Further Management

Patients who have required two doses of IM adrenaline or a previous biphasic reaction will need to be observed for a minimum of 6 hours after their symptoms have resolved.

If the patient has required more than two doses of adrenaline, has severe asthma or their reaction has involved severe respiratory compromise, or they may continue to absorb the allergen (e.g. slow release medicaitons), then they will require a minimum of 12 hours observation after resolution of symptoms. This is also the case for presentations at night or where access to emergency care is difficult.

NICE recommends[1] that prior to discharge, a healthcare professional with the appropriate skills and competencies should offer patients (or their parent/carer) the following:

• information about anaphylaxis, including the signs and symptoms of anaphylaxis
• information about the risk of a biphasic reaction (and clear instructions to return to hospital if symptoms return)
• information on what to do if anaphylaxis occurs
• prescription of adrenaline auto-injectors and demonstration of the correct use of the adrenaline injector and when to use it
• advice about how to avoid the suspected trigger
• information about the need for referral to a specialist allergy service and the referral process
• information about patient support groups

Patients should be provided with an emergency management or action plan.

adrenaline auto-injector

• A prescription for two should be given rather than a single auto-injector
• Patients should be advised to have the auto-injector easily available at all times (including for example in school, on holidays or when away from home).
• Three types are commercially available (EpiPen®, Jext® and Emerade®).
• They come in 0.3ml and 0.15ml strengths (EpiPen® and Jext®) and 0.5ml, 0.3ml and 0.15ml strengths (Emerade®) with varying shelf-lives, prices and needle lengths.

You should be comfortable with demonstrating the brand approved in your local area.