Anaphylaxis - recognition and treatment

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Anaphylaxis is a major allergic reaction with the potential to kill. It should always be taken seriously. Anaphylaxis can be caused by any substance, but the commonest reactions follow ingestion of foods, stings from wasps and bees and exposures to chemicals. It is not uncommon to see anaphylactic reactions with exercise and up to 50% of these are associated with foods.

For any insect bite or sting, immediately apply neat Lugol's iodine 15%. Paint the bite yellow! Expect this to reduce the redness, swelling and itch. I am anaphylactic to wasp stings and for me this works instantly. A further benefit is it may reduce the risk of picking up an infection such as Lyme disease since iodine contact kills all microbes.

Mild reactions

Itchy skin, flushed skin, blotchy skin, a raised red itchy rash. Swelling of the mouth, tickling, tingling or itching of the throat, mouth and lips. Stomach ache.

Firstly take a dose of antihistamines – any one will do. Crunch it up in the mouth and swallow. Apply cold water or ice packs to the affected area – sometimes this is sufficient to stop the reaction.

If the symptoms do not settle, consider taking an ampoule of adrenaline and using it in your nebuliser, or empty this into the mouth and gargle and inhale this way.

If the above symptoms progress, or if there is any hint of further reactions, do not waste time. Use injected adrenaline or EpiPen.

Severe/anaphylactic reactions

Marked swelling of lips or tongue. Difficulty in swallowing, wheeze or difficulty in breathing, change in voice or inability to speak, drowsiness, blue lips, feeling faint, loss of consciousness. Pulse – the pulse may be going fast, or conversely might be going very slow. Blood pressure may fall.

If in doubt whether or not to use EpiPen or adrenaline by injection, use it. No-one has ever died following an intramuscular injection of adrenaline given early in an anaphylactic attack. The injection needs to be into the muscle.

Some people need a second injection of EpiPen, so make sure you always have two to hand*. Should you ever require one injection of EpiPen, then you need to be seen and assessed by a doctor as soon as reasonably possible. If you need Epipen, also take prednisolone 30mgs (6 tablets) or hydrocortisone 100mgs. These take up to 6 hours to work but they help prevent a second attack.

If you do need a second EpiPen injection then please make sure to inject in the opposite thigh to the one you injected in first. This recommendation was re-enforced in the inquest into Natasha Ednan-Laperouse's death - see below 
  • Natasha Ednan-Laperouse died after she ate a baguette that contained sesame.
  • Her father injected her with two Epi-Pens in an attempt to reverse the allergic reaction. The first epi-pen was injected into her right outer thigh. *But Natasha wasn't improving and she begged for the second Epi-Pen to be given which her father did, once again into her right outer thigh.
  • But it made no difference at all.
  • At Natasha's inquest, an Allergy Specialist was asked why in her opinion, the Epi-Pens had not worked. One of the reasons she gave, was that when the first Epi-Pen had been injected into Natasha's thigh, the adrenaline would have caused all the blood vessels in that area to constrict. Her allergic reaction was so severe that she required another dose of adrenaline to be administered quickly, but when injected into the same place as before, the adrenaline would not have been able to enter the blood vessels, it had nowhere to go. To counter this, she told the coroner that the second Epi-Pen injection should have been injected into her other leg - the opposite thigh.
  • Natasha's parents have formed the Natasha Allergy Research Foundation and recently [Oct 2019] "Natasha's Law" has come into force, requiring full ingredient and allergen labelling on all food made on premises and pre-packed for direct sale. See UK Govt Press Release regarding "Natasha's Law"

How to use an EpiPen Adrenaline

Pull off the grey safety cap. Place the black tip onto the side of the thigh at right angles to the leg. Press hard into the thigh until you hear the pen click (the injection can be given through clothing). Hold in place for ten seconds. Remove EpiPen - note what time it is.

There is a very useful website called There are useful resources here:

  • They can send you an Epipen dummy trainer pen
  • There is a demonstration video of how to use your Epipen
  • There is an Epipen expiry service

Do click on this link!

Adrenaline has a short lifespan, so do check the dates on your ampoules and EpiPen regularly. I like all my patients to have three EpiPens – one for the house, one for the car and one for the handbag (or manbag!)!

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