Guidelines for Management of Anaphylaxis

As many as 5 percent of Americans have experienced anaphylaxis. Many more may be at risk. An epidemic of allergies means that more and more EMS agencies are routinely dealing with anaphylaxis. Appropriate management can be life-saving, and has already reduced anaphylaxis mortality to less than 1 percent. Brush up on your anaphylaxis management skills with these tips.

Diagnosing Anaphylaxis

Whenever an allergic patient experiences breathing difficulties, throat swelling, or a rash, it’s important to consider anaphylaxis as a possible culprit. Patients having their first anaphylactic reaction may not know they have an allergy, so ask about recent exposure to common allergens, such as new foods, medication, environmental chemicals, and insect stings.

Warning signs of anaphylaxis include:

• A red, itchy rash that looks like hives. The rash often appears suddenly.
• Swelling of the throat or mouth.
• Swelling anywhere else on the body.
• Wheezing or labored breathing.
• Loss of consciousness.
• Diarrhea or vomiting.
• Red or pale white skin.
• Hoarseness.

Acute Management Phase

Acute management of anaphylaxis involves ensuring the patient can breathe and removing the immediate threat to their life and health. Follow these steps:

1. Remove the allergen, if possible. For example, if there is a bee stinger still in the skin, remove it without pinching it.
2. Lay the patient flat, and do not allow them to walk or stand. If they have trouble breathing, allow them to sit up supported, with the legs extended out. Elevate the lower extremities. Rarely, anaphylaxis can trigger an extreme hypotensive event that prevents adequate cardiac filling. This can cause death in a matter of moments, so don’t neglect this important step.
3. Administer epinephrine via an intramuscular injection if consistent with your protocol. If symptoms are severe, initiate IV epinephrine if consistent with your protocol.
4. Ensure the airway is clear. If initial epinephrine fails or the patient continues to have trouble breathing, they may require intubation.
5. Transport the patient to the hospital and continue monitoring vital signs even if they appear stable. Anaphylaxis can cause a life-threatening secondary reaction minutes or hours following the initial reaction. Do not assume that a patient is in the clear because they appear normal. Anaphylaxis always requires subsequent monitoring.

Some patients may need additional treatment, such as:

• Saline solution if the patient is hypotensive.
• Supplemental oxygen.
• Cricothyroidotomy if severe upper airway edema occludes the airway.

Portable emergency suction devices are safer to use on patients in anaphylaxis because they do not require moving or lifting the patient, allowing prompt delivery of care. For help selecting the right portable emergency suction machine, download our free guide, The Ultimate Guide to Purchasing a Portable Emergency Suction Device.

Post-Anaphylaxis Observation

Anaphylactic reactions are often biphasic. In a biphasic reaction, the patient experiences a subsequent anaphylaxis episode several hours following the initial allergic reaction. Although patients may appear fine, or even insist that they do not need to be transported, anaphylaxis always warrants transport. Though anyone can experience a biphasic reaction, the risk is slightly increased among patients whose initial anaphylactic reaction was delayed. People with an allergy to galactose-alpha-1,3-galactose (alpha-gal allergy), sometimes called mammalian meat allergy, appear to have a much higher risk of biphasic anaphylaxis.  

In most cases, a patient will require monitoring for 6-24 hours following an anaphylactic reaction.

Sometimes, first responders are called to patients experiencing a secondary reaction after being discharged from the hospital. Treatment for these biphasic reactions is the same as for initial reactions. It’s important to ask if patients have recently experienced anaphylaxis because this always suggests a biphasic reaction as a possible explanation for breathing issues.

Once a patient has had an anaphylactic reaction, they will likely need to carry an EpiPen. First responders should discuss long-term allergy preparedness with their patients and encourage them to broach the topic with providers. Death from anaphylaxis is almost entirely preventable, and an EpiPen plays a key role in prevention.