GCC Nursing Guide — Anaphylaxis Management

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Life-Threatening Emergency

Anaphylaxis is a severe, rapidly progressive systemic allergic reaction that can cause death within minutes. Adrenaline IM is the ONLY first-line treatment. Do not delay for antihistamines.

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Definition

Clinical understanding of anaphylaxis

Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It involves skin or mucosal tissue involvement AND either respiratory compromise OR cardiovascular collapse. It is mediated by IgE (immune) or non-immune mechanisms leading to mast cell and basophil degranulation with massive histamine and mediator release.

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Anaphylaxis vs Severe Allergic Reaction

A severe allergic reaction (e.g., urticaria, angioedema alone) is NOT anaphylaxis unless it involves airway/breathing/circulation compromise or end-organ dysfunction. Anaphylaxis = multi-system, life-threatening. The distinction matters because only anaphylaxis mandates immediate adrenaline.

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Diagnostic Criteria — 3 Clinical Scenarios

Any ONE of the following three criteria confirms anaphylaxis

Criteria 1 — Sudden Onset + Skin/Mucosal

Sudden onset illness affecting skin or mucosa (urticaria, flushing, angioedema) PLUS at least ONE of: respiratory compromise (dyspnoea, wheeze, stridor, hypoxia) OR reduced BP or end-organ dysfunction (hypotonia, collapse, incontinence).

Criteria 2 — Known Allergen Exposure

Exposure to a known allergen for the patient PLUS at least ONE of: reduced BP OR bronchospasm OR laryngeal symptoms — even without skin involvement.

Criteria 3 — Hypotension After Exposure

Reduced BP after exposure to a known or likely allergen (e.g., IV drug, food ingestion) — even without skin features. Systolic <90mmHg in adults; >30% drop from baseline; infant/child age-specific thresholds.

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Signs & Symptoms by System

System	Symptoms	Signs	Severity Indicator
Skin / Mucosal	Itch, burning, tingling	Urticaria, flushing, angioedema, erythema	Often first; may be absent in severe cases
Respiratory	Dyspnoea, wheeze, throat tightening, hoarse voice	Stridor, wheeze, cyanosis, SpO₂ ↓	Life-threatening
Cardiovascular	Dizziness, chest pain, palpitations	Tachycardia, hypotension, pale, collapse	Life-threatening
GI	Nausea, cramping, diarrhoea, vomiting	Abdominal rigidity	Common in food allergy
Neurological	Anxiety, confusion, sense of doom	Altered consciousness, incontinence	End-organ sign — severe

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Common Triggers in the GCC Region

Highest risk agents relevant to Gulf clinical practice

Foods

Tree nuts / peanuts Highest Risk
Sesame Very Common GCC — tahini, hummus, bread, halva
Shellfish — shrimp, crab, lobster common in Gulf diet
Egg — common childhood allergen
Cow's milk — paediatric presentations
Wheat, fish, soy

Insect Venom

Bee stings Outdoor Workers — desert beekeeping, construction sites
Wasp venom

Drugs

Penicillin / Cephalosporins — commonest drug trigger
NSAIDs OTC in GCC — ibuprofen/diclofenac bought without prescription
IV Radiocontrast media High CT Rate — extremely common in GCC hospitals
Anaesthetic agents — neuromuscular blocking agents, chlorhexidine
ACE inhibitors, biologics

Other Causes

Latex — healthcare settings, surgical gloves
Exercise-induced — especially with food co-factor
Idiopathic — no identifiable trigger (~20%)
Seminal fluid, cold/heat

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ADRENALINE FIRST — Every Time, No Exceptions

Do not delay adrenaline for antihistamines, observations, or to find IV access. IM adrenaline to the anterolateral thigh is the single most important intervention. Time to adrenaline is the key determinant of outcome.

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ABCDE Emergency Response — Step by Step

Simultaneous team-based approach

Call for Help — Activate resuscitation/code team immediately. Do not manage alone. Assign roles: one nurse manages airway/adrenaline, one establishes IV access, one monitors and documents, one prepares medications.
Remove the Trigger — Stop any IV infusion immediately. Remove bee stinger by scraping (do not squeeze venom sac). Remove food if still in mouth. Discontinue latex exposure. Stop blood transfusion or contrast infusion.
ADRENALINE IM — IMMEDIATELY — Inject into the anterolateral mid-thigh (preferred: penetrates faster through muscle, even through clothing). Do NOT give IV unless cardiac arrest or experienced anaesthetist present.

Adrenaline IM Dosing — 1:1000 concentration (1mg/mL)

Adult / Child >30kg0.5mg = 0.5mL IM

Child 15–30kg0.3mg = 0.3mL IM

Child <15kg (infant)0.01mg/kg IM (max 0.3mg)

Repeat if no responseEvery 5 minutes — do not hesitate
Position the Patient — Critical: position depends on symptoms:
- Hypotension / shock: Supine (flat) with legs elevated — maximises venous return
- Respiratory compromise / wheeze: Sitting up — optimises diaphragm function
- Vomiting / pregnant: Left lateral position — reduces aspiration and aortocaval compression
- NEVER stand or sit up a collapsed patient suddenly — can cause fatal cardiac arrest (empty ventricle syndrome)
High-Flow Oxygen — 15L/min via non-rebreathe mask (100% O₂). Aim SpO₂ >95%. If airway compromise: early anaesthetic input — may require RSI or surgical airway. Bag-valve-mask if hypoventilating.
IV Access ×2 Large Bore — Insert two large-bore cannulas (14–16G preferred) simultaneously if possible. Obtain bloods: FBC, U&E, tryptase (at 1–2hrs), LFTs, coagulation.
Fluid Resuscitation — IV crystalloid (0.9% NaCl or Hartmann's): 500–1000mL rapid bolus for adults with hypotension. Repeat boluses titrated to response. Children: 10mL/kg bolus. Colloids not recommended first-line.
Monitoring — Continuous — Attach continuous cardiac monitor (ECG), pulse oximeter (SpO₂), and BP (every 2–5 min). Document all vital signs with timestamps. Set low SpO₂ and BP alarms.

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Patient Positioning — Critical Summary

Clinical Situation	Correct Position	Rationale
Hypotension / shock	Supine + legs elevated	Maximises venous return, prevents cardiac arrest
Wheeze / bronchospasm / respiratory distress	Sitting upright	Optimises breathing mechanics
Vomiting / unconscious	Left lateral (recovery)	Prevents aspiration of vomit
Pregnant (>20 weeks)	Left lateral tilt	Prevents aortocaval compression
Collapsed patient	NEVER stand up suddenly	Empty ventricle — fatal cardiac arrest risk

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Adrenaline Dose Calculator

Interactive tool — select patient category and route

Patient Category

Weight (kg)

Route

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Adrenaline First — All Other Drugs Are Adjuncts

Chlorphenamine, hydrocortisone, and salbutamol are secondary measures. They do NOT treat anaphylaxis. They support recovery after adrenaline has been given. Never delay or substitute adrenaline with these agents.

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Second-Line Drug Reference

Drug	Dose / Route	Indication	Key Point
Chlorphenamine Antihistamine	10mg IV or IM (adult) 5mg child 6–12yr 2.5mg child <6yr	Urticaria, angioedema, pruritus — after adrenaline	Does NOT treat anaphylaxis. NOT first-line. Antihistamines relieve skin symptoms only — they do NOT reverse airway compromise or shock.
Hydrocortisone Corticosteroid	200mg IV (adult) 100mg child >6yr 50mg child 6mo–6yr 25mg infant <6mo	Prevention of biphasic reaction; prolonged anaphylaxis	Onset 4–6hrs — has NO immediate effect. Does NOT replace adrenaline. Prevents late-phase reaction.
Salbutamol Bronchodilator	5mg nebulised (adult/child) or MDI 4–8 puffs via spacer	Persistent wheeze / bronchospasm after adrenaline	Do not use instead of adrenaline. Adjunct for residual bronchospasm. IV salbutamol if nebulised fails.
Glucagon For beta-blockers	1–2mg IV over 5 min, then infusion 5–15mcg/min	Patients on beta-blockers — adrenaline resistance	Beta-blockers blunt adrenaline response. Glucagon bypasses beta-receptors. Ask about beta-blocker use in all anaphylaxis patients.
IV Adrenaline Specialist Only	1:10,000 concentration 50–100mcg IV boluses	IM adrenaline failed AND cardiac arrest imminent; experienced anaesthetist/intensivist present	Extremely dangerous if IV adrenaline given by inexperienced staff — cardiac arrhythmia, hypertensive crisis risk. Never as routine first-line IV.
Vasopressin Refractory	0.03–0.04 units/min IV infusion	Refractory anaphylactic shock — vasodilatory shock not responding to adrenaline	ICU setting. Adjunct vasopressor when adrenaline insufficient.
Methylene Blue Refractory	1–2mg/kg IV over 20 min	Refractory anaphylaxis with vasoplegia	Inhibits NO-mediated vasodilation. Evidence limited but used in refractory cases.

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Repeat Adrenaline — Do Not Hesitate

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If no improvement after 5 minutes — give a SECOND dose of adrenaline IM

There is no maximum number of IM adrenaline doses. A common error is giving only one dose and waiting too long. If symptoms persist or return, repeat IM adrenaline every 5 minutes. Multiple doses are safe and necessary.

First dose no response after 5 minutes → Give 2nd IM adrenaline dose immediately
Second dose no response → Consider IV adrenaline — call anaesthetist/ICU
All doses must be documented with exact time given
If auto-injector used in community → go to ED; patient needs further doses and monitoring

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Observation Period

After initial resuscitation and stabilisation

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Biphasic Reaction Risk — Mandatory Observation

A biphasic reaction — return of anaphylaxis symptoms after apparent full recovery — occurs in 1–23% of cases and can occur 1–72 hours after the initial episode. Patients must be monitored even after apparent recovery.

Risk Level	Observation Duration	Criteria
Low Risk	Minimum 6 hours from last adrenaline dose	Mild reaction, single adrenaline dose, rapid full resolution, no asthma history
Moderate Risk	12 hours minimum	Required multiple adrenaline doses, history of severe/biphasic reactions, asthma or respiratory disease
High Risk	24 hours minimum — consider ICU	Refractory anaphylaxis, cardiac involvement, uncertain trigger, severe asthma, ongoing symptoms

Observation must include: continuous SpO₂ monitoring, BP every 15–30 min for first 2 hours, then hourly. Patient must not mobilise or self-care until stable >2hrs.

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Serum Tryptase — Diagnostic Marker

Mast cell degranulation marker — confirms diagnosis

When to Take

Sample 1: ASAP after resuscitation commences (baseline)
Sample 2: 1–2 hours after reaction onset (peak tryptase)
Sample 3: >24 hours after reaction (or at follow-up) — baseline reference

Interpretation

Peak tryptase >11.4 mcg/L suggests mast cell activation
Tryptase can be normal in food-triggered anaphylaxis
Elevated baseline suggests underlying mastocytosis — refer haematology
Used retrospectively to confirm diagnosis for allergy referral

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Patient Discharge Education Points

EpiPen Use

Always carry 2 EpiPens at all times — two because one may fail or reaction needs 2nd dose
Use early — at first signs of anaphylaxis. Do NOT wait until severe
After using EpiPen: go to ED immediately — adrenaline wears off in 15–20 min
Oral antihistamine alone is NOT treatment for anaphylaxis

Trigger Avoidance

Read all food labels — inform restaurants of allergy
In GCC: be aware of sesame in all Arabic foods
Avoid NSAIDs without medical advice
Inform all healthcare providers of drug allergies

Action Plan

Wear Medicalert/SOS bracelet listing allergy
Carry written emergency card (in English AND Arabic)
Know your 3 signs requiring EpiPen: throat tightening, severe wheeze, collapse
Inform school/workplace — provide spare EpiPen and action plan

Follow-Up

Allergy/Immunology referral — skin prick testing, specific IgE (RAST), component testing
Venom immunotherapy if bee/wasp sting — highly effective
Desensitisation programmes for food allergy in selected patients
Review in 1 week with GP — confirm referral, EpiPen supply

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Nurse Responsibility — EpiPen Training is Clinical Duty

Every patient discharged after anaphylaxis must have their EpiPen technique observed and confirmed before leaving. Both patient AND primary carer must demonstrate competency. Use a trainer device — never a live device for practice.

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Auto-Injector Devices Available in GCC

Device	Doses Available	GCC Availability	Notes
EpiPen (Pfizer/Mylan)	0.3mg (adult), 0.15mg (junior)	Most widely available	Orange tip = needle end; Blue safety cap must be removed first
Jext	0.3mg, 0.15mg	Limited GCC availability	Yellow cap removed; yellow end is needle end
Emerade	0.15mg, 0.3mg, 0.5mg	Not available in some GCC countries	Larger needle — better for obese patients; 0.5mg dose available

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GCC Availability Warning

EpiPens can be expensive and intermittently out of stock in community pharmacies across GCC countries. They are prescription-only in most GCC countries. Nurses must educate patients on stocking multiple devices and storage requirements (room temperature, avoid extreme heat — important in Gulf climate).

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EpiPen Injection Technique — Step by Step

Demonstrate using trainer device. Confirm patient can repeat independently.

Remove from carrier tube — take out EpiPen. Hold firmly in dominant hand with fist. Do NOT put thumb over either end.
Remove Blue Safety Cap — pull straight off with non-dominant hand. Do NOT recap after use. The device is now armed.
Select injection site — outer mid-thigh. Can inject through clothing — no need to remove clothing in emergency. Avoid inner thigh and buttocks.
Press firmly — place orange tip firmly against outer mid-thigh. Press down hard until you hear a CLICK — injection has started.
Hold for 10 seconds — keep pressed firmly. Count to 10. This ensures full dose delivery. (Older guidance was 3 sec — current guidance is 10 sec.)
Remove and massage — remove device, orange safety shield extends over needle automatically. Massage injection site for 10 seconds.
Call emergency services — immediately call ambulance / go to ED. Do NOT wait to see if EpiPen worked. A second dose may be needed after 5–15 minutes if no improvement.
Dispose safely — place used EpiPen in sharps bin or take to ED. Never re-cap. Show used device to ED staff as evidence of use and timing.

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Common EpiPen Errors — Teach to Avoid

Error	Consequence	Management
Injection into hand or digit (thumb, finger)	Severe vasospasm — digits may become white, cold, pulseless — can lead to digital ischaemia	Immediate emergency: apply local heat, phentolamine injection, surgical review
Not removing blue cap first	Device will not fire — patient receives no adrenaline	Train: "Blue to the sky, orange to the thigh"
Holding for less than 10 seconds	Incomplete dose delivery — underdose	Train counting aloud
Injecting into inner thigh or buttocks	Slower absorption — less reliable, potential sciatic nerve injury (buttocks)	Train: outer mid-thigh only
Waiting too long to use	Irreversible anaphylaxis — death	Train: "Use early, at first signs"
Relying on oral antihistamine alone	Disease progression — does not treat airway or shock	Emphasise: antihistamine is NOT anaphylaxis treatment
Not going to ED after EpiPen use	Biphasic reaction without monitoring — potential death	All EpiPen uses require ED attendance

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Carers, Schools & Workplaces

Carer / Family Training

All family members/carers who may be present during a reaction must be trained
Children cannot always self-inject — carer injection is primary route
Practice with trainer device regularly (every 6 months)
Check expiry dates — replace before expiry
Keep EpiPen at room temperature — avoid car glovebox in GCC heat (can reach 70°C+)

School / Workplace Action Plans

Provide school with written anaphylaxis action plan — with photo
Schools should have EpiPen accessible — not locked away
GCC school policies vary — some schools refuse to administer. Advocate for change.
Workplace first aid kits: GCC recommendation includes EpiPen for high-risk environments
Arabic anaphylaxis action plan cards available from allergy societies

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GCC-Specific Allergen Profile

Regional considerations for Gulf nursing practice

Sesame Allergy — GCC Priority Allergen

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Sesame is an endemic allergen in Middle Eastern cuisine. It must be treated as a primary allergen — equivalent to peanut — in GCC practice.

Hummus — tahini (sesame paste) is primary ingredient
Tahini — pure sesame paste — many Arabic dishes
Ka'ak, samboosa, bread — sesame seeds on surface or in dough
Halva — sesame-based confectionery
Sesame oil — used in cooking without disclosure
Cross-contamination risk in shared kitchens
Sesame is now a declared allergen in many countries — not universally labelled in GCC

Bee Venom — Occupational Risk

Desert beekeeping is traditional and widespread in GCC
Outdoor construction workers — major exposed population (South Asian expat workers particularly)
Venom immunotherapy (VIT) is highly effective — 95% protection against future sting
Refer all sting-triggered anaphylaxis patients to allergy for VIT assessment

IV Radiocontrast Media

GCC has very high CT scan rates per capita
Contrast-induced anaphylaxis risk — must flag allergy at pre-procedure check
Pre-medication with steroids/antihistamines for at-risk patients
Nurse role: screen all CT/MRI patients for contrast allergy history
Iso-osmolar contrast (iodixanol) lower anaphylaxis risk

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NSAIDs — OTC Access in GCC

NSAIDs (ibuprofen, diclofenac, naproxen) are available over-the-counter without prescription in many GCC pharmacies. This leads to:

High rates of NSAID-triggered anaphylaxis in patients unaware of prior sensitivity
Patients may not disclose NSAID use as a "medication" when asked about drugs
Nurses must specifically ask: "Do you take any pain tablets — like ibuprofen or Brufen?" in all anaphylaxis assessments
NSAID hypersensitivity can be aspirin-exacerbated respiratory disease (AERD), urticaria-type, or true anaphylaxis
Cross-reactivity between different NSAIDs is common — patient should avoid all NSAIDs until specialist review

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EpiPen Access and Affordability in GCC

Issue	GCC Reality	Nursing Action
Cost	EpiPen can cost 80–200+ USD per device. Two devices needed = significant expense. Insurance may not cover.	Discuss with patient — social worker referral if unaffordable. Document prescription.
Availability	Frequently out of stock in community pharmacies, especially in smaller GCC cities and rural areas	Advise calling multiple pharmacies. Some hospital pharmacies stock — provide list.
Storage in heat	GCC temperatures can reach 50°C+ outdoors, 70°C in car glovebox	Store at 15–25°C. Use insulated case. Never leave in car. Replace if exposed to extreme heat.
Prescription requirement	Prescription only in UAE, KSA, Qatar, Kuwait, Bahrain, Oman	Ensure prescription given at discharge. Repeat prescription plan arranged.

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Hidden Allergens in Arabic Cuisine

Important for patient education in GCC

Arabic Food	Hidden Allergen	Anaphylaxis Risk
Hummus	Sesame (tahini), lemon	HIGH — sesame major component
Tahini / Tahina sauce	Sesame (pure)	VERY HIGH
Halva	Sesame, nuts	HIGH
Baklava / Knafeh	Tree nuts (pistachio, walnut), milk	HIGH
Shawarma bread / Ka'ak	Sesame seeds	MODERATE–HIGH
Mandi / Kabsa rice	Nut garnish (pine nuts, almonds), spice blends	MODERATE
Luqaimat (doughnuts)	Sesame topping, milk, egg	MODERATE
Balaleet	Egg, saffron, nut garnish	MODERATE
Mixed mezze platter	Multiple — sesame, nuts, dairy, eggs	HIGH — cross-contamination

Advise patients with sesame or nut allergy to inform restaurant staff specifically. In GCC Arabic restaurants, chefs may not be aware of allergen labelling requirements. The patient must advocate for themselves and carry their EpiPen always.

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Anaphylaxis Training in GCC Schools & Workplaces

Current GCC School Situation

No uniform GCC-wide school anaphylaxis policy — varies by emirate/country
Some schools in UAE, Qatar now have anaphylaxis action plan systems
Some schools still refuse to keep or administer EpiPens on premises — patient advocacy required
Arabic anaphylaxis action plans must be culturally appropriate and translated
School nurse (if present) should have annual anaphylaxis training refresher

Workplace Requirements

Large GCC workplaces (construction, hospitality, healthcare) should have on-site EpiPens in first aid kits
First aiders should have anaphylaxis training as part of GCC occupational health standards
Healthcare settings: all clinical staff should demonstrate annual anaphylaxis simulation competency
Arabic allergy identification cards available from GCC allergy societies — provide to patients

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Arabic Allergy Resources & Communication

Arabic anaphylaxis action plan: Available from Emirates Allergy & Immunology Society (EAIS), Saudi Society of Allergy, and Allergy Society of GCC
Key Arabic phrases for allergy history:
- "هل لديك حساسية من أي طعام أو دواء؟" — Do you have allergy to any food or drug?
- "هل حدث رد فعل تحسسي شديد من قبل؟" — Have you had a severe allergic reaction before?
- "هل تحمل قلم الأدرينالين؟" — Do you carry an adrenaline pen?
Encourage patients to carry bilingual (Arabic/English) emergency allergy cards
Ensure discharge materials are provided in patient's preferred language — Arabic, Urdu, Hindi, Tagalog common in GCC