Any person, 4 weeks to 15 years, presenting with an urticarial rash, without respiratory or anaphylactic symptoms.
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.
If anaphylaxis symptoms, switch to anaphylaxis protocol.
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 of symptoms
- Features of the rash
- History of events before the onset
- Pain assessment
- Pre-hospital treatment
- Past admissions
- Medical and surgical history
- Current or recent illness
- Current medications
- Known allergies
- Immunisation status
- Current weight
- Recent travel
Signs and symptoms
- Elevated lesions with a flat centre, surrounded by an erythematous wheal:
- itchy
- can be found on any part of the body
- vary in size, from millimetres to centimetres
- may appear within minutes and usually resolve within 24 hours
- Angioedema
- Irritability
- Fever
- Viral symptoms
- Signs of chronic atopy, i.e. eczema
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
- History of anaphylaxis
- Less than 6 months old
- Prolonged fever over 5 days
- Chronic urticaria over 6 weeks
Clinical
- Systemic features and/or unwell child
- Non blanching petechial or purpuric rash
- Associated bruising
- Painful lesions, but not itchy
- Joint pain and/or swelling
- Mucosal involvement
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.
Position
Assessment | Intervention |
---|---|
General appearance/first impressions | Position of comfort |
Airway
Assessment | Intervention |
---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
Assessment | Intervention |
---|---|
Respiratory rate and work of breathing Auscultate chest (breath sounds) Oxygen saturation (SpO2) | Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93% |
Circulation
Assessment | Intervention |
---|---|
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm | Assess circulation Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern Consider 12 lead ECG |
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 | Remove identifiable causes Inspect oral cavity Non-blanching petechial or purpuric rash, escalate as per local CERS protocol |
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
- Urticaria is most commonly idiopathic or post-viral.
- Other causes can be due to medications, contact allergy, bites and stings, foods and autoimmune conditions.
- Assess for evolving anaphylaxis.
Interventions and diagnostics
Specific treatment
Give antihistamine:
- 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.
A cool compress may be applied to the rash to provide symptom relief.
Avoid aspirin and NSAIDs.
Avoid topical steroids as they do not alleviate symptoms or reduce the duration of the 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).
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 |
---|---|---|---|
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 | |
0.25–15 L/min, device dependent | Inhalation | Continuous | |
15 mg/kg Maximum dose 1000 mg | Oral | Pain score 1–10 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
- The Royal Children's Hospital Melbourne. Clinical practice guidelines: Urticaria. Melbourne: Victoria Health; 2019 [cited 1 Mar 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Urticaria/
- Macy E. Practical Management of New-Onset Urticaria and Angioedema Presenting in Primary Care, Urgent Care, and the Emergency Department. Perm J. 2021 Nov 22;25. DOI: 10.7812/tpp/21.058
- American Society of Health-System Pharmacists. AHFS Drug Information. United States: American Society of Health-System Pharmacists; 2022 [cited 1 Mar 2023]. Available from: http://online.statref.com/document/ZYsgfuBN-un-IGwdMij6vt
- 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 Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 23 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- Asero R. New-onset urticaria. UpToDate Wolters Kluwer; 2023 [cited 10 March 2023]. Available from: https://www.uptodate.com/contents/new-onset-urticaria?search=urticaria&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
- Merative Micromedex. Cetirizine Hydrochloride. United States: Merative Micromedex; 2023 [cited 1 Mar 2023]. Available from: https://www.micromedexsolutions.com.acs.hcn.com.au/micromedex2/librarian/CS/A0A607/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/298CEE/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Cetirizine&UserSearchTerm=Cetirizine&SearchFilter=filterNone&navitem=searchALL#
- NSW Health. Australian Medicines Handbook Children's Dosing Companion: Loratadine. Australia: Australian Government, NSW; 2023 [cited 1 Mar 2023]. Available from: https://childrens.amh.net.au.acs.hcn.com.au/monographs/loratadine
- The Sydney Children's Hospital Network. Meds 4 Kids Dosing Guide. Australia: NSW Health; 2023 [cited 23 Feb 2023]. Available from: https://webapps.schn.health.nsw.gov.au/meds4kids/
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/urticarial-rash