⚠ Definition
Anaphylaxis is a severe, systemic hypersensitivity reaction — rapid in onset, potentially life-threatening. It is an IgE-mediated (or non-IgE-mediated) reaction causing massive mast cell and basophil degranulation with widespread mediator release.
✓ WAO/EAACI Diagnostic Criteria
1
Criterion 1
Sudden onset of illness affecting skin or mucosa (urticaria, flushing, angioedema) AND either:
Two or more of the following occurring rapidly after allergen exposure:
Skin/mucosa involvement
Respiratory compromise
Reduced BP / end-organ dysfunction
Persistent GI symptoms
3
Criterion 3 — Known Allergen
Reduced BP after exposure to a known allergen for that patient: Adult SBP <90 mmHg or >30% drop from baseline. Infant/child age-specific hypotension thresholds apply.
Anxiety, sense of impending doom, confusion, agitation, loss of consciousness, seizure
LOC = severe — immediate intervention
Ring & Messmer Grading (I–IV)
Grade I — Mild
Skin/mucosa only: generalised erythema, urticaria, angioedema. No end-organ involvement. Mild symptoms — monitor closely; may progress.
Grade II — Moderate
Multi-organ: mild hypotension (SBP 90–100), tachycardia, mild bronchospasm, mild GI. Adrenaline usually required — do not delay.
Grade III — Severe
Life-threatening: severe bronchospasm/laryngeal oedema, significant hypotension, LOC. Immediate adrenaline IM + full resuscitation team.
Grade IV — Cardiac Arrest
Circulatory and/or respiratory arrest. CPR + adrenaline IV per ALS. May require IV adrenaline infusion, ECMO, ICU.
⚠ ADRENALINE IS THE ONLY FIRST-LINE TREATMENT — Give immediately. Do not delay for antihistamines or steroids.
Time from recognition to adrenaline injection is the single most important prognostic factor.
Step-by-Step Anaphylaxis Management
1
CALL FOR HELP & NOTE THE TIME
Activate emergency response. Note exact time of onset and of first adrenaline dose. Assign roles: airway, drugs, documentation, family liaison.
2
POSITION THE PATIENT
Default Supine with legs elevated (increases venous return). If respiratory distress Semi-recumbent or sitting. NEVER suddenly stand or sit up a hypotensive patient — fatal vasovagal collapse reported.
3
ADRENALINE IM — OUTER MID-THIGH
Adult 0.5mg (500mcg) = 0.5mL of 1:1000 adrenaline. Paediatric 0.01mg/kg up to 0.5mg max.
Inject into anterolateral thigh — may inject through clothing if necessary. Hold in place 10 seconds. Massage site briefly to aid absorption.
Auto-injector technique: Remove blue safety cap → press firmly against outer thigh (click) → hold 10 seconds → massage. EpiPen 0.3mg (adult), EpiPen Jr 0.15mg (child). Jext/Emerade follow same principle.
4
HIGH-FLOW OXYGEN
10–15 L/min via non-rebreather mask. Target SpO₂ ≥94%. In severe bronchospasm consider early nebulised salbutamol (5mg) alongside adrenaline.
5
IV ACCESS + FLUID RESUSCITATION
Wide-bore IV (14–16G). Rapid bolus: 500–1000 mL 0.9% NaCl (adult) / 20 mL/kg (paediatric). Reassess and repeat if hypotension persists. Colloids not recommended over crystalloid in anaphylaxis.
6
CONTINUOUS MONITORING
Continuous BP, HR, SpO₂, respiratory rate. ETCO₂ if available. 12-lead ECG. Record all observations with timestamps. Re-assess every 5 minutes.
7
REPEAT ADRENALINE — EVERY 5 MINUTES IF NO RESPONSE
Same dose/route. Maximum 3 doses IM before considering IV adrenaline infusion (ICU/resus team involvement). Document each dose with time.
8
SECOND-LINE MEDICATIONS
Chlorphenamine 10mg IV (antihistamine — H1 blocker — symptom relief only, does NOT reverse anaphylaxis, administer after adrenaline). Hydrocortisone 200mg IV (prevents biphasic reaction — evidence limited but routine practice; onset 4–6h). Salbutamol 5mg nebulised if persistent bronchospasm after adrenaline.
Adrenaline Dosing Summary
Age / Weight
Dose (1:1000 IM)
Volume
Auto-injector
Adult / >50 kg
500 mcg (0.5 mg)
0.5 mL
EpiPen 0.3mg or 2×
Child 30–50 kg
300 mcg (0.3 mg)
0.3 mL
EpiPen 0.3mg
Child 15–30 kg
150–300 mcg
0.15–0.3 mL
EpiPen Jr 0.15mg
Child <15 kg
0.01 mg/kg
0.01 mL/kg
No auto-injector — draw up
Infant <6 months
0.01 mg/kg (with caution)
As calculated
Specialist guidance
⚠ Adrenaline Route Warning
IV adrenaline in anaphylaxis is ONLY for cardiac arrest or ICU setting with continuous cardiac monitoring and expert supervision. Undiluted IV adrenaline has caused deaths in non-arrest patients. IM outer thigh is the correct route in the emergency setting.
❌ Do NOT Do
Give antihistamines instead of adrenaline
Delay adrenaline for any reason
Stand up a hypotensive patient
Discharge after single dose with no observation period
Give IV adrenaline without cardiac monitoring
Rely on steroids as first-line treatment
✓ Best Practice Reminders
Document trigger, time, doses, and response
Alert allergy team for follow-up
Prescribe adrenaline auto-injector on discharge
Provide written anaphylaxis action plan
Arrange allergy clinic referral
Minimum 6h observation (see Tab 3)
Biphasic Anaphylaxis
⚠ Biphasic Reaction
Recurrence of anaphylaxis symptoms 1–72 hours after initial resolution, WITHOUT re-exposure to allergen. Occurs in up to 20% of cases. Most common within 6–12 hours.
Risk Factors for Biphasic
Severe initial reaction
Unknown or persistent allergen exposure
Delayed adrenaline administration
Large allergen dose (e.g. large bee swarm)
History of previous biphasic reactions
Asthma as comorbidity
Observation Period Guidelines
Scenario
Minimum Obs
Mild, known trigger, responded rapidly
4–6 hours
Moderate, trigger identified
6–12 hours
Severe / refractory / biphasic risk
12–24 hours
Unknown trigger, evening, remote area
24 hours
Asthma / prior severe biphasic
24 hours (admit)
Admission Criteria
Admit to ICU
Refractory anaphylaxis (≥3 adrenaline doses)
Cardiovascular collapse / arrest
Requires IV adrenaline infusion
Intubated / airway compromise
Admit to Ward
Severe initial Grade III reaction
High biphasic risk factors
Asthma / pulmonary comorbidity
Unknown trigger
Observe & Discharge
Grade I–II with rapid resolution
Identified, avoidable trigger
No high-risk features
Adrenaline auto-injector prescribed
Refractory Anaphylaxis
Definition: No adequate clinical response after 3 doses of IM adrenaline. Requires ICU involvement, expert management, and escalating interventions.
A
IV Adrenaline Infusion
Start at 0.1 mcg/kg/min and titrate to clinical response. Requires continuous cardiac monitoring and arterial line. Prepared as dilute solution (typically 1mg in 100mL — 10 mcg/mL).
B
Glucagon — Beta-Blocker Patients
Beta-blockade reduces adrenaline efficacy (antagonism at beta receptors). Glucagon acts via a non-adrenergic mechanism: 1–2 mg IV bolus (may repeat), then infusion 5–15 mcg/min. Monitor for vomiting/aspiration risk.
C
Methylene Blue
For distributive shock refractory to adrenaline. Inhibits nitric oxide synthase pathway. Dose: 1–2 mg/kg IV over 20 minutes. Evidence largely case-report level — specialist consultation required.
D
Airway Management — High Risk
Laryngeal oedema makes intubation extremely difficult. Awake fibreoptic intubation preferred if time allows. Video laryngoscopy with surgical airway standby (cricothyrotomy kit at bedside). RSI risk: failed airway in laryngeal oedema is rapidly fatal.
E
ECMO
Extracorporeal membrane oxygenation for refractory anaphylactic cardiac arrest where conventional resuscitation fails. Veno-arterial ECMO (VA-ECMO). Evidence from case series — considered when ROSC not achieved with standard ALS + adrenaline.
💡 Nurse Role in Refractory Anaphylaxis
Prepare IV adrenaline infusion (verify concentration carefully — 10-fold dose errors reported). Maintain accurate drug/time log. Communicate clearly with team about adrenaline dose count. Support family. Prepare for potential surgical airway and ICU transfer.
Allergy Investigation
Skin Prick Testing (SPT)
Gold standard for IgE-mediated allergy. A drop of allergen extract is placed on the forearm and a lancet pricks through it.
Nursing Preparation:
Stop antihistamines ≥72 hours before test (cetirizine, loratadine, fexofenadine — longer washout for some)
Stop tricyclic antidepressants 7 days prior
Ensure histamine positive control is placed (validates reactive skin)
Negative control (saline) to check for dermatographism
Read at 15–20 minutes: wheal ≥3mm = positive
Resuscitation equipment & adrenaline mandatory on site
Intradermal Testing (IDT)
More sensitive than SPT. 0.02–0.05mL of dilute allergen injected intradermally. Used for drug allergy investigation (especially antibiotics, NM blockers).
Key Points:
Higher systemic reaction risk than SPT
IV access required before testing
Resuscitation must be immediately available
Read at 20 minutes (immediate) and 48–72h (delayed)
Only performed in specialist allergy setting
Serum-Specific IgE (sIgE/RAST)
Blood test measuring IgE antibodies to specific allergens. Safe (no systemic reaction risk). Lower sensitivity than SPT for many allergens.
Baseline tryptase (3–4 weeks after reaction) to rule out mastocytosis
Component-Resolved Diagnostics (CRD)
Tests for individual protein components of allergens. Predicts clinical severity and cross-reactivity.
Component
Allergen
Significance
Ara h 2
Peanut
Predicts severe systemic reactions
Ara h 8
Peanut
Cross-reactive with birch pollen — usually mild
Gal d 1
Egg white
Ovomucoid — predicts persistence
Ber e 1
Brazil nut
High risk severe anaphylaxis
Oral Food Challenge (OFC)
Gold Standard for Food Allergy Diagnosis — Graded supervised challenge with increasing doses of suspected food allergen. Nurse-led monitoring is essential throughout.
Nursing Role in OFC
IV access inserted before challenge
Baseline observations documented
Adrenaline and resuscitation equipment prepared
Administer graded doses per protocol (e.g. 1, 3, 10, 30, 100mg protein)
Observe 30–60 minutes between doses
Document any subjective or objective symptoms
Nurse stops challenge immediately if reaction develops
Post-challenge observation ≥2 hours after final dose
HR increase >20bpm from baseline without explanation
SpO₂ drop >3%
Any BP change outside protocol thresholds
Allergy Documentation & Safety
Documentation Requirements
Never write "allergy" without full details
Document: exact drug/food name, dose, route, reaction description, severity, date
Distinguish true allergy from intolerance/side effect
Record whether reaction was confirmed by allergy testing
Update pharmacy, electronic prescribing, and nursing notes
Alert allergy wristband — correct colour per hospital policy
Cross-Reactivity Patterns
Allergen
Cross-Reactive
Risk
Penicillin
Cephalosporins (side-chain similarity)
1–2%
Penicillin
Carbapenems
<1%
Latex
Banana, Kiwi, Avocado, Chestnut
30–50%
Birch pollen
Apple, Pear, Peach, Hazelnut
Oral allergy syndrome
Shellfish
House dust mite (tropomyosin)
Clinically variable
Sesame
Other tree nuts/seeds
Variable
Allergen Immunotherapy (AIT)
Immunotherapy modifies the allergic immune response — the only disease-modifying treatment for IgE-mediated allergy. Requires specialist allergy supervision and nurse preparedness for systemic reactions.
Subcutaneous Immunotherapy (SCIT)
Injections of increasing allergen doses administered subcutaneously. Used for: venom allergy, allergic rhinitis/asthma.
Nursing Protocol:
Build-up phase: weekly injections (12–20 weeks)
Maintenance phase: monthly injections (3–5 years)
Mandatory 30-minute observation post-dose
Resuscitation equipment at injection site — non-negotiable
Withhold if patient is unwell, has asthma flare, or recent viral illness
Do not give if patient took beta-blocker on same day
Document injection site, lot number, dose, reaction
Sublingual Immunotherapy (SLIT)
Allergen drops or tablets placed under the tongue. For: pollen allergy, house dust mite. Suitable for home administration after first clinic dose.
Nursing Role:
First dose always in clinic with 30-minute observation
Educate patient on home administration technique
Hold under tongue 1–2 minutes then swallow
Withhold if oral sores/ulcers present
Instruct patient: carry adrenaline auto-injector at all times
Common side effects: oral pruritus, tingling — usually mild and transient
Oral Immunotherapy (OIT)
Structured dose escalation for peanut, cow's milk, hen's egg. Palforzia (FDA/EMA approved peanut OIT). Highest systemic reaction risk of all AIT modalities.
Nurse-Led Protocol:
All dose escalations performed in clinic with nurse observation
IV access before dose escalation (build-up phase)
Each dose increment: 2-hour observation minimum
Adrenaline auto-injector dispensed before each escalation
Patient must not exercise 2h pre/2h post dose
Withhold if febrile, eczema flare, or GI illness
Daily home maintenance doses between escalation visits
Adrenaline Auto-Injector Training
Patient & Carer Education Checklist:
When to use: symptoms of anaphylaxis (not mild urticaria alone)
Always carry TWO auto-injectors — second dose if no response after 5 min
Demonstrate technique using trainer device
Outer thigh (can inject through clothing)
Hold firmly for 10 seconds after click
Massage injection site after removal
Call emergency services AFTER injection — even if improved
Check expiry date regularly, store at room temperature (not refrigerated)
EpiPen/Jext/Emerade — different devices, train for specific brand
Anaphylaxis Action Plan & Community Safety
Written Action Plan
Patient name, photo, allergen(s)
Step-by-step response instructions
Auto-injector brand and dose
Emergency contacts
Hospital to attend
Signed by allergy physician
School / Workplace
Provide copy of action plan to school nurse
Train class teacher/supervisor
Auto-injector stored accessibly (not locked)
Cafeteria/canteen allergen awareness
Emergency protocol posted in staff room
MedicAlert Bracelet
Recommended for all patients with severe allergy
Identifies allergen for emergency responders
Especially important: latex, venom, drug allergy
Arabic and English inscription available
Nurse to advise and refer to MedicAlert registration
GCC-Specific Allergy Context
🦐 Seafood Allergy in GCC
Seafood allergy is highly prevalent in GCC countries due to high consumption of shrimp, lobster, crab, and fish. Crustacean allergy (shrimp/crab/lobster) is among the most common causes of severe anaphylaxis in the Gulf region.
Tropomyosin is the major allergen in crustaceans — heat-stable
Cross-reactivity between shrimp, crab, lobster (50–75%)
Cross-reactivity with house dust mite (tropomyosin) — patients with HDM allergy may be at higher risk
Fish allergy (parvalbumin) separate from shellfish — cross-reactivity variable
Document specific species reactions — patient may tolerate some fish but not others
🍳 Sesame Allergy in GCC
Sesame is integral to Arabic cuisine and carries significant hidden allergen risk. Tahini (sesame paste) is a base ingredient in hummus, baba ghanoush, halva, and many sauces.
Sesame oil in cooking may or may not be tolerated (highly refined = less allergenic, cold-pressed = allergenic)
Sesame seeds on bread (ka'ak, samit) — common hidden source
Now designated a major allergen in UAE/Saudi (mandatory labelling)
Cross-reactivity with tree nuts/kiwi reported
Educate patients to read labels and enquire at restaurants explicitly
🏥 Latex Allergy in GCC Healthcare
Increasing prevalence among GCC healthcare workers — primarily from repeated glove use. GCC hospitals progressively transitioning to latex-free environments.
Most commonly: Type I IgE-mediated (urticaria → anaphylaxis) and Type IV (contact dermatitis)
Occupational exposure: surgical gloves, IV tubing ports, ET tubes, urinary catheters
Latex-free policy: use only non-latex gloves and latex-free equipment for affected patients
Traditional Arabic remedies — some contain plant allergens; document herbal medicine use
🐝 Bee & Wasp Venom Anaphylaxis
Desert beekeeping is widespread across GCC. Outdoor workers (construction, agriculture, labourers) at elevated risk. Apis mellifera (honey bee) predominant species.
Venom immunotherapy (VIT) — highly effective, reduces risk from 60% to <5% with subsequent sting
Refer all patients with systemic venom reactions to allergy clinic for VIT consideration
Adrenaline auto-injector mandatory for all patients with systemic reactions until VIT established
Remove stinger promptly (scrape — do not squeeze to avoid injecting more venom)
🙈 Hajj Mass Gathering
Hajj involves 2+ million pilgrims in close proximity in Makkah. Anaphylaxis risk: bee stings, food reactions, medication errors, heat stress. WHO and Saudi Ministry of Health protocols in place.
Hajj health teams carry adrenaline as priority drug
Pilgrims with severe allergy: carry auto-injector, wear MedicAlert, register with Hajj health authority
Bee stings common during stoning ritual (Jamarat) — mass bee disturbance
Food allergy: diverse international cuisine, labelling challenges, communal kitchens
Nurses stationed at Hajj clinics trained in rapid anaphylaxis management
Dehydration and heat potentiate anaphylaxis severity
Arabic Food Allergen Labelling
Mandatory Allergen Labelling (UAE/Saudi Arabia — since 2018)
Gulf Standardisation Organisation (GSO) regulations require labelling of 14 major allergens on all pre-packaged food products sold in GCC countries, in Arabic and English.
Hospital formulary: halal-certified medications where possible
Gelatin in capsules — porcine source may be an issue
Some vaccines contain trace egg protein (influenza)
Nurse role: liaise with pharmacy on halal alternatives
Document patient preferences and religious requirements
School Nurse Training GCC
UAE: MOHAP guidelines mandate allergy training for school nurses
Saudi Arabia: MoH school health program includes anaphylaxis protocols
Annual refresher training recommended
Each school: minimum 2 auto-injectors, written protocols, parental consent
Multilingual action plans (Arabic/English/Urdu) for diverse GCC populations
⏳ ANAPHYLAXIS TREATMENT CALCULATOR & TIMER
— mg
Enter weight above to calculate adrenaline dose
Elapsed Time
00:00:00
Not started — press ANAPHYLAXIS CALLED
Next Adrenaline Due / Obs Countdown
—:——
Adrenaline repeat (5 min) / Observation timer
⏱ 5 MINUTES SINCE LAST ADRENALINE — Consider repeat dose if no improvement
⚠ 3 ADRENALINE DOSES GIVEN — ESCALATE TO ICU / Consider IV adrenaline infusion
🕑 OBSERVATION PERIOD COMPLETE — Safe to assess for discharge if clinically appropriate
Adrenaline Doses Given
1
2
3
⚠ ICU
Response Checklist
✓
Call for Help — Emergency team activated, time noted
IMMEDIATE
✓
Adrenaline IM — Outer mid-thigh, correct dose
0 min
✓
Position — Supine + legs elevated (or semi-recumbent if respiratory distress)
0 min
✓
Oxygen — 10–15 L/min via non-rebreather mask, SpO₂ target ≥94%
1–2 min
✓
IV Access — Wide-bore 14–16G, send FBC/U&E/tryptase
2–3 min
✓
IV Fluids — 500–1000 mL 0.9% NaCl rapid bolus (adult) / 20 mL/kg (paed)
3–5 min
✓
Monitoring — Continuous BP/HR/SpO₂, document every 5 min
Ongoing
✓
Chlorphenamine 10mg IV + Hydrocortisone 200mg IV (after adrenaline)
5–10 min
00:00
Elapsed
0
Adrenaline Doses
0/8
Checks Done
—
Obs Period
GCC Anaphylaxis & Allergy Nursing Guide — Based on WAO/EAACI/BSACI guidelines and GCC regional practice | For educational and clinical reference use | Always follow local hospital protocols | Updated April 2026