Adult Home Anaphylaxis Management

Anaphylaxis is a severe, life-threatening, generalised or systemic

hypersensitivity reaction. This is characterised by rapidly developing life-threatening
airway and/or breathing and/or circulation problems usually associated with skin and
mucosal changes1. The onset of the reaction is usually within minutes but may occur
up to one hour after exposure.
This guideline should be read in conjunction with the following policies/legislation:
Management of Medical Emergencies and Cardiorespiratory Arrest CPS
Poisons Regulations 1965 (WA) provides instructions for the storage and
handling of medications by a Registered Nurse
Safety Information and Nursing Management
Patients should be educated on the clinical signs of anaphylaxis and on the
appropriate course of action following any form of adverse reaction
A bag of 1L sodium chloride 0.9% and a gravity giving set to be retained in the
patients home while receiving intravenous therapy
In the event of moderate to severe anaphylaxis:
Adrenaline to be administered as per the standing order on the Medication
chart contained in the Anaphylaxis kit (following the Anaphylaxis Management
Guideline)
If adrenaline is administered a patient addressograph label is to be applied to
the medication chart with date, time and signatures completed and filed in the
patients medical record
Registered Nurses who are working in the community to undergo education in
the recognition and management of anaphylaxis on commencement of
employment and to maintain currency of practice as per the Scope of Nursing
Practice Decision Making Framework
Nurses attending a home visit to administer intravenous therapy must carry an
anaphylaxis kit into the patients home
The anaphylaxis kits will be checked each day by nurses carrying kits and all kits
will be formally checked on a weekly basis by a registered nurse
Anaphylaxis Kit Equipment:
Laerdal pocket mask
Oropharyngeal airways size 3, 4 and 5
Adrenaline 1mg/1mL x 5
2mL syringes x 5
Drawing up needles x 5
23 gauge needles for IMI injection x 5
Alcohol wipes x 5
Sphygmomanometer
Stethoscope
Record of vital signs document
Sharps container
Basic Life Support Algorithm Card
Medication Chart with standing order for adrenaline prescribed
PLUS: 1L sodium chloride 0.9% (retained in patients home)
Gravity giving set (retained in patients home)
In the event that a patient shows signs of adverse allergic reaction the RPH
Adult Home Anaphylaxis Management Guideline to be followed.
Version 2
Compiled: 1997
Title; RPH Adult Home Anaphylaxis Management Guideline
Document owner: Nursing Director Cancer and Neuroscience Division
th
Endorsed by: Resuscitation Committee & Nursing Practice Committees Royal Perth Hospital 15 August 2013
th
Authorised by Acting Director of Nursing Robyn Kovac 25 August 2013

RPH Adult Home Anaphylaxis Management Guidelines1

Assess Severity
Airway

Observe for airway swelling - stridor, difficulty swallowing,

drooling, throat tightness

Breathing

Observe for difficulty breathing

Monitor oxygen saturation (if available)
Administer oxygen 10 litres/minute via a Hudson Mask (if
available)
Respiratory Rate
Auscultate chest

Circulation

Pulse
Blood pressure

Exposure

Observe for rash/swelling

Severity

Features

Mild/Early sensations of warmth, itching, feeling anxious

Moderate dyspnoea and/or wheeze

Severe

erythematous or urticarial rash

oedema of face, neck soft tissues
abdominal pain, vomiting
hypoxaemia, cyanosis, bronchospasm,
laryngeal oedema (stridor, drooling)
hypotension, arrhythmia, cardiac arrest

Cease administration of (or exposure to) causative agent - if known

Mild/Early Severity

Ensure administration of (or exposure to) causative agent has ceased

Stay with the patient
Report to appropriate medical officer and arrange transport to Royal Perth
Hospital for medical review
Reassess every 5 minutes and if develops moderate to severe symptoms,
see below
Continue to observe until transfer to hospital or full resolution of symptoms
Complete documentation

Moderate/Severe anaphylaxis

Ring 000 to obtain ambulance

Ensure administration of (or exposure to) causative agent has ceased
Give IM adrenaline 500 micrograms (0.5mL of 1mg/mL ampoule) in lateral thigh
Maintain IV access
Give IV sodium chloride 0.9% 1000mL stat (if possible)
Lie patient flat if possible, elevate legs if hypotensive
Reassess airway, breathing and circulation
If reaction still continuing 5 minutes after 1st dose, give 2nd dose IM
adrenaline 500 micrograms (0.5mL of 1mg/mL ampoule) in lateral thigh
IM adrenaline 500 micrograms can be repeated every 5 minutes if necessary
Ambulance transfer to an emergency department
Notify appropriate medical officer and complete documentation

1. Adapted from Resuscitation Council (UK) Emergency treatment of anaphylactic reaction. Guidelines
for healthcare providers. January 2008. Available at URL: http://www.resus.org.uk/pages/reaction.pdf
Version 2
Compiled: 1997
Title; RPH Adult Home Anaphylaxis Management Guideline
Document owner: Nursing Director Cancer and Neuroscience Division
th
Endorsed by: Resuscitation Committee & Nursing Practice Committees Royal Perth Hospital 15 August 2013
th
Authorised by Acting Director of Nursing Robyn Kovac 25 August 2013