INFORMATION SHEET FOR CANDIDATE

You are with the triage nurse when a 60 year old lady,
Mrs. Graham, presents with her husband who rushed
her to hospital from home where she developed
sudden onset of breathing difficulties after she
initially complained about tingling around her mouth
whilst eating a take-away meal. She looks quite
unwell, is in obvious respiratory distress, she has an
audible wheeze and stridor. She can not speak and
points to her large tongue and then promptly
collapses.
WHAT IS THE MOST LIKELY DIAGNOSIS
AND YOUR IMMEDIATE MANAGEMENT?

DIAGNOSIS:
ANAPHYLAXIS!!!
The patient has facial and tongue swelling, probably swelling of her airway and she could
get into severe trouble in a very short time.
Mild to moderate allergic reaction
Tingling of the mouth
Hives, welts or body redness
Swelling of the face, lips, eyes
Vomiting, abdominal pain
Severe allergic reaction- ANAPHYLAXIS
Difficulty and/or noisy breathing
Swelling of the tongue
Swelling or tightness in the throat
Difficulty talking or hoarse voice
Wheeze or persistent cough
Loss of consciousness and/or collapse
Pale and floppy (young children)
MANAGEMENT:
DRABC:
Danger:
none
Response:
patient drowsy, call for immediate help, resuscitation team
Airway:
Guedel airway difficult to place, prepare for intubation, anticipate
difficult airway - ?cricothyroidotomy / tracheostomy
Breathing:
Give 100% O2, add beta agonist or adrenaline via nebuliser,
prepare for intubation!
Circulation:
BP now 80/55, Pulse 130, give immediately 0.5 mg adrenaline im!
Insert i.v. line and start fluids, give steroids, ie 8 mg
dexamethasone iv or 50 mg prednisolone iv.
Consider antihistamines and H2 antagonists
PROGRESS:
The patient responds well to your treatment and does not require intubation. She is now
stable.
WHAT IS YOUR FURTHER MANAGEMENT?
1. HISTORY:
The patient tells you that she has had eczema, allergic
rhinitis as a child and lots of allergies all her life, including
against nuts, although this was her worst reaction and
presumably the meal must have contained some traces of
nuts.
2. EXAMINATION:
Now it is time to perform a complete physical examination
3. ADMIT:
The patient had a life-threatening episode and could easily
develop a biphasic / multiphasic (delayed degranulation
of mast cells) reaction with recurrence of broncho spasm or
shock, usually (90%) within 4 hours.

4. ANAPHYLAXIS MANAGEMENT PLAN:

1. BEING PREPARED
For individuals with anaphylaxis and parents, or those who
care for individuals with anaphylaxis should be prepared by;
i. o knowing their allergic trigger/s
ii. o knowing how to avoid the trigger/s (if possible)
iii. o being able to recognise the early symptoms of an allergic
reaction and anaphylaxis
iv. o having a first aid anaphylaxis plan. This may include
having an automatic adrenaline injector device (EpiPen)
available it is important to know how to use the device.
2. IF ANAPHYLAXIS OCCURS FOLLOW THE FIRST AID
ACTION PLAN:
1. Seek emergency medical assistance (eg call an ambulance).
2. Lay the person flat and elevate the legs if the person is dizzy or
seems confused or has a reduced level of consciousness, unless this
makes it more difficult for the person to breath.
3. Use the EpiPen as detailed on the action plan;
This is usually recommended at the first sign of any respiratory
and/or cardiovascular symptoms (see list on action plan).
In some cases patients may be given instructions to inject the
EpiPen immediately after exposure to the trigger or at the onset of
any symptoms.
4. Follow standard resuscitation measures (ABC) if there is no
pulse, no breathing or loss of consciousness - If oxygen is available
give at a high flow rate.
WHAT IS THE UNDERLYING PATHOPHYSIOLOGY OF ANAPHYLAXIS?
A specific IgE mediated degranulation of mast cells and their chemical mediators,
also known as a Type I hypersensitivity reaction.
A range of chemicals can be released form mast cells:
1. HISTAMINE: causes hypotension, increases capillary permeability,
cutaneous vasodilation and wheal formation, oedema (lips, tongue,
subglottic, pulmonary) itching, bronchiolar constriction
2. LEUKOTRIENS: (SRS-A = slow release substance of anaphylaxis)
chemotactic for monocytes and eosinophils, causes bronchoconstriction,
increases mucous production, increases vascular permeability
3. EOSINOPHIL AND NEUTROPHIL CHEOTACTIC FACTORS: attract
neutrophils and eosinophils to affected areas
4. PLATELET ACTIVATING FACTOR: heparin like activity
5. CYTOKINES: TNF (tumour necrosing factor), interleukins
6. SEROTONIN
7. COMPLEMENT ACTIVATION