Anaphylaxis Severe Allergy - Referral of Adults, Emergency Department, GRI (143)

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Introduction

Emergency Care and Medical Specialties Directorate

West Of Scotland Anaphylaxis Service

Adult Anaphylaxis / Severe Allergy Clinic – Referral Criteria

This service is designed to investigate and manage life threatening allergic reactions in adults (13 years and over).

Anaphylaxis

Patients who have had, or are suspected to have had systemic allergic reactions.

These reactions include wheeze, stridor, breathlessness, oro-pharyngeal angioedema, syncope or pre-syncope usually (but not exclusively) in the presence of flushing, urticaria, swelling or angioedema. These reactions occur within 1 – 2 hours of exposure to a likely trigger or exercise and resolve within 24 hours of onset (Longer lasting or delayed reactions are rarely due to allergy). The absence of these features makes alternative diagnoses more likely.

A mast cell tryptose taken 1-4 hours after the reactions is extremely helpful in managing these patients and any patient who is referred should have this checked by a yellow topped bottle to Immunology.

Food allergy

Patients who are suspected as having type I hypersensitivity reactions to food i.e. not food intolerance or celiac disease. These reactions are systemic (as above) or affect the mouth, tongue, lips or oro-pharynx and occur within 1-2 hours of exposure to food and resolve within 24 hours of onset (longer lasting or delayed reactions are rarely due to food allergy).

Isolated urticaria, abdominal symptoms, bowel irregularity or discomfort in the absence of more typical allergy symptoms should not be referred to the anaphylaxis service.

Bee/wasp venom reactions

When anaphylaxis to insect venom is recorded, patients can be referred for appropriate advice and consideration of desensitisation therapy.

Adrenaline prescription

When a patient has been issued with adrenaline auto-injector by another service for a presumed anaphylactic reaction referral could be considered for review of this decision and education on correct use.

Drug allergy

When symptoms suggest IgE mediated reaction including: bronchospasm, collapse, urticaria or angioedema within 1 hour of exposure. However: Diagnostic tests for drug allergy are limited and rarely guarantee that a drug safety.while desensitisation is not usually possible
The gold standard for diagnosis is a direct drug challenge – this carries risks and many patients / doctors will prefer avoidance unless there is a clear need for therapy and lack of suitable alternative drugs.
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ANAESTHETIC reactions – patients with acute episodes consistent with an IgE mediated reaction should be referred.

Latex allergy

Where symptoms are due to contact to latex, eg children’s balloons, condoms or work place contact.

We are unable to investigate or manage

Urticaria +/- angioedema: when occurring in the absence of systemic features of allergy as above. Urticaria/angioedema is usually not caused by allergy or specific triggers and should not be referred see 2a-d, below. Follow national guidelines at: www.dermatology.nhs.scot/dermatology-pathways/ 

1. The following suggest symptoms MIGHT be allergic (may refer as above):

a. Symptoms ONLY within minutes of exposure to single food/food group
b. Symptoms ONLY with exercise/activity
c. Symptoms occur within minutes of exposure to latex

2. The following suggest urticaria/angioedema is NOT allergic
a. Symptoms are present first thing in the morning
b. Symptoms persist (even in varying intensity) for days / weeks
c. Symptoms have been frequent and regular over a period > 6 weeks d. Symptoms have occurred while on ACE inhibitor or NSAID therapy.

(Duration of prior therapy does not affect the chances of angioedema being related to a drug).

Angioedema WITHOUT urticaria: unless there are features to suggest allergy as in 1a-c, above, consider Immunology referral. Angioedema is rarely due to allergy or specific triggers.

Food Intolerance: no dedicated service available.

Rhinitis/Asthma: this falls under the remit of ENT/respiratory medicine.

Eczema/Dermatitis: this falls under the remit of Dermatology.

Last reviewed: 11 May 2021

Next review: 26 May 2023

Author(s): Malcolm Shepherd

Version: 4

Author Email(s): [email protected]

Approved By: Emergency Care & Medical Services Clinical Governance Forum

Document Id: 143