Anaphylaxis: Recognising and Responding to Severe Allergic Reactions

Anaphylaxis is a severe, rapid, potentially fatal allergic reaction. It kills within minutes to hours if untreated. Adrenaline (epinephrine) via injection is the only effective immediate treatment. Antihistamines and steroids are secondary. Every family with a known severe allergy sufferer should have an EpiPen and know how to use it. The specific delay between symptoms starting and adrenaline given is often the difference between life and death.

What triggers anaphylaxis

• Foods — peanut, tree nuts, shellfish, egg, milk (children), sesame.
• Insect stings — bee, wasp, some ants.
• Medications — penicillin, some antibiotics, aspirin/NSAIDs, contrast dyes.
• Latex.
• Exercise (rarely, sometimes combined with food).
• Idiopathic (unknown cause) in some cases.

Symptoms — usually within minutes

• Skin: hives, itching, flushing, swelling — especially face, lips, tongue.
• Respiratory: wheezing, throat tightness, difficulty breathing, hoarse voice.
• Cardiovascular: rapid pulse, dizziness, fainting, drop in BP.
• Gastrointestinal: nausea, vomiting, abdominal cramps.
• Neurological: confusion, anxiety, sense of impending doom.
• Combination of symptoms across body systems suggests anaphylaxis.

The specific diagnostic criteria (any one)

• Sudden skin/mucosal symptoms + respiratory OR cardiovascular symptoms.
• Two or more of skin, respiratory, cardiovascular, GI shortly after exposure to likely allergen.
• Low BP shortly after exposure to known allergen.

The immediate response — the specific 5 steps

• Give adrenaline (EpiPen/Emerade auto-injector) immediately if available.
• Call ambulance (108).
• Lie the person flat with legs raised (do NOT sit up if breathing OK — worsens BP drop).
• If breathing difficulty preferred, semi-sitting is acceptable.
• Give second dose of adrenaline after 5-15 minutes if not improving.

How to use an EpiPen

• Remove blue safety cap.
• Grip firmly with orange tip pointing down.
• Firmly push orange tip against outer thigh (through clothing OK).
• Hold for 3 seconds.
• Massage the site briefly.
• Note the time given.
• Second dose available in case symptoms persist or return.

What NOT to do

• Do NOT wait to see if symptoms resolve on their own.
• Do NOT rely on antihistamines alone (Benadryl won't stop anaphylaxis).
• Do NOT sit the person upright if BP is dropping.
• Do NOT give food or drink.
• Do NOT delay ambulance.
• Do NOT panic if adrenaline given without needing it — safer than not giving it when needed.

The specific case for early adrenaline

The most common preventable factor in anaphylaxis deaths is delayed adrenaline. Studies consistently show that giving adrenaline within 5-10 minutes of symptom onset dramatically improves survival. Waiting to see if symptoms progress often means the person collapses before treatment. If in doubt, give adrenaline.

After adrenaline

• Ambulance still needed — biphasic reactions occur 1-8 hours later.
• Hospital observation typically 4-6 hours minimum after severe reaction.
• Steroids and antihistamines often given as adjuncts.
• Second dose of adrenaline if symptoms persist or return.
• Allergy specialist referral for diagnostic workup.

The specific EpiPen management

• Store at room temperature — heat and cold both damage.
• Check expiry date monthly — replace before expiry.
• Carry two at all times — one may fail or need repeat dose.
• Adults, teens, and children over 30 kg use 0.3 mg dose.
• Children under 30 kg use 0.15 mg (junior) dose.
• Available in India — Emerade, Fastject, some pharmacies stock EpiPen.
• Cost around ₹6,000-10,000 for auto-injector, expires in 12-18 months.
• Trainer devices available for practice.

Living with severe allergy

• Complete avoidance of the allergen.
• Read every food label.
• Ask at restaurants explicitly.
• Medical ID bracelet or lock-screen medical ID.
• Family, friends, teachers, employers informed.
• Written anaphylaxis action plan.
• Multiple EpiPens (home, school/work, always carrying).
• Regular review with allergist.
• Consider immunotherapy if applicable to allergen.

What to record

• Documented allergens (with method of diagnosis).
• Previous reactions with severity.
• Current management plan.
• Location of EpiPens (home, work, school, always-carried).
• Any near-misses or reactions and their treatments.
• Contacts of allergist.

The specific school and workplace preparation

• Anaphylaxis action plan on file.
• EpiPen at school in accessible location (nurse's office, classroom).
• Teachers trained in recognition and use.
• Safe food policy where relevant.
• Emergency contact protocol.

Anaphylaxis is a specific emergency where the specific correct response — adrenaline, ambulance, lay flat — needs to be automatic. Hesitation kills; action saves.

References

• AAAAI — anaphylaxis guidelines
• WAO — World Allergy Organization
• PMC — anaphylaxis management India