Emergency management of anaphylaxis and the impact of the new UK advanced life support guidelines
Anaphylaxis is a severe, potentially life-threatening allergic reaction that requires urgent and effective management. The UK Resuscitation Council updated its advanced life support (ALS) guidelines for anaphylaxis in 2021, emphasising early and repeated adrenaline administration, intravenous (IV) f...
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| Veröffentlicht in: | Clinical medicine (London, England) Jg. 25; H. 6; S. 100519 |
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01.11.2025
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| Abstract | Anaphylaxis is a severe, potentially life-threatening allergic reaction that requires urgent and effective management. The UK Resuscitation Council updated its advanced life support (ALS) guidelines for anaphylaxis in 2021, emphasising early and repeated adrenaline administration, intravenous (IV) fluid use, and reduced reliance on antihistamines and steroids.
A retrospective audit was carried out to compare the management of anaphylaxis at two English NHS hospitals, namely the University Hospital of North Midlands (UHNM) and the Shrewsbury and Telford Hospital (SATH), before (2018) and after (2022/23) the ALS guideline implementation. Adherence to NICE anaphylaxis guidance was also assessed.
Data from 272 patients revealed significant improvements in recognition of anaphylaxis in 2022 compared with 2018 (70.8% vs. 50%; p=0.001). The use of adrenaline and IV fluids increased, whereas the use of antihistamines and steroids declined, aligning with the new guidance. Tryptase measurement (checked in 45% of patients) and specialist referral rates (67% at UHNM vs. 3% at SATH; p=0.0001) remained suboptimal at both centres. A case example highlights the risks of misdiagnosis and adrenaline overuse in patients with recurrent urticarial presentations.
Anaphylaxis management in these centres has changed in keeping with the new ALS guidelines, although antihistamines and steroids were still used in the acute management of around 50% of the patients. Adrenaline overuse may be an unintended consequence of the guideline, which needs monitoring. There may have been some improvement in anaphylaxis recognition, but serum tryptase measurement and referral to allergy specialists remain poor. |
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| AbstractList | AbstractBackgroundAnaphylaxis is a severe, potentially life-threatening allergic reaction that requires urgent and effective management. The UK Resuscitation Council updated its advanced life support (ALS) guidelines for anaphylaxis in 2021, emphasising early and repeated adrenaline administration, intravenous (IV) fluid use, and reduced reliance on antihistamines and steroids. MethodsA retrospective audit was carried out to compare the management of anaphylaxis at two English NHS hospitals, namely the University Hospital of North Midlands (UHNM) and the Shrewsbury and Telford Hospital (SATH), before (2018) and after (2022/23) the ALS guideline implementation. Adherence to NICE anaphylaxis guidance was also assessed. ResultsData from 272 patients revealed significant improvements in recognition of anaphylaxis in 2022 compared with 2018 (70.8% vs. 50%; p=0.001). The use of adrenaline and IV fluids increased, whereas the use of antihistamines and steroids declined, aligning with the new guidance. Tryptase measurement (checked in 45% of patients) and specialist referral rates (67% at UHNM vs. 3% at SATH; p=0.0001) remained suboptimal at both centres. A case example highlights the risks of misdiagnosis and adrenaline overuse in patients with recurrent urticarial presentations. ConclusionAnaphylaxis management in these centres has changed in keeping with the new ALS guidelines, although antihistamines and steroids were still used in the acute management of around 50% of the patients. Adrenaline overuse may be an unintended consequence of the guideline, which needs monitoring. There may have been some improvement in anaphylaxis recognition, but serum tryptase measurement and referral to allergy specialists remain poor. Anaphylaxis is a severe, potentially life-threatening allergic reaction that requires urgent and effective management. The UK Resuscitation Council updated its advanced life support (ALS) guidelines for anaphylaxis in 2021, emphasising early and repeated adrenaline administration, intravenous (IV) fluid use, and reduced reliance on antihistamines and steroids. A retrospective audit was carried out to compare the management of anaphylaxis at two English NHS hospitals, namely the University Hospital of North Midlands (UHNM) and the Shrewsbury and Telford Hospital (SATH), before (2018) and after (2022/23) the ALS guideline implementation. Adherence to NICE anaphylaxis guidance was also assessed. Data from 272 patients revealed significant improvements in recognition of anaphylaxis in 2022 compared with 2018 (70.8% vs. 50%; p=0.001). The use of adrenaline and IV fluids increased, whereas the use of antihistamines and steroids declined, aligning with the new guidance. Tryptase measurement (checked in 45% of patients) and specialist referral rates (67% at UHNM vs. 3% at SATH; p=0.0001) remained suboptimal at both centres. A case example highlights the risks of misdiagnosis and adrenaline overuse in patients with recurrent urticarial presentations. Anaphylaxis management in these centres has changed in keeping with the new ALS guidelines, although antihistamines and steroids were still used in the acute management of around 50% of the patients. Adrenaline overuse may be an unintended consequence of the guideline, which needs monitoring. There may have been some improvement in anaphylaxis recognition, but serum tryptase measurement and referral to allergy specialists remain poor. Background: Anaphylaxis is a severe, potentially life-threatening allergic reaction that requires urgent and effective management. The UK Resuscitation Council updated its advanced life support (ALS) guidelines for anaphylaxis in 2021, emphasising early and repeated adrenaline administration, intravenous (IV) fluid use, and reduced reliance on antihistamines and steroids. Methods: A retrospective audit was carried out to compare the management of anaphylaxis at two English NHS hospitals, namely the University Hospital of North Midlands (UHNM) and the Shrewsbury and Telford Hospital (SATH), before (2018) and after (2022/23) the ALS guideline implementation. Adherence to NICE anaphylaxis guidance was also assessed. Results: Data from 272 patients revealed significant improvements in recognition of anaphylaxis in 2022 compared with 2018 (70.8% vs. 50%; p=0.001). The use of adrenaline and IV fluids increased, whereas the use of antihistamines and steroids declined, aligning with the new guidance. Tryptase measurement (checked in 45% of patients) and specialist referral rates (67% at UHNM vs. 3% at SATH; p=0.0001) remained suboptimal at both centres. A case example highlights the risks of misdiagnosis and adrenaline overuse in patients with recurrent urticarial presentations. Conclusion: Anaphylaxis management in these centres has changed in keeping with the new ALS guidelines, although antihistamines and steroids were still used in the acute management of around 50% of the patients. Adrenaline overuse may be an unintended consequence of the guideline, which needs monitoring. There may have been some improvement in anaphylaxis recognition, but serum tryptase measurement and referral to allergy specialists remain poor. |
| ArticleNumber | 100519 |
| Author | Kadambi, Madhavi Goktas, Polat Goddard, Sarah Inani, Mohit Cooper, Angela Diwakar, Lavanya Hughes, Deborah Elshehawy, Mahmoud Clarke, Daniel |
| Author_xml | – sequence: 1 givenname: Mahmoud orcidid: 0009-0001-3678-7103 surname: Elshehawy fullname: Elshehawy, Mahmoud organization: Acute Medicine, Shrewsbury and Telford Hospitals NHS Trust, Shrewsbury, United Kingdom – sequence: 2 givenname: Madhavi surname: Kadambi fullname: Kadambi, Madhavi organization: Specialist Registrar in Allergy, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom – sequence: 3 givenname: Deborah surname: Hughes fullname: Hughes, Deborah organization: Department of Immunology and Allergy, UHNM, Stoke on Trent, United Kingdom – sequence: 4 givenname: Daniel surname: Clarke fullname: Clarke, Daniel organization: Department of Immunology and Allergy, UHNM, Stoke on Trent, United Kingdom – sequence: 5 givenname: Angela surname: Cooper fullname: Cooper, Angela organization: Department of Immunology and Allergy, UHNM, Stoke on Trent, United Kingdom – sequence: 6 givenname: Mohit surname: Inani fullname: Inani, Mohit organization: Acute Medicine, Shrewsbury and Telford Hospitals NHS Trust, Shrewsbury, United Kingdom – sequence: 7 givenname: Polat orcidid: 0000-0001-7183-6890 surname: Goktas fullname: Goktas, Polat organization: Associate Professor in Computer Science, Sabanci University, Ankara, Turkey – sequence: 8 givenname: Sarah orcidid: 0000-0002-5055-8446 surname: Goddard fullname: Goddard, Sarah organization: Department of Immunology and Allergy, UHNM, Stoke on Trent, United Kingdom – sequence: 9 givenname: Lavanya orcidid: 0000-0003-4369-6637 surname: Diwakar fullname: Diwakar, Lavanya email: l.diwakar@bham.ac.uk organization: Department of Immunology and Allergy, UHNM, Stoke on Trent, United Kingdom |
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| References_xml | – volume: 4 start-page: 13 year: 2011 end-page: 37 ident: bib0004 article-title: World allergy organization guidelines for the assessment and management of anaphylaxis publication-title: World Aller Organiz J – volume: 30 start-page: 1144 year: 2000 end-page: 1150 ident: bib0006 article-title: Lessons for management of anaphylaxis from a study of fatal reactions publication-title: Clin Experim Allergy – volume: 24 start-page: 733 year: 2017 end-page: 741 ident: bib0007 article-title: H1-antihistamines reduce progression to anaphylaxis among emergency department patients with allergic reactions publication-title: Acad Emerg Med – volume: 22 start-page: 332 year: 2022 end-page: 339 ident: bib0001 article-title: Emergency treatment of anaphylaxis: concise clinical guidance publication-title: Clin Med – volume: 9 start-page: 1438 year: 2021 end-page: 1441 ident: bib0003 article-title: The COVID-19 pandemic in 2021: avoiding overdiagnosis of anaphylaxis risk while safely vaccinating the world publication-title: J Aller Clin Immunol: In Pract – year: 2020 ident: bib0005 article-title: Anaphylaxis: assessment and referral after emergency treatment – volume: 77 start-page: 357 year: 2022 end-page: 377 ident: bib0002 article-title: EAACI guidelines: anaphylaxis (2021 update) publication-title: Allergy – volume: 77 start-page: 357 issue: 2 year: 2022 ident: 10.1016/j.clinme.2025.100519_bib0002 article-title: EAACI guidelines: anaphylaxis (2021 update) publication-title: Allergy doi: 10.1111/all.15032 – volume: 30 start-page: 1144 issue: 8 year: 2000 ident: 10.1016/j.clinme.2025.100519_bib0006 article-title: Lessons for management of anaphylaxis from a study of fatal reactions publication-title: Clin Experim Allergy doi: 10.1046/j.1365-2222.2000.00864.x – volume: 9 start-page: 1438 issue: 4 year: 2021 ident: 10.1016/j.clinme.2025.100519_bib0003 article-title: The COVID-19 pandemic in 2021: avoiding overdiagnosis of anaphylaxis risk while safely vaccinating the world publication-title: J Aller Clin Immunol: In Pract – year: 2020 ident: 10.1016/j.clinme.2025.100519_bib0005 – volume: 22 start-page: 332 issue: 4 year: 2022 ident: 10.1016/j.clinme.2025.100519_bib0001 article-title: Emergency treatment of anaphylaxis: concise clinical guidance publication-title: Clin Med doi: 10.7861/clinmed.2022-0073 – volume: 24 start-page: 733 issue: 6 year: 2017 ident: 10.1016/j.clinme.2025.100519_bib0007 article-title: H1-antihistamines reduce progression to anaphylaxis among emergency department patients with allergic reactions publication-title: Acad Emerg Med doi: 10.1111/acem.13147 – volume: 4 start-page: 13 issue: 2 year: 2011 ident: 10.1016/j.clinme.2025.100519_bib0004 article-title: World allergy organization guidelines for the assessment and management of anaphylaxis publication-title: World Aller Organiz J doi: 10.1097/WOX.0b013e318211496c |
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