St Emlyn’s Lesson Plans

Anaphylaxis: act early, reassess, plan discharge

Discuss the first few minutes of anaphylaxis treatment, then work through observation and discharge decisions.

Early-career Emergency Medicine · 45-minute session

For learners

Before: Allow about 17 minutes in total.

When we meet: We will discuss a worsening reaction and a patient who has recovered but wants to leave.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Algorithm on paper or screen, a clock, empty labelled training ampoule or photograph, and an auto-injector trainer if available. No patient-identifiable material is needed.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 17 minutes in total.

Core preparation

RCUK emergency treatment of anaphylactic reactions · About 15 minutes

Read the RCUK recognition and initial-treatment algorithm, then the observation table. Focus on when to repeat adrenaline, when to call for expert help and how observation is chosen.

https://www.resus.org.uk/library/additional-guidance/guidance-anaphylaxis/emergency-treatment-anaphylactic-reactions

Think about (allow 2 minutes): What might delay your first dose of adrenaline in a patient with evolving anaphylaxis?

Picture the scene

A 23-year-old arrives with severe wheeze and a new rash. The handover calls it asthma. What would make you change the working diagnosis?

By the end of the session

Recognise evolving airway, breathing or circulation problems as possible anaphylaxis, including when skin changes are absent.
Give a clear initial treatment plan and specify what will trigger repeat treatment and expert help.
Explain observation and discharge decisions using reaction severity, response and the person’s circumstances.

After the session

Check where your department keeps auto-injector trainers and how a patient actually obtains replacement devices before leaving.

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 17 minutes in total.

Before learners arrive

Check the local adrenaline presentation, refractory response team and allergy-referral route. Have the current RCUK algorithm available, including its observation table.
Spend ten minutes rehearsing the two cases and decide which decisions your group can reasonably make independently. Invite an anonymised learner case as a substitute if it tests the same decisions.

Equipment: Algorithm on paper or screen, a clock, empty labelled training ampoule or photograph, and an auto-injector trainer if available. No patient-identifiable material is needed.

Setup: Use clinician, nurse and observer roles for the first case. The observer records treatment priorities and reassessment. Rotate the roles for the discharge discussion.

If the preparation has not been completed

Replace the five-minute opening with shared preparation: give pairs three minutes with the RCUK initial-treatment algorithm, then two minutes to identify an action that cannot wait and who will reassess it. Keep the algorithm open during the cases. In the 30-minute plan, use five minutes here and reduce the first case from 12 to 10 minutes.

Suggested session plan

0–5 min — Wheeze and rash. Read only the hook. Allow thirty seconds of silent thinking, then ask what is dangerous about accepting the asthma label.
5–20 min — First five minutes and refractory escalation. Reveal each stage only after a plan is stated. Spend most time on adrenaline, reassessment and role allocation.
20–32 min — Observation and discharge. Ask pairs to propose a discharge plan, then compare it with the observation table.
32–40 min — Rehearse explanation and device use. One learner explains the plan to another acting as the patient. Invite specific feedback on clarity and feasibility.
40–45 min — What would you change on shift? Each person names one action they can reliably improve on their next shift.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

Wheeze, rash and falling blood pressure

A 23-year-old develops wheeze, widespread urticaria and light-headedness soon after eating. They can speak only short phrases; BP is 82/48. A colleague is preparing nebulised salbutamol.

Add this information as the discussion develops:

Ask the group for their first three spoken instructions before giving further information.
Five minutes after the first IM adrenaline dose, wheeze and hypotension persist. Ask who is reassessing, who is recording time and who is calling for additional help.
After a second appropriate dose, circulation remains poor. Pause the scenario and identify the refractory pathway and specialist responsibilities.

Ask the group:

Which features distinguish this from isolated urticaria or an asthma exacerbation?
What exactly would you ask the nurse to prepare: drug, dose, concentration, route and site?
How would you position this patient and avoid a dangerous attempt to stand or walk?
Which proposed treatments address the immediately life-threatening problem, and which would distract from it?

Discussion notes

Points to draw out:

RCUK recommends adult IM adrenaline 500 micrograms using 1 mg/mL solution into the anterolateral thigh; repeat after five minutes if airway, breathing or circulation problems persist. Call for help and reassess ABCDE while oxygen, monitoring, access and appropriate IV fluids are organised.
Persistent compromise after two appropriate IM doses requires urgent experienced support and the refractory algorithm. IV adrenaline in a patient with circulation is specialist treatment; do not turn this into an unsupervised bolus-dosing exercise.
Antihistamines do not treat airway/breathing/circulation compromise; corticosteroids are not routine emergency anaphylaxis treatment. The facilitator should ask who remains responsible for reassessment while tasks are delegated.

Common misconceptions:

Waiting for a rash or hypotension before treating a rapidly worsening airway problem.
Giving several adjuncts while nobody records the time of adrenaline or assesses response.

For a more experienced group: Remove the rash and add a recent antibiotic infusion. Ask the group to explain why the diagnostic label changes less than the immediate priorities.

Well now, keen to leave

A 47-year-old has recovered after ambulance adrenaline. Their own auto-injector was unusable; they live alone and the last bus is about to leave.

Add this information as the discussion develops:

Ask learners to identify missing information before choosing an observation duration.
Reveal that two doses were needed and symptoms resolved only recently. Ask the group to revisit its first proposal.

Ask the group:

When does the observation clock start?
What must be physically available, understood and arranged before discharge?
How would you explain residual uncertainty without frightening the patient into unnecessary admission?

Discussion notes

Points to draw out:

Use the current risk-stratified observation table after symptom resolution; a universal six-hour rule is inadequate. Assess severity, treatment response, continued exposure, comorbidity and access to help.
Arrange auto-injectors and device-specific practice, written emergency advice and allergy follow-up. Ask the patient to demonstrate what they would do, rather than simply asking whether they understand.

Common misconceptions:

Counting travel and waiting time as recovery observation.
Writing a prescription without checking whether usable devices will actually be available.

For a more experienced group: Add childcare responsibilities and explore a workable shared plan without allowing social pressure to override clinical concerns.

Important clinical points

Use current RCUK drug concentrations and route; cardiac-arrest adrenaline instructions are a different pathway.
Do not delay treatment to obtain tryptase or other tests.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

What would make you treat before the diagnosis was certain?
How do you recognise an inadequate response?
Which three practical defects could make an apparently sensible discharge unsafe?

Key teaching points:

Treat airway, breathing or circulation compromise promptly with IM adrenaline.
Record the time of treatment and reassess the response so repeat doses and escalation are not delayed.
Before discharge, check that observation, usable auto-injectors, advice and follow-up are all in place.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

Diagnosis and discharge decisions involve judgement. Use the current guidance with senior input when response, exposure or social circumstances are unclear. A rash alone does not establish anaphylaxis.

If the discussion drifts

What would you do in the next sixty seconds, who will do it, and how will you know whether it worked?

For a more experienced group

Explore refractory deterioration as a team-leadership exercise with a critical-care colleague. Keep infusion preparation within local specialist policy.

A 30-minute version

30-minute option: opening 3, first case 12, discharge case 10, explanation and closing 5. Omit the rash-free extension and lengthy discussion of mechanisms.

Evidence and guidance

RCUK emergency treatment of anaphylactic reactions — May 2021 guidance on recognition, initial treatment, refractory reactions and observation; included in the RCUK 2025 guideline resources.https://www.resus.org.uk/library/additional-guidance/guidance-anaphylaxis/emergency-treatment-anaphylactic-reactions