". ECG.
The management of anaphylaxis involves treating Hydrocortisone^. Blood pressure.
the acute episode and implementing strategies in the
community to prevent reoccurrences.
'Life-threatening problems:
Airway: swelling, inoarseness, stridor.
Treatment in hospital Recognition and rapid treatment
Breathing: rapid breathing, wheeze, fatigue, cyanosis, SpO^ < 9 2 % , confusion.
of the acute episode are vital. This includes rapid CitcHlation: pale, ciammy, low blood pressure, faintness, drowsy/coma.
assessment of airway, breathing and circulation using
the ABCDE approach. If a child is in cardio-respiratory ^iV fluid chailenge:
'Adienaiine (give IM unless experieticed with IV adrenaline)
arrest they should be managed via a standard arrest Aduit:
IM doses of 1:1000 adrenaline (npeat after 5 minutes if rx> better)
500-1,OOOmL
protocol (Resuscitation Council (UK) 2010). The key Adult 5 0 0 micrograms IM (0.5mL).
Ciiiid: crystaiioid
steps for the treatment of anaphylaxis in hospital are Child more than 12 years: 5 0 0 micrograms IM (0.5mL).
20mLykg.
Child 6-12 years: 3 0 0 micrograms IM (0.3mL).
shown in the anaphylaxis algorithm published by the Stop IV colloid if tinis
Child less than 6 years: 150 micrograms IM (0.15 mL).
migiit be tiie cause of
Resuscitation Council (UK) (2008) (Figure 1).
Adrenaiine IV to be given only by experienced specialists anapi^yiaxis
Titrate: aduits 5 0 micrograms; chiidren 1 microgram/kg
Adrenaline This is the medication of choice for the
treatment of acute anaphylaxis. The first-aid dose ^Chlorphenamine 'Hydrocortisone
of adrenaline is O.Olmg/kgof a lmg/mL (1:1,000) (iMorsiowiV) (iMorsiowiV)
Aduit or ciniid more than 12 years: lOmg 200mg
diljtion to a maximum dose of 0.3mg in a child or Chiid 6-12 years: 5mg lOOmg
0.5mg in an adult. Ciiiid 6 months to 5 years: 2.5mg 50mg
> 1 2 years: 500 micrograms (meg) intramuscular Chiid iess than 6 months; 250 microgramVi<g 25mg
(IM) (0.5mL) - same as the adult dose. 300mcg (Resuscitation Councii (UK) 2008)
(0.3mL) - if child is small or prepubertal.
>six to 12 years: 300mcg IM (0.3mL). response and if there is no improvement in the
>six months to six years: 150mcg IM (0.15mL). patient's condition.
<six months: 150mcg IM (0.15mL) (Resuscitation The alpha-adrenergic effects of adrenaline increase
Council (UK) 2008). peripheral vascular resistance, blood pressure and
The guidelines recommend that the dose can be coronary artery perfusion, while reducing angiodema
repeated at five-minute intervals, according to patient and urticaria. Its betaj adrenergic effects increases
heart rate and contraction while its beta^ adrenergic Treatinent in the community
effects cause bronchodilation and inhibits the release of Anaphylaxis mostly initiates in the community setting
inflammatory mediators. There are no contraindications and for this reason patients need to recognise the early
for the use of adrenaline in an anaphylactic reaction. symptoms of anaphylaxis and when they need to use
There are other medicines that can help, such as: their adrenaline. This [adrenaline] should be given
Antihistamines Hj antagonist, for example to a child with life-threatening signs or symptoms of
chlorphenamine and cetirizine, can be used to treat itch anaphylaxis. If these are absent it is recommended that
and hives which occur in anaphylaxis. However, there is the child is carefully watched and reassessed. Allergic
no research evidence of their efficacy in anaphylaxis and reactions which affect the skin only can be treated with
for this reason they should never delay the administration antihistamines.
of adrenaline if required (Sheikh e al 2007). Antihistamines are best given in liquid form
Chlorphenamine to encourage rapid absorption, for example
> 1 2 years and adults: lOmg IM or intravenous (IV) chlorphenamine and cetirizine. If, however, the child's
injection slowly. condition deteriorates in any way then adrenaline must
>six to 12 years: 5mg IM or IV injection slowly. be administered. Adrenaline should be administered
>six months to six years: 2.5mg IM or IV and repeated every five to 15 minutes until clinical
injection slowly. improvement is seen. In the community, the best way
<six months: 250m^kg IM or IV injection slowly of providing first aid treatment with adrenaline is by
(Resuscitation Council (UK) 2008). using an AAI which delivers an intramuscular injection
of adrenaline into the mid-anterolateral aspect of the
Inhaled beta^ agonists These can be administered thigh. Intramuscular adrenaline is absorbed rapidly with
via a spacer device or nebuliser as a treatment for peak concentrations being reached within ten minutes
bronchospasm associated with anaphylaxis. of administration (Simons et al 1998).
Adrenaline is currently available in the UK in
Oxygen For patients experiencing respiratory symptoms two types of single-use AAls (Table 2, page 34). As the
or low blood pressure, high flow oxygen should be journal went to press, a third adrenaline autoinjector,
delivered. Jext, was due to be launched later in 2 0 1 1 , Jext
150mcg has been licensed for children 15-30kg and at
Corticosteroids These should only be given after first 300mcg for children of 30kg and above.
line emergency treatment has been received, that is AAls should be kept at room temperature, away
adrenaline and/or antihistamines. from heat sources and direct sunlight. All devices will
Hydrocortisone have an expiry date and should be renewed at this
> 1 2 years and adults: 200mg IM or IV injection slowly. time. Information about EpiPen and Anapen use and
>six to 12 years: lOOmg IM or IV injection slowly. registration for their expiry scheme is available on the
>six months to six years: 50mg IM or IV injection slowly. following websites www.anapen.co.uk and
Patients should have access to their AAls at all (epinephrine) 1:1000 chlorphenamine hydrocortisone
times. Despite this, evidence suggests that up to given intramuscularly IM or slow I M or slow IV
70 per cent of patients do not carry their AAls at all (IM) intravenous (IV)
times. (McLean-Tooke ef al 2003). There is ongoing injection
debate on the number of AAls that patients should carry > 1 2 years 500 micrograms (meg). lOmg 200mg
or have access to. 300mcg small child or
The number of AAls that should be prescribed prepubertal, 0.5mL,
depends on careful assessment of the risk factors and 0.3mL
individual child and family circumstances, for example >six to 12 300mcg, 5mg lOOmg
the remoteness of location from medical facilities, years 0.3mL
and weight of child of more than 60kg. There is no >six months 150mcg, 2.5mg 50mg
self-injectable adrenaline pen for infants under 15kg. to six years 0.15mL
The alternative to prescribing the 0.15mg dose is
<six months 150mcg, 250mcg/kg 25mg
to show parents how to draw up the correct dose of
0.15mL
adrenaline using a needle and syringe. This, however,
presents the risk of drug errors occurring. Therefore, (Adapted from Resuscitation Council (UK) 2008)
above the age of six months it is recommended that it
is safer to use the 0.15mg AAI (Resuscitation Council delivery of anaphylactic training in primary care. Box 2,
(UK) 2008). It is crucial that, at all times, a child page 34, summarises the key areas and actions that
should have access to at least one of their AAls. shoulc be covered when a diagnosis of anaphylaxis is
made in a child.
Education Now do time out 4.
Age, lifestyle, hobbies and access to medical care
should be considered in management strategies. Emergency plans
Obviously, the mainstream of management is careful The prescribing of adrenaline has almost doubled in
avoidance of trigger factors. Education is adapted recent years (Sheikh ef al 2008) but there is evidence
depending on the trigger implicated. to suggest that a significant proportion of patients fail
Dietitians are vital members of the multidisciplinary to use their AAI when an event occurs (Simons ef al
team and in food allergy can offer specific trigger-related 2009). Some are uncertain whether their reaction is
advice, including alternative names for food items, severe enough to require treatment and others turn to
exclusion of foods in a diet, ingredient checking on other medication choices as first-line treatments, such as
labels, eating out, takeaway foods and recipe plans. It antihistamines and asthma inhalers. They may be afraid
is important that children do not follow a restricted diet to inject or simply have forgotten how to use the device.
or exclusion diet unless supervised by a dietitian as they Individual management plans (IMPs) have been
require a well-balanced diet to ensure adequate growth shown to result in up to an eight fold reduction
and development. in frequency of anaphylactic events and a 60-fold
There are some circumstances where desensitisation reduction in severe reactions (Nurmatov ef al 2008).
may be an option for management. This is true for Education is an ongoing process and regular revision
those children who have had an anaphylactic episode is encouraged.
on contact with a stinging insect. Immunotherapy
(desensitisation) is not routine in clinical practice;
Education and training
for this reason children should be referred to an
allergy specialist. Some clinics in the UK are offering Study the Walker ef al (2010) article and
immunotherapy either sublingually or subcutaneously others, for example, Muraro (2010), to review
for foods such as milk, egg and peanut, animal danders alternative models of care and packages
and grass pollen. that Ccin be adapted to use in your area of
There is, however, ongoing research in these areas to practice to train professionals and families
determine the efficacy and extent of the desensitisation in cinaphylaxis management. Consider some
and its long-term effects. Healthcare professionals need of the ways parents cope with the fear of
to be trained to use AAls correctly and safely so that inadvertent exposure. What do you need to
they can, in turn, teach parents, careers and children. include in your training to support them?
Walker ef al (2010) describe best practice for the
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