Choo, K.J.L., Simons, F.E.R., Sheikh, A. For children with a generalised allergic reaction, consider referral to a local Immunologist (via ED or GP) on discharge. Circulation, 137(1), e1-e6. Food allergy and anaphylaxis is increasing in Australian children, and anaphylaxis is relatively common in Australian schools. Anaphylaxis: a practice parameter update 2015. Onsite or via Retrieval Services Queensland (RSQ). Patients may present with symptoms that range in severity, but cardiac collapse and respiratory compromise cause the most urgent concern. In up to 30% of reactions, a cause cannot be identified.1, The prevalence of anaphylaxis in the paediatric population is estimated to be 1 in 1000.6 Admission rates for anaphylaxis are increasing in Australia with food allergies affecting 4 – 8% of children less than five years of age.1 Deaths from anaphylaxis are relatively rare but they are increasing in Australia with 324 deaths recorded between 1997 and 2013.7, Risk factors for fatal anaphylaxis include:1,8. With planning and training, anaphylaxis can be treated effectively. Dr. Wang, a lead author of the clinical report on the emergency plan, is a member of the AAP Section on Allergy and Immunology Executive Committee. Seek urgent paediatric critical care advice (onsite or via RSQ) for a child in shock who is not responding to Adrenaline and fluids. Consider pre-hospital treatment. An Australian survey of parent-reported allergy and anaphylaxis found that 1 in 170 preschool children had suffered at least one episode of anaphylaxis. ANZCOR Guidelines. Rapidly evolving generalised multi-system allergic reaction characterised by: Cardio-vascular compromise including hypotension, Stridor, drooling or respiratory distress, Upper airway obstruction causes including, Flushing of the face, headache, heart palpitations, itching, blurred vision, cramps and diarrhoea within minutes to an hour of consuming contaminated fish, Scombroid poisoning (histamine poisoning from fish) – easily confused as seafood is a common cause of anaphylaxis, 5 mL of undiluted 1:1000 Adrenaline nebulised with oxygen. (1998), ‘Epinephrine absorption in children with a history of anaphylaxis’, Simons, F.E.R., Gu, X., Simons, K.J. This review aims to provide an overview of current policies and practices for anaphylaxis management in Australian schools, including approaches to risk mitigation and anaphylaxis … required to diagnose, treat and optimally manage anaphylaxis. Santillanes, G., Davidson, J. The use of other laboratory and radiological tests should be guided by patient co-morbidities and circumstances, including incidental trauma.9. Children’s Advice and Transport Coordination Hub (CATCH), Queensland Paediatric Transport Triage Tool. For further information and fact sheets please visit the Sydney Children’s Hospital Network . Common allergens include peanuts, tree nuts, wheat, sesame, egg, cow’s milk, fish, shellfish and on rare occasions spices, fruit and soy.5 Other causative agents include drugs, insects, latex, allergen therapy and, less commonly, exercise, cold and immunisations. Queensland Health, Department of Emergency Medicine: Royal Children’s Hospital (Brisbane). Canadian epidemiological data indicate that the rate of children who visited emergency departments between 2006-2014 for anaphylaxis more than doubled. Children with a localised allergic reaction may be safely discharged. INTRODUCTION  Anaphylaxis is a potentially fatal disorder that is under-recognized and undertreated. The review presents the definition of anaphylaxis provided by the National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network. Up to 40% of children in Australia and New Zealand are affected by allergic disorders at some time during their life, with 20% having current symptoms. Intervention and stabilisation should occur immediately. Anaphylaxis is a severe, immediate, and potentially life-threatening allergic reaction that involves the child's entire body. View. (2001), ‘Epinephrine absorption in adults: Intramuscular versus subcutaneous injection’, J. Davis, J.E., Norris, R.L. one or more of the following cutaneous features: one or more of the following gastrointestinal features: no respiratory or cardiovascular signs or symptoms. She owns a house-call based pediatrics practice in the Bay Area, CA. in children - 2 - Allergy and anaphylaxis – Emergency management in children – Medications Clinical features of a generalised allergic reaction* Gastrointestinal Cutaneous • abdominal pain • vomiting • loose stools • generalised pruritus • urticaria/angioedema • erythema *May also be present in anaphylaxis The most common allergic conditions in children are food allergies, eczema, asthma and hayfever (allergic rhinitis).1. Australian Society of Clinical Immunology and Allergy (ASCIA). Histamine levels fall too rapidly to be clinically useful. Treatment of anaphylaxis is intra-muscular adrenaline 10 micrograms/kg or 0.01ml/kg of 1:1000 (maximum 0.5ml), into lateral thigh which should be repeated after 5 minutes if the child is not improving. When to consider admission to inpatient ward from SSU *Loratadine, Fexofenadine and Desloratadine are not available within QH Hospitals but are available in the community. 4 (4): pp. Refer to the ASCIA website (https://allergy.org.au/ ) for registered local Immunologists. Clinical information. Initial management includes rapid triage and clinical assessment of the patient’s airway patency, breathing (ventilation and oxygenation) and circulation. Food allergy and anaphylaxis is increasing in Australian children, and anaphylaxis is relatively common in Australian schools. Consider early involvement of local paediatric/critical care service. 1 Deaths from anaphylaxis are relatively rare but they are increasing in Australia with 324 deaths recorded between 1997 and 2013. McLean-Tooke, A.P.C., Bethune, C.A., Fay, A.C., et al. 3 For children with a history of mild potential hypersensitivity reaction only, these authors recommend a supervised in-hospital provocation test (challenge) dose when the relevant vaccine is next required. Dr. Sheriff practices lifestyle medicine and believes in bringing medicine back to its roots! RSQ (access via QH intranet) Children with a general allergic reaction may be safely discharged provided symptoms have not progressed and are improving within one hour of observation. A small number of people may experience a severe allergic reaction called anaphylaxis. History taking should include specific information on allergic symptoms prior to hospital presentation with particular emphasis on cardiovascular or respiratory symptoms. Update in pediatric anaphylaxis: a systematic review. Similarly, a survey of South Australian preschool- and school-aged children revealed a parent-reported food-induced anaphylaxis rate of 0.43 per 100 school children, which accounted for more than one half of all cases of anaphylaxis in this age group. Anaphylaxis is often under-diagnosed due to the variable nature and duration of symptoms. In July 2005, a panel of allergy and immunology experts convened at the Second Symposium on the Definition and Management of Anaphylaxis . The College's care pathway for anaphylaxis is presented in two parts: 1. an algorithm with the stages of ideal care, and 2. a set of competences required to diagnose, treat and optimally manage anaphylaxis. Emergency treatment of anaphylactic reactions- Guidelines for healthcare providers: This set of guidelines, slides and posters will provide guidance to healthcare providers who are expected to deal with an anaphylactic reaction. Epinephrine (adrenaline) can be life-saving when administered as rapidly as possible once anaphylaxis is recognized. They are not strict protocols, and they do not replace the judgement of a senior clinician. (2016), ‘Increase in anaphylaxis fatalities in Australia from 1997 to 2013’. All patients should also be given an epinephrine autoinjector and an action plan. Anaphylaxis Guidelines Anaphylaxis Training, Guidelines, Procedures for Schools and Children's Services For ASCIA guidelines go to Prevention of Anaphylaxis in Schools, Preschools and Childcare: 2015 update Preparation for early intubation including a range of ETT sizes (with several sizes smaller than usual) is recommended. This guideline is intended as a guide and provided for information purposes only. Admission is recommended for children with anaphylaxis who: Consider admission to a SSU for children who are responding to treatment but require a period of observation prior to meeting the criteria for discharge. Branganza, S.C., Acworth, J.P., Mckinnon, D.R., et al. (2007), ‘Allergic emergencies in children: The pivotal role of epinephrine’. Algorithms are designed for use by trained medical professionals who have completed a full APLS course only. Emergency care should always involve a rapid primary survey with evaluation of (and immediate management of concerns with) airway, breathing, circulation and disability (ABCD). Anaphylaxis is under-recognised as symptoms may have resolved prior to ED presentation. age (teenagers and adults are at higher risk), all foods and medications consumed several hours before the reaction, current medications such as beta-blockers (as may affect response to treatment), co-morbid diseases such as asthma (as can affect the severity of the reaction). Investigation and management protocols tend to vary; however, one general approach and management algorithm is shown in Figure 2. During the same time period, anaphylaxis deaths remained uncommon and stable overall at ~0.64 deaths per million people per year, however medicine induced anaphylaxis deaths increased in the order of 300%. Patients who experience anaphylaxis should be evaluated by an allergist for possible causes; if found, avoidance of the inciting antigen is the best management. Refer to local Paediatrician if no local Immunology service. Nazia Sheriff @oliveleafpedsdoc. Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. In anaphylaxis, the airway should always be considered potentially “difficult” and caution should be exercised when opting for heavy sedation or long-acting paralytic agents.9 Laryngeal mask airway (LMA) may not be effective due to oropharyngeal angioedema and bronchospasm. (2010), ‘An evidence-based review of pediatric anaphylaxis’, de Silva, I.L., Mehr, S.S., Tey, D., et al. The Royal College of Paediatrics and Child Health (RCPCH) care pathway for anaphylaxis is presented in two parts: an algorithm with the stages of ideal care and a set of competences . This field is for validation purposes and should be left unchanged. It may be mild and resolve spontaneo… Are you looking for the new resuscitation guidelines? Abdominal pain, vomiting (these are signs of anaphylaxis for insect allergy) (2013). No significant clinical decisions should be made based on these images from this website without first consulting with a board-certified attending physician. Permission requests for commercial use to [email protected] or +61 3 8672 2800. Foods are a common cause of anaphylaxis in the pediatric … Fexofenadine and Desloratadine can be prescribed to infants 6 months and over. Notify early of child potentially requiring transfer. The index vaccine challenge may be administered as a split dose (eg … Anaphylaxis algorithm March 2008 When skills and equipment available: • Establish airway • High flow oxygen Monitor: • IV fluid challenge 3 • Pulse oximetry • Chlorphenamine 4 • ECG • Hydrocortisone 5 • Blood pressure Adrenaline 2 • Call for help • Lie patient flat • Raise patient’s legs Diagnosis - look for: This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) in Queensland with symptoms suggestive of an acute allergic reaction or anaphylaxis. Refer to flowchart for a summary of the emergency management of children with an acute allergic reaction. Admission to an inpatient service is recommended for children who require more than two Adrenaline doses (due to possibility of recurrent symptoms) or who are failing to improve after 12 hours of care. Investigations are not routinely recommended. We recommend that this pathway is implemented locally by a multidisciplinary team with a focus on creating networks between staff in primary and community health care, social care, education … Clinical Pediatrics, 52(5):451-461. An allergic reaction is an immunologically-mediated adverse reaction which occurs when a person’s immune system reacts to a substance (allergen) in the environment which would normally be innocuous. local guidelines / protocols based on the attached Clinical Practice Guideline in place in all hospitals and facilities required to assess or manage children with gastroenteritis. (2007), ‘H1-antihistamines for the treatment of anaphylaxis with and without shock’. ASCIA HP Guidelines Acute Management Anaphylaxis 2020 267.98 KB Anaphylaxis definitions Any acute onset illness with typical skin features (urticarial rash or erythema/flushing, and/or angioedema), plus involvement of respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms; or It is caused by an IgE-mediated release of histamine, leukotrienes and prostaglandins from tissue mast cells and peripheral blood basophils.1,2 This reaction is multisystem in nature with systemic cardiovascular and/or respiratory symptoms and involvement of other systems such as the skin and gastrointestinal tract. Continuous cardiac and oxygen saturation monitoring is recommended. The first clinical criterion, describing acute onset of illness with involvement of cutaneous manifestations, should be applicable to the majority of anaphylax… Where Adrenaline IV is indicated, a continuous low dose Adrenaline infusion is the safest and most effective form of administration.13 Significant adverse events including fatal cardiac arrhythmia and cardiac infarction have been reported when Adrenaline IV is administered too rapidly, inadequately diluted or in excessive dose.14 An Adrenaline IV bolus is not recommended. Lieberman P, Nicklas RA, Randolph C, et al. Occasionally tryptase levels collected within three hours of symptom onset may be useful but should only be collected on advice from Immunologist/Allergist. Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. GrepMed and the images sourced through this website are NOT a substitute for clinical judgement. First point of call is the onsite/local paediatric service, Queensland Emergency Care Children Working Group, Queensland Health medical and nursing staff, Allergy, anaphylaxis, acute allergic reaction, Paediatric, emergency, guideline, children, 60011, NSQHS Standards (1-8): 1 Clinical Governance, 4 Medication Safety, 8 Recognising and Responding to Acute Deterioration. Pumphrey, R. (2004), ‘Anaphylaxis: Can we tell who is at risk of a fatal reaction?’, Current Opinion in Allergy and Clinical Immunology. On this page, you’ll find a selection of resources relating to anaphylaxis. Caregivers of a child who has suffered anaphylaxis must receive two Adrenaline autoinjectors along with education on use and an individualised action plan on discharge from ED. These Guidelines have been developed by the Western Australian Anaphylaxis Management Implementation Group (AMIG) to assist child Patients presenting with milder symptoms can rapidly deteriorate and should be closely monitored. one or more of the following respiratory features: one or more of the following cardiovascular features: pallor and floppiness (in young children), effective for all the symptoms and signs of anaphylaxis, associated with a decreased fatality rate if administered promptly, high flow supplemental oxygen via non-rebreather mask is recommended, children with circulatory compromise should be nursed lying down, elevate the lower extremities to conserve circulating volume, IV access with two large-bore (age-appropriate) cannula, or intraosseous access, is recommended for children with severe symptoms at risk of circulatory compromise, may help relieve bronchospasm if lower airway obstruction (wheeze) is a concern, should only be used as an adjunct to first-line treatment for anaphylaxis, not recommended in acute anaphylaxis as there is no evidence to support use, two-to-four-day-course taken orally is recommended to alleviate persistent symptoms after a severe allergic reaction, for access to paediatric critical care telephone advice, to coordinate the retrieval of a critically unwell child, Queensland Children’s Hospital experts via, local and regional paediatric videoconference support via Telehealth Emergency Management Support Unit, discuss with onsite/local paediatric service, contact RSQ on 1300 799 127 for aeromedical transfers, parents / carers should be educated on allergic reactions and instructed to return immediately if symptoms recur, Adrenaline autoinjectors must be prescribed (and if possible dispensed) to all children who have suffered any allergic reaction (mild, moderate or severe) secondary to nut exposure as subsequent exposures may lead to more severe reactions (including anaphylaxis) and are less predictable compared to other foods, resolution of respiratory and CVS symptoms, an observation period of four hours following administration of, two Adrenaline autoinjectors (AAI) or ampoules according to weight (see table below), education on how and when to administer the AAI or Adrenaline ampoules (refer to, general information regarding allergies and anaphylaxis management (see, the child and their caregiver/s should be encouraged to document the circumstances leading up to an episode of anaphylaxis (up to six to eight hours prior to symptoms), refer (via ED or GP) to Immunologist/Allergy specialist if available locally, otherwise refer to local Paediatrician, if allergen known to be food related, consider referral to local dietician, have persistent symptoms four hours after treatment, required more than two Adrenaline doses (due to possibility of recurrent symptoms). (2008), ‘Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock’. 1. ANZCOR guidelines and algorithms, including those released on 13 January 2016, are freely available on this web page.. ANZCOR is the Australian and New Zealand Committee on Resuscitation, of which the Australian Resuscitation Council and New Zealand Resuscitation Council are its members. (2008), ‘Paediatric anaphylaxis: a 5-year retrospective review. Anaphylaxis: Meeting the Challenge for Western Australian Children, which outlined recommendations for anaphylaxis management in school and child care settings, was endorsed by the Western Australian government in 2007. Davis, J. In the event of retrieval, inform your local paediatric service. It has been endorsed for use statewide by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland. Sodium Chloride 0.9% administered rapidly in 20 mL/kg bolus. This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Immunologists, Queensland Children’s Hospital, Brisbane. Do not allow children with anaphylaxis to stand or walk. The American Academy of Pediatrics (AAP) recommends a lateral thigh epinephrine injection of 0.01 mg per kg, but no more than 0.30 mg, for children with anaphylaxis. (2006), ‘Paediatric emergency department anaphylaxis: Different patterns from adults’. Anaphylaxis is potentially life-threatening and always requires an emergency response. These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. Seek urgent paediatric critical care advice (onsite or via Retrieval Services Queensland (RSQ)) for a child requiring more than two doses of, Seek senior emergency/paediatric advice as per local practices for a child with airway concerns following administration of. Clinical common-sense should be applied at all times. Many allergic reactions are mild, but some can be extremely severe. Anaphylaxis is the most severe form of an allergic reaction and is life threatening. Adrenaline autoinjectors must be prescribed (and if possible dispensed) to all children who have suffered any allergic reaction (mild, moderate or severe) secondary to nut exposure as subsequent exposures may lead to more severe reactions (including anaphylaxis) and are less predictable compared to other foods. They defined anaphylaxis as, “A serious allergic reaction that is rapid in onset and may cause death”. Children with less severe generalised allergic symptoms may initially appear stable but have the potential for rapid deterioration.9, Studies have demonstrated that peak plasma levels are achieved significantly faster after IM injection into the thigh compared with SC injection into the arm.11,12. Anaphylaxis is more common in children than adults. The Clinical Practice Guideline reflects what is currently regarded as a safe and appropriate approach to the management of acute gastroenteritis in infants and children. Once the patient is stabilised, the allergen trigger for the event should be identified (if possible). No randomised controlled trials (in adults or children) were identified in a Cochrane Systematic Review of glucocorticoids for the treatment of anaphylaxis.15 The primary action of glucocorticoids is down-regulation of the late-phase eosinophilic inflammatory response, as opposed to the early-phase response. (2010), ‘Glucosteroids for the treatment of anaphylaxis (review)’, Schleimer, R.P. Anaphylaxis is an acute systemic allergic reaction in response to an allergen or trigger. Mullins, R.J., Wainstein, B.K., Barnes, E.H., Liew, W.K., Campbell, D.E. Children suffering from anaphylaxis who have respiratory distress without circulatory instability should be initially nursed in a sitting up position. Most allergic reactions do not cause major problems, even though for many people they may be a source of extreme irritation and discomfort. Allergic diseases have approximately doubled in western countries over the last 25 years. 1 Case fatality rates were approximately 1:1000 for food anaphylaxis (commonest in children) and 1:100 for medicine and insect venom anaphylaxis (mostly in adults). This review aims to provide an overview of current policies and practices for anaphylaxis management in Australian schools, including approaches to risk mitigation and anaphylaxis … Chipps, B.E. This occurs as a result of direct mast cell stimulation in response to a trigger and requires the same treatment.3,5, Food allergies are the most common cause of anaphylaxis in children. Anaphylaxis and Generalised Allergic Reaction (GAR) Anti-Malarial Therapy - CHW Anticoagulant Therapy of Venous Thromboembolism (VTE) Incl Heparin Administration - SCH (2008). Signs and symptoms of allergic reactions Emergency departments tend to miss the diagnosis of anaphylaxis if the symptoms have resolved or if there is not a previous history of anaphylaxis.4, Non-immunologic anaphylaxis or ‘anaphylactoid’ reaction is an acute systemic reaction which is clinically identical to anaphylaxis. Simons, F.E.R., Roberts, J.R., Gu, X., et al. (2005), ‘Allergies and anaphylaxis: analysing the spectrum of clinical manifestations’. Consider discharge for children who meet the following criteria: Prior to discharge, consider other factors including the time of day, parents/carers comprehension and compliance, access to transport should return be required and distance to the local hospital. This may partly be due to failure to appreciate that anaphylaxis is a much broader syndrome than \"anaphylactic shock,\" and the goal of therapy should be early recognition and treatment with epinephrine to prevent progression to life-threatening respiratory and/or cardiovascular symptoms and signs, including shock. Although fatalities are rare, anaphylaxis must always be considered a medical emergency requiring immediate treatment. Anaphylaxis is a severe allergic reaction that occurs quickly and can be fatal. Anaphylaxis is uncommon but not rare, with new cases arising at rates of between 8.4 and 21 per 100 000 patient years. Recognise and address, if possible, risk factors for fatal anaphylaxis, including (2003), ‘Adrenaline in the treatment of anaphylaxis: What is the evidence?’. Collaboration among health care providers, patients and their families, school personnel and other community members can promote better care of children at risk for anaphylaxis. Anaphylaxis is variable and unpredictable. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula) AND at least 1 of the following: Anaphylaxis may also be accompanied by signs of general allergic reaction.1,3 Urticaria / skin symptoms may be transient or subtle. While the vast majority of children respond well to Adrenaline IM, airway swelling can occur rapidly. 6 Admission rates for anaphylaxis are increasing in Australia with food allergies affecting 4 – 8% of children less than five years of age. Given the potential for rapid deterioration administer Adrenaline IM immediately into the thigh if anaphylaxis is suspected. Contact the most senior resources available onsite (critical care/anaesthetic/ENT) prior to intubating a child with anaphylaxis. • ongoing airway, breathing or circulation involvement. What is Pediatric Anaphylaxis? Algorithms must be used as published, with no alterations. The prevalence of anaphylaxis in the paediatric population is estimated to be 1 in 1000. 285-290. 7 The algorithm has numbers which correspond to the competences outlined within the body of the document. Sheikh, A., Shehata, Y.A., Brown, S.G.A., et al. Anaphylaxis in Children INFORMAL COPY WHEN PRINTED Page 2 of 4 Public I4-A4 Purpose and Scope of PCPG The ‘Anaphylaxis in Children’ Paediatric Clinical Practice Guideline (PCPG) is primarily aimed at medical staff working in any of the primary care, local, regional, general or tertiary hospitals. Anaphylaxis is a rapidly evolving generalised multi-system allergic reaction to an allergen or trigger characterised by respiratory and/or cardiovascular features that can be fatal. This website was made to assist in clinical knowledge recall and to supplement and support clinician judgement. Thomson, H., Seith R., Craig, S. (2017) ‘Inaccurate diagnosis of paediatric anaphylaxis in three Australian Emergency Departments’. (2009). Short-term glucocorticoid treatment is seldom associated with adverse effects.16 The proposed rationale for corticosteroid administration is to prevent biphasic or protracted reactions.2 However, in two paediatric studies of biphasic reactions the administration of steroids did not appear to be preventative.2 Steroids are not recommended unless there is a component of asthma aggravation with the anaphylaxis which should be treated concurrently as per the Asthma Guideline. Although these images are curated, as they are sourced from the community, there is no way to guarantee a consistent standard of accuracy and quality across the library of images. Contributed by. Source: The Australian Society of Clinical Immunology and Allergy1. For information on the management of children at risk of anaphylaxis in … Allergens can enter the body via a number of different portals, including inhalation, ingestion, contact with skin and injection (parenteral medication or insect stings and bites). (2008), ‘Pharmacology of glucocorticoids in allergic disease’, in. It is estimated that one in every 100 school-age children have anaphylaxis. This group of experts also published a set of three clinical criteria for diagnosing anaphylaxis, as outlined in Table 2. It can occur within seconds or minutes of exposure to something the child is allergic to, such as a peanut or the venom from a bee sting. While corticosteroids are commonly recommended as second-line treatment internationally, little evidence supports their use in anaphylaxis. May also involve other systems such as the skin or gastrointestinal tract. This clinical report from the American Academy of Pediatrics is an update of the 2007 clinical report on this topic. The most senior resources available onsite at the time as per local practices. Anaphylaxis is a severe, generalized allergic or hypersensitivity reaction that is rapid in onset and may cause death. The algorithm has numbers which correspond to the competences outlined within the body of the document. Pediatric Anaphylaxis Algorithm #Anaphylaxis #Algorithm #Pediatrics #Peds #Allergy. Sheikh, A., ten Broek, V.M., Brown, S.G.A., et al. Nebulised Adrenaline may help relieve upper airway obstruction and/or bronchospasm but should only be administered in addition to Adrenaline IM.

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