Any person, 4 weeks to 15 years, presenting with a multisystem allergic reaction characterised by an acute onset of cardiovascular or respiratory symptoms, usually associated with typical skin features and/or gastrointestinal symptoms.
Escalate immediately as per local CERS protocol.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Onset and timing of symptoms
- Exposure to allergens or envenomation
- Pain assessment
- Pre-hospital treatment, including the use of an adrenaline auto-injector
- Past admissions
- Medical and surgical history, including respiratory, cardiac conditions or atopy
- Current medications
- Known allergies or hypersensitivities
- Immunisation status
- Current weight
Signs and symptoms
Anaphylaxis can occur with one or more of the following signs and symptoms:
- Difficult or noisy breathing
- Hoarse voice or difficulty talking
- Tongue swelling
- Throat tightness and/or swelling
- Wheeze or persistent cough
- Pale or floppy, in young children
- Collapse
- Hypotension or ongoing dizziness
- Gastrointestinal symptoms, including abdominal pain or vomiting
- Urticarial rash
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- Previous anaphylaxis
- Requiring multiple doses of adrenaline before hospital
- Poorly controlled asthma
- Pre-existing cardiac and respiratory conditions
- Recent new pharmacological therapy
- Known anaphylaxis to nuts, shellfish, insect stings or medications
Clinical
- Altered level of consciousness
- Collapse
- Central cyanosis
- Severe respiratory distress or airway compromise
- Angioedema
- Envenomation
- Arrhythmias
Remember child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
Remove allergen including sting, if present.
Position
Assessment | Intervention |
---|---|
General appearance/first impressions | Do not allow patient to sit up suddenly, stand, or walk
Allow patient to adopt a safe position of comfort as tolerated. If hypotensive, elevate feet |
If there are signs of anaphylaxis, escalate immediately as per local CERS protocol:
- Airway compromise
- Respiratory distress
- Dizziness or collapse
- Circulatory compromise
- Gastrointestinal symptoms
- Persistent and progressive rash
- Clinician or patient concern for anaphylaxis.
Adrenaline dosing
Give adrenaline (epinephrine) 10 microg/kg (0.01 mL/kg of 1:1000) IM injection into lateral thigh. Maximum single dose 500 microg (0.5 mL of 1:1000). Patient's own auto-injector may be used to avoid delay, if trained. Repeat dose every 5 minutes as required.
Refer to table below for dosing if unable to obtain exact weight.
Age (years) | Weight (kg) | Volume (mL) of adrenaline 1:1000 ampoules |
---|---|---|
Up to 2 | Up to 10 | 0.1 mL |
2–3 | 15 | 0.15 mL |
4–6 | 20 | 0.2 mL |
7–10 | 30 | 0.3 mL |
10–12 | 40 | 0.4 mL |
12 and over | 50 and over | 0.5 mL |
Airway
Assessment | Intervention |
---|---|
Patency of airway Signs of airway compromise:
| Maintain airway patency Consider airway opening manoeuvres and positioning Assist ventilation if clinically indicated Apply oxygen Apply continuous cardiorespiratory monitoring If airway compromise is present, give: nebulised adrenaline (epinephrine) 5 mg (equivalent to 5 mL or 5 ampoules of 1:1000) undiluted, with 8–10 L of oxygen via nebuliser. If symptoms remain, repeat once after 30 minutes Nebulised adrenaline (epinephrine) is not first-line therapy, but may be a useful adjunct to IM adrenaline (epinephrine), if upper airway obstruction is present |
Breathing
Assessment | Intervention |
---|---|
Respiratory rate and work of breathing Auscultate chest (breath sounds) Oxygen saturation (SpO2) | To assist with breathing difficulties, keep patient supine at 45° – do not sit upright suddenly |
Circulation
Assessment | Intervention |
---|---|
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm | Assess circulation Attach cardiac monitor (consider defibrillator) Check blood pressure every 5 minutes until within normal limits (outside Yellow Zone and Red Zone criteria) |
IVC and/or pathology | If persistent tachycardia and/or hypotension or poor response to treatment: insert IV cannula, if trained If unable to obtain IV access, insert intraosseous, if trained |
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension | If signs of shock present, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL |
Disability
Assessment | Intervention |
---|---|
AVPU | If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength |
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment as clinically indicated |
Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment |
Exposure
Assessment | Intervention |
---|---|
Temperature | Measure temperature |
Head-to-toe inspection, including posterior surfaces | Check and document any abnormalities Check for the presence of urticarial rash, erythema or skin flushing Consider giving antihistamine and comfort measures once stabilised |
Fluids
Assessment | Intervention |
---|---|
Hydration status | Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses |
Glucose
Assessment | Intervention |
---|---|
BGL |
Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):
If BGL less than 2 mmol/L OR symptomatic (Red Zone Criteria) OR unable to tolerate oral glucose:
|
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
- No specific focused assessment. Use clinical judgement and A to G assessment to determine focused assessment.
Precautions and notes
- Sitting upright suddenly or standing during anaphylaxis can be fatal.
- Most reactions occur within 30 minutes of exposure, but may be delayed several hours.
- Antihistamines have no role in treating or preventing respiratory or cardiovascular symptoms of anaphylaxis.
- Antihistamines primarily relieve cutaneous symptoms such as urticaria, itchiness and erythema.
- Patients with a history of acute hereditary angioedema (HAE) will not respond to adrenaline. Provide airway and breathing support and escalate as per local CERS protocol.
- Asthma and cardiovascular disease are associated with an increased risk of severe or fatal anaphylaxis.
Interventions and diagnostics
Specific treatment
- Do not allow patient with anaphylaxis to walk, sit up or stand suddenly. It can be fatal.
- Treat supine or on their side.
Airway compromise
If airway compromise is present, give:
nebulised adrenaline (epinephrine) 5 mg (equivalent to 5 mL or 5 ampoules of 1:1000) undiluted, with 8–10 L of oxygen via nebuliser. If symptoms remain, repeat once after 30 minutes.
Nebulised adrenaline (epinephrine) is not first-line therapy, but may be a useful adjunct to IM adrenaline (epinephrine), if upper airway obstruction is present.
Known asthma and/or wheeze
- Treat anaphylaxis first, including repeat doses of adrenaline.
- Able to breathe via spacer: give salbutamol by MDI via spacer, every 20 minutes for up to 3 doses, if required.
- 1–6 years: 6 puffs (100 microg/puff)
- 6 years and over: 12 puffs (100 microg/puff).
- Unable to breathe adequately via spacer: give nebulised salbutamol with 8–10 L of oxygen via nebuliser. Place nebule into nebuliser chamber and give every 20 minutes for up to 3 doses, if required.
- 1–6 years: one 2.5 mg nebule
- 6 years and over: one 5 mg nebule.
- If anaphylaxis has resolved but wheeze persists, consider wheeze (including viral-induced or suspected asthma) protocol
Urticarial rash
- For symptomatic treatment once haemodynamically stable, give antihistamine to alleviate itch:
- 6 months–1 year: desloratadine 1 mg, orally once daily
- 1–6 years: desloratadine 1.25 mg, orally once daily
- 6–12 years: desloratadine 2.5 mg, orally once daily
- 12 years and over: desloratadine 5 mg, orally once daily or if over 30 kg and can swallow tablets, loratadine 10 mg, orally once daily.
- Cool compress may be applied to rash to provide symptom relief.
- Avoid aspirin and NSAIDs.
- Avoid topical steroids. They do not alleviate symptoms or reduce the duration of rash.
Analgesia
If pain score 1–6 (mild–moderate): give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg
If severe pain present, give analgesia and escalate as per local CERS protocol.
Consider non-pharmacological pain relief (appendix).
Nausea and/or vomiting
If nausea and/or vomiting is present and over 6 months give:
ondansetron:
- 8–15 kg: 2 mg, orally once only
- 15–30 kg: 4 mg, orally once only
- Over 30 kg: 8 mg, orally once only.
Radiology
Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.
Pathology
Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.
Medications
The patient’s weight is mandatory for calculating fluid and medication doses.
The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
Drug | Dose | Route | Frequency |
---|---|---|---|
5 mg | Inhalation via nebuliser | If symptoms remain, repeat once after 30 minutes | |
10 microg/kg Maximum dose 500 microg (0.5 mL of 1:1000) per dose | IM (lateral thigh) | Repeat dose every 5 minutes as required | |
Adrenaline (epinephrine) auto-inject | 150 microg | IM (lateral thigh) | Patient's own auto-injector Repeat dose every 5 minutes as required |
300 microg | |||
500 microg | |||
6 months–1 year: 1–6 years: 6–12 years: 12 years and over: | Oral | Once daily | |
Glucose 40% gel | 4 weeks–1 year: 1–5 years: 5 g 6–11 years: 10 g 12 years and over : 15 g | Buccal | Repeat after 15 minutes if required |
12 years and over, can swallow tablets and over 30 kg: | Oral | Once daily | |
Over 6 months and 8–15 kg: 15–30 kg: Over 30 kg: | Oral | Once only | |
0.25–15 L/min, device dependent | Inhalation | Continuous | |
15 mg/kg Maximum dose 1000 mg | Oral | Pain score 1–10 Once only | |
1–6 years: 6 years and over: | Inhalation via nebuliser | Repeat every 20 minutes for up to 3 doses, if required | |
OR | |||
1–6 years: 6 years and over: | Inhalation via spacer | Repeat every 20 minutes for up to 3 doses, if required | |
20 mL/kg Maximum dose 1000 mL | IV/intraosseous | Bolus Once only |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- Samuels M (ed), Wieteska S (ed), Advanced Life Support Group. Advanced paediatric life support: A practical approach to emergencies 6th edition. UK: Wiley-Blackwell; 2016.
- Australian Medicines Handbook Children’s Dosing Companion. Adelaide: AMH; c2023 [cited 03 May 2023]. Available from: https://childrens.amh.net.au.acs.hcn.com.au/
- Sicherer SH. Anaphylaxis in infants. UpToDate; 2021 [cited 23 Feb 2023]. Available from: https://www.uptodate.com/contents/anaphylaxis-in-infants?search=anaphylaxis%20in%20infants&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
- McHugh K, Repanshek Z. Anaphylaxis: Emergency Department Treatment. Emerg Med Clin North Am. 2022;40(1):19-32. Available from: https://pubmed.ncbi.nlm.nih.gov/34782088/
- Australian Prescriber. Anaphylaxis: emergency management for health professionals. Aust Prescr. 2018;2018(41):54. Available from: https://www.nps.org.au/australian-prescriber/articles/anaphylaxis-emergency-management-for-health-professionals#authors
- Australian Prescriber. Anaphylaxis: emergency management for health professionals [Update 1]. Aust Prescr. 2022;2022(45):100. Available from: https://www.nps.org.au/australian-prescriber/articles/anaphylaxis-emergency-management-for-health-professionals-update-1
- Campbell RL, Kelso JM. Anaphylaxis: Emergency treatment. UpToDate; 2022 [cited 23 Feb 2023]. Available from: https://www.uptodate.com/contents/anaphylaxis-emergency-treatment
- Australia New Zealand Resuscitation Council. ANZCOR guideline 9.2.7 First aid management of anaphylaxis. Australia: Australian Rescuscitation Council; 2016 [cited 23 Feb 2023]. Available from: https://resus.org.au/the-arc-guidelines/
- Australasian society of clinical immunology and allergy. ASCIA Action, first aid, management, travel and treatment plans and guides. Australia: ASCIA; 2022 [cited 23 Feb 2023]. Available from: https://www.allergy.org.au/hp/ascia-plans-action-and-treatment#r4aa
- Australasian society of clinical immunology and allergy. ASCIA guidelines - Acute management of anaphylaxis. Australia: ASCIA; 2023 [cited 23 Feb 2023]. Available from: https://allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines
- NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 23 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- The Royal Children's Hospital Melbourne. Clinical practice guidelines: Anaphylaxis. Melbourne: Victoria Health; 2021 [cited 23 Feb 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Anaphylaxis/
- The Royal Children's Hospital Melbourne. Clinical practice guidelines: Gastroenteritis. Melbourne: Victoria Health; 2019 [cited 23 Feb 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Gastroenteritis/
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- NSW Emergency Care Institute. Clinical tools: Anaphylaxis. Sydney: Agency for Clinical Innovation; 2021 [cited 23 Feb 2023]. Available from: https://aci.health.nsw.gov.au/networks/eci/clinical/tools/anaphylaxis
- NSW Emergency Care Institute. Clinical tools: Angioedema. Sydney: Agency for Clinical Innovation; 2021 [cited 23 Feb 2023]. Available from: https://aci.health.nsw.gov.au/networks/eci/clinical/tools/angioedema
- Soar J, Pumphrey R, Cant A, et al. Emergency treatment of anaphylactic reactions--guidelines for healthcare providers. Resuscitation. 2008 May;77(2):157-69. DOI: 10.1016/j.resuscitation.2008.02.001
- The Royal Children's Hospital Melbourne. Oxygen delivery. Melbourne: Victoria Health; 2017 [cited 23 Feb 2023]. Available from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Oxygen_delivery/
- Frith K, Smith J, Joshi P, et al. Updated anaphylaxis guidelines: management in infants and children. Aust Prescr. 2021;2021(44):91-5. Available from: https://www.nps.org.au/australian-prescriber/articles/updated-anaphylaxis-guidelines-management-in-infants-and-children
Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
Currency | Due for review: Jan 2026. Based on a regular review cycle. |
Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/anaphylaxis