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Referral and warning signs
When to refer
All suspected cases of anaphylaxis require immediate emergency management. Refer to HC3/HC4 or Hospital immediately for advanced care, monitoring, and potential intensive care admission. Patients require observation for several hours due to risk of biphasic reaction.
Red flags
- Difficulty breathing (stridor, wheezing, shortness of breath)
- Hypotension or signs of shock
- Sudden collapse or loss of consciousness
- Swelling of tongue or throat (angioedema)
- Confusion or agitation
Signs and symptoms
- Body itching
- Hives (urticarial rash)
- Swelling of lips, eyes, tongue (angioedema)
- Difficulty in breathing (stridor, wheezing)
- Hypotension and sudden collapse
- Excessive sweating
- Thin pulse
- Abdominal cramps
- Vomiting
- Diarrhoea
Risk factors
- Allergy to pollens
- Allergy to some medicines (e.g., penicillins, vaccines, acetylsalicylic acid)
- Allergy to certain foods (e.g. eggs, fish, cow’s milk, nuts, some food additives)
- Reaction to insect bites (e.g., wasps and bees)
Diagnosis
Clinical assessment
Diagnosis is primarily clinical based on rapid onset of characteristic signs and symptoms affecting multiple systems (skin/mucosa, respiratory, cardiovascular, GI) after exposure to a potential allergen.
Diagnostic criteria
Rapid onset involving skin/mucosal tissue AND either respiratory compromise OR reduced BP/end-organ dysfunction. Consider in any sudden onset hypotension or bronchospasm or upper airway obstruction.
Management
Non-pharmacological management
- Determine and remove the cause if possible
- Secure the airways (call for help early)
- Administer high-flow oxygen
- Restore BP: lay the patient flat and raise feet (if breathing not compromised)
- Keep patient warm
- Monitor the patient closely for several hours (reaction may recur)
Pharmacological treatment
- Adrenaline (epinephrine) injection 1:1000 (1 mg/ml) IM into anterolateral thigh immediately. Dose: Adult: 0.5 mg (0.5 ml); Child 6-12 years: 300 micrograms (0.3 ml); Child <6 years: 150 micrograms (0.15 ml). Repeat every 5-10 minutes based on BP, pulse, respiratory function.
- IV fluids: Sodium chloride 0.9% infusion 20 ml/kg IV rapidly initially, then adjust rate according to BP.
- Hydrocortisone 200 mg IM or slow IV stat (Adjunctive, slower onset). Dose: Child 6-12 years: 100 mg; Child 1-5 years: 50 mg; Child <1 year: 25 mg.
- Antihistamine (for itching/urticaria, adjunctive): Chlorpheniramine 4 mg PO/IM/IV q6h (Child 5-12y: 2mg q6h; 2-5y: 1mg q6h; 1-2y: 1mg q12h) OR Cetirizine 5mg PO daily (Adults/Child >6y); 2.5mg PO daily (Child 1-6y) OR Promethazine 25-50 mg deep IM/slow IV/PO (Child 5-10y: 6.25-12.5mg; 1-5y: 5mg).
- Repeat adrenaline and hydrocortisone every 2-6 hours prn depending on progress. Follow specific Ugandan treatment algorithms/guidelines.
Monitoring
Monitor airway, breathing, circulation (BP, pulse rate), mental status, and skin findings closely and frequently. Monitor for recurrence of symptoms for several hours.
Complications
- Airway obstruction
- Cardiovascular collapse
- Respiratory arrest
- Death
Prevention
- Always ask about allergies before prescribing/administering medications
- Keep emergency drugs (especially adrenaline) readily available
- Counsel allergic patients on avoidance
- Advise severely allergic patients to wear an alert bracelet/tag and carry an epinephrine auto-injector if available/appropriate
Patient education
- Explain the nature of the severe allergic reaction
- Emphasize the importance of avoiding known triggers/allergens
- If an auto-injector is prescribed, teach patient and family how and when to use it
- Advise wearing a medical alert identification
Uganda-specific notes
Intramuscular (IM) adrenaline into the anterolateral thigh is the preferred route and first-line treatment. Ensure availability of adrenaline and other emergency drugs at all health facilities. Remember to complete and submit an Adverse Drug Reaction (ADR) reporting form.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 1, Section 1.1.1