Emergency Management: Anaphylaxis

The National Allergy Strategy has partnered with Allergy & Anaphylaxis Australia to deliver a series of webinars to help parents and guardians manage food allergies and the risk of anaphylaxis in children’s education and care services, primary and secondary schools and camps.

The second in the series was “Emergency management of anaphylaxis” presented on Zoom on Wednesday 27 April 2022.

This webinar covers:

• Recognising allergic reactions, including anaphylaxis.
• ASCIA Action Plans.
• Information about EpiPen® and Anapen®, demonstrates use of both devices and what resources are available.
• Positioning a person having anaphylaxis and what resources are available.
• An expert panel answering audience questions.

The webinar recording is available below along with 8 questions that were answered specifically during the webcast. There are also further written questions and answers available.  

• Emergency Management: Anaphylaxis - Full webinar
  Questions

• Dr Katie Frith - ASCIA Action Plans and Recognising Anaphylaxis
• Maria Said - Adrenaline Injectors
• Our GP told us we were getting an EpiPen, but the pharmacist gave us an Anapen. Are pharmacies allowed to substitute the brands?
• If a second adrenaline injector is needed, should it be given in a different leg?
• If you administer an antihistamine for a food allergic reaction based on initial symptoms of a mild reaction, can this mask warning signs and symptoms for a severe reaction? If the initial reaction is hives, how long after can an anaphylaxis reaction occur? And if hives subside with antihistamines, does this mean an anaphylaxis will not occur? Also, will giving an antihistamine stop a reaction progressing to anaphylaxis?
• What is the minimum standards of care that should be expected from paramedics or ambulance staff? When arriving in ED following an anaphylaxis, should there be access to a cardiac monitor and how long someone should be observed for?
• Why do insect bite anaphylaxis cause stomach pains? Can anything help abdominal pain following a mild reaction? Sometimes my child can have stomach pain for hours after reaction.
• Are any other brands of adrenaline injectors coming onto the market in Australia? Does the Anapen come with a hard case like the EpiPen does?
• Managing anaphylaxis in babies under 7.5 kilos. We know that typically adrenaline injectors are only prescribed to babies over 7.5 kilos. So what do you do if you've got a baby having an anaphylaxis and they haven't been prescribed an adrenaline injector?"
• Should you remove clothing before administrating an adrenaline injector? And is there any difference in that for EpiPen or Anapen in your answer?
• Is there a way to get into the yellow EpiPen® so you can draw up the adrenaline - to give a half dose for children 7.5-20kg?

  It is important that you do not tamper with adrenaline injector devices. If you only have a 300 microgram adrenaline injector, this can be given to children over 10kg if a 150mg is not available in preference to giving no adrenaline injector at all. If the child is under 10kg, you should follow the advice provided when you call for an ambulance

• Can we predict the severity of anaphylaxis based on skin prick testing?

   Skin prick testing provides an indication of the likelihood of a person having an allergic reaction, but not the severity of the allergic reaction. Clinical immunology/allergy specialists will determine the likelihood of a severe allergic reaction based on allergy test results and information on what has happened to that person before when given that food or stung/bitten by an insect. If someone has had a previous anaphylaxis, they are more likely to have another anaphylaxis to that same trigger.

• Can you use a different device in an emergency? For example, if a person is prescribed an EpiPen® 300 but only an Anapen® 300 is available.

  Yes, you can use either the EpiPen® (300 microgram) or Anapen® 300 (300 microgram) as they both contain a singled pre-measured dose of adrenaline.

• Can the degree of allergy change?

  The severity of people’s allergies can change. People who have had a mild or moderate allergic reaction in the past can have severe reactions in the future. People can also outgrow their allergy (not be allergic anymore). However, it is very individual and does depend on what the trigger allergen is. Importantly, allergic reactions do not become more severe with each reaction. Some people may only ever have mild reactions.

• I have recently been diagnosed with wheat dependent exercise induced anaphylaxis and was wondering is there any information I can get regarding it.

  Allergy & Anaphylaxis Australia has information about exercise induced anaphylaxis including food-related exercise induced anaphylaxis - https://allergyfacts.org.au/allergy-anaphylaxis/other-allergic-conditions/eia

  ASCIA has a dietary avoidance information sheet to help you avoid wheat - https://allergy.org.au/patients/food-allergy/ascia-dietary-avoidance-for-food-allergy/wheat

• One GP suggested taking antihistamine first and waiting for more symptoms to develop. Another GP suggested given the adrenaline injector straight away (for nut allergy). What would your suggestion be? Thankfully my child has never had a severe reaction in the past 14 years.

  If a person has hives or swelling of the lips, or face that does not affect their breathing, taking an antihistamine can help make the person feel less itchy and more comfortable. Antihistamines, however, will not prevent a severe allergic reaction so you should continue to watch for any signs of anaphylaxis. ASCIA recommends giving the adrenaline injector if there are any signs (even only one sign) of anaphylaxis or if there is any doubt as to whether it is anaphylaxis or not. If in doubt, it is best to give the adrenaline injector and call triple zero for an ambulance.  It is better to give an adrenaline injector and not need it, rather than need adrenaline and give it too late.

• What is the percentage of self-resolved anaphylaxis? My daughter's first anaphylaxis self- resolved, and I thank goodness every day as we did not have an adrenaline injector at that point.

  We currently do not know how many cases of anaphylaxis self-resolve. Therefore, it is recommended that if there any signs of anaphylaxis, an adrenaline injector should be given, and an ambulance called. Deaths from anaphylaxis have usually occurred due to a number of factors including a delay in giving adrenaline.

• Are nurses covered in emergency department to give adrenaline via EpiPen®?

  The Acute Anaphylaxis Clinical Care Standard, released in November 2021, provides clear guidance for hospital staff about giving adrenaline. Click here for more information.

• What is an example of a non-sedative anti histamine?

  There are many different brands of non-sedating antihistamines, and your local pharmacist will be able to provide you with the different options. Some are available as syrups for younger children.

• We have two adrenaline injectors for my 3 year old daughter. We keep one at childcare and one at home. I am concerned that if we needed to use another adrenaline injector in a reaction because the first didn't work, we wouldn't have a second device at home. Would you have any suggestions for this?

  This is very common as most children in childcare and school will provide either the childcare or school with one of the child’s prescribed devices. As part of completing an individualised anaphylaxis care plan, parents should discuss with the childcare (or school) whether one of the child’s adrenaline injectors will be kept on site or whether two devices go to and from childcare (or school) each day. Parents can also purchase a third adrenaline injector over the counter (at full price) from the pharmacy (some private health funds cover part of cost depending on cover).

• What are your thoughts on using the black cap from an Anapen® to cap the device after use?

  If you have a hard plastic container available, it may be easier to place the used Anapen® in that rather than using the black needle shield. The distributor of Anapen® are developing a hard plastic case that the device can be kept in before and after use.

• Our EpiPen® carrier got wet with a tipped water bottle. Does this mean we need to get new EpiPen®s?

  The adrenaline injectors should not need replacing, however, if you are unsure, you can ask your pharmacist to check the device or contact the distributor of the device.

• Why do we have two adrenaline injector devices?

  Both EpiPen® and Anapen® devices are widely used in other countries. Most countries have multiple brands of adrenaline injector devices available, and this is important for the following reasons:

  • To ensure continued supply of life saving adrenaline, particularly if one brand has stock shortages.
  • To provide choice of dose, including people over 50kg who may prefer a higher dose (500 microgram).
  • A 500 microgram device can potentially prevent the need for further doses of adrenaline.
  • To encourage suppliers to provide devices with longer shelf life.
  • To provide choice for consumers to access different devices.
• Is there a cost difference between the adrenaline injectors?

  In Australia, both Anapen® and EpiPen® cost the same through PBS subsidised prescription (known as an ‘authority script’). When purchased over the counter (not on prescription), the devices will have a similar cost also. Please note that the cost of the devices may depend on location (for example, metropolitan versus rural and remote). Pharmacies vary in price for adrenaline injectors bought over the counter just like any other over the counter medicine.

• Why are there shortages of adrenaline injectors?

  From time to time there are issues with supply for many reasons, such as manufacturing issues or increased demand for the devices. Anapen® and EpiPen® are not manufactured in Australia and we rely on the devices being supplied to Australia.

• Can you talk about exposure to allergens during a long flight? Is the risk of anaphylaxis higher?

  Allergy & Anaphylaxis Australia has useful information about flying with food allergies:

  https://allergyfacts.org.au/resources/help-sheets/air-travel

  https://allergyfacts.org.au/resources/help-sheets/nuts-on-planes

  https://allergyfacts.org.au/resources/help-sheets/travel-info

• Is medical jewellery useful?

  Medical jewellery can inform first aiders that a person is at risk of anaphylaxis if the person is unable to speak for themselves (if they are unconscious). There are different types of medical jewellery available and the decision to wear or not wear medical jewellery is up the individual (or their parent/carer). It is very important however, for people with medication allergy to wear medical identification jewellery because if they are unconscious, they are likely to be given medication by health professionals.

• Is anaphylaxis prioritised with ambulances at this point in time in Australia considering the issues and current shortages situation?

  Anaphylaxis is considered a medical emergency and ambulance services aim to get to the person as quickly as possible, even with the current challenges. We would recommend using an adrenaline injector early and if practical, having a second device available.

• Can you just buy autoinjectors over the counter at a chemist?

  Yes. Adrenaline injectors are available from pharmacies without a prescription at full retail price (not PBS subsidised).  If they are purchased directly from pharmacies without a prescription, you should request training from the pharmacist on how to use the adrenaline injector.

• What do you do if a person doesn’t have their adrenaline injector on them?

  Lay the person flat or allow them to sit with legs out in front of them (not on a chair) if they are having trouble breathing. Call an ambulance (call triple zero – 000). Commence CPR at any time if person is unresponsive and not breathing normally. The person having anaphylaxis should not be allowed to stand, sit up suddenly or walk, even if they look like they have recovered. They should be carried on a stretcher or trolley bed to the ambulance.

  In the school setting staff can use a general use adrenaline injector device if they have one available or may be able to use another person’s prescribed device, replacing that person’s device as soon as possible.

• Does a pharmacist have a duty of care to give a bystander a second adrenaline injector if after 5 minutes the first hasn't fixed the problem?

  Health professionals, including pharmacists should assist people having an anaphylaxis where they can. Delay in administration of adrenaline increases the risk of fatality, therefore if an adrenaline injector is available, it should be given as per the instructions on the person’s ASCIA Action Plan or the ASCIA First Aid Plan for Anaphylaxis.

• What is the use by date of adrenaline injectors?

  The shelf life of adrenaline injectors is normally one to two years from date of manufacture for both Anapen® and EpiPen®.

Content updated May 2022