|
| Recommendation | Evidence Level | Grade |
|
| First-line intervention: adrenaline | | |
Adrenaline is potentially lifesaving and must therefore promptly be administered as the first-line
treatment for the emergency management of anaphylaxis. | IV | C |
| Earlier administration of adrenaline should be considered on an individual basis when an allergic reaction is likely to develop into anaphylaxis. | V | D |
| Adrenaline should be administered by intramuscular injection into the midouter thigh. | I | B |
| In patients requiring repeat doses of adrenaline, these should be administered at least 5 min apart. | V | D |
With inadequate response to two or more doses of intramuscular adrenaline, adrenaline may be administered as an infusion by appropriately experienced intensive care, emergency department,
and critical care physicians, with appropriate cardiac monitoring. | IV | D |
|
| Second-line interventions | | |
| Trigger of the anaphylaxis episode should be removed. | V | D |
| Help should be called promptly and simultaneously with patient’s assessment. | V | D |
| Patients experiencing anaphylaxis should be positioned supine with elevated lower extremities if they have circulatory instability, sitting up if they have respiratory distress, and in recovery position if unconscious. | V | D |
| High-flow oxygen should be administered by face mask to all patients with anaphylaxis. | V | D |
| Intravenous fluids (crystalloids) should be administered (boluses of 20 mL/kg) in patients experiencing cardiovascular instability. | V | D |
| Inhaled short-acting beta-2 agonists should additionally be given to relieve symptoms of bronchoconstriction. | V | D |
|
| Third-line interventions | | |
| Oral H1- (and H2-) antihistamines may relieve cutaneous symptoms of anaphylaxis. | I | B |
| Systemic glucocorticosteroids may be used as they may reduce the risk of late-phase respiratory symptoms. High-dose nebulized glucocorticoids may be beneficial for upper airway obstruction. | V | D |
|
| Monitoring and discharge | | |
| Patients who presented with respiratory compromise should be closely monitored for at least 6–8 h, and patients who presented with circulatory instability require close monitoring for 12–24 h. | V | D |
| Before discharge, the risk of future reactions should be assessed and an adrenaline autoinjector should be prescribed to those at risk of recurrence. | V | D |
| Patients should be provided with a discharge advice sheet, including allergen avoidance measures (where possible) and instructions for the use of the adrenaline autoinjector. | V | D |
| Specialist and food allergy specialist dietitian (in food anaphylaxis) followup should be organized. Contact information for patient support groups should also be provided. | V | D |
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