Anaphylaxis prevention, action plans and autoinjectors — formative SAQs

SAQ 1 (10 marks)

A 6-year-old girl weighing 19 kg was reviewed in the emergency department after an anaphylactic reaction to peanut at a friend's house. She had lip swelling, wheeze and pallor, and recovered after one dose of intramuscular adrenaline from her friend's sibling's EpiPen Jr. She has never had an adrenaline autoinjector prescribed for herself, has asthma treated with a salbutamol inhaler only, and attends before-and-after-school care. Her parents ask what she needs to stay safe. [1]

Question: Outline the prevention prescription you would provide at discharge, including the written documents, the device and dose, the education, the school and care setting plan, and the follow-up. (10 marks) [10]

Model answer

The two written plans (2 marks). The child is issued both the green ASCIA Allergic Reaction Plan (for any future mild-to-moderate skin reaction, where the carer gives an antihistamine and watches for escalation) and the red ASCIA Anaphylaxis Action Plan (which triggers adrenaline the moment airway, breathing or circulatory involvement, or a multi-system reaction, is recognised). The plans are dated, carry her photo, and are distributed to every carer — parents, the school, and the before-and-after-school care. The colour-coded plan removes diagnostic deliberation at the moment of crisis: the carer reads the colour, they do not diagnose. [10]

The device and the dose (2 marks). At 19 kg she is within the 7.5 to 20 kg band, so she is prescribed the 0.15 mg adrenaline autoinjector (EpiPen Jr or Anapen 150), given intramuscularly into the outer middle third of the thigh and held for three seconds. Best practice is to prescribe two devices — one for home and one for school or care — and a trainer device for rehearsal. The family is taught that the dose is repeated after five minutes if there is no response, which is why the second device and the ambulance are essential. The critical counselling point is that the moment she reaches 20 kg the device must be up-titrated to the 0.3 mg device, and her weight is checked at every review. [10]

Education and technique (2 marks). Every carer is taught to recognise the anaphylaxis features (throat tightness, wheeze, collapse, pallor, a rapid multi-system reaction) and to demonstrate correct device technique on the trainer device — cap off, orange end to the outer mid-thigh, push and hold three seconds, can go through clothing. The child is taught at an age-appropriate level. Technique is rehearsed because it decays, and the family is told the device expires (around twelve to eighteen months) and must be replaced before the expiry date. [9]

The school and care plan (2 marks). The school and the before-and-after-school care each receive a copy of the red plan and a device, a named staff member is confirmed as trained, storage is agreed to be accessible rather than locked away, and the response is rehearsed. Label-reading and cross-contamination advice for peanut is given, and the school's peanut management approach is confirmed. Trigger avoidance is the daily layer that makes the device a backup rather than a first resort. [10]

Asthma and follow-up (2 marks). Her asthma is formally optimised — she moves onto a preventer and an asthma action plan, because uncontrolled asthma multiplies anaphylaxis fatality risk and an allergic wheeze treated as asthma delays adrenaline. A referral to the allergy service is made for component testing (Ara h 2) and a review of whether oral food challenge or immunotherapy is appropriate. Follow-up is set at a minimum of annually, at every reaction, and at every weight-band transition. She is sent home only after a period of observation for the biphasic window. [11] [12]

SAQ 2 (10 marks)

A 15-year-old boy with confirmed peanut anaphylaxis presents for review. He has used his adrenaline autoinjector three times in two years, each after accidental exposure at social events. He has asthma that has been poorly controlled on salbutamol alone. He admits he usually leaves his device at home when he goes out with friends, and he drinks alcohol at parties. He is due to move to an adult service in two years. [11]

Question: Discuss his fatal-anaphylaxis risk factors, and outline a prevention plan that addresses them, including asthma management, the device-carrying problem, adolescent-specific counselling, and transition. (10 marks) [11]

Model answer

Risk stratification (3 marks). He sits squarely in the classic fatal-anaphylaxis triad: adolescence, peanut allergy, and uncontrolled asthma — the three recurring risk factors identified in Turner and colleagues' synthesis of fatal-anaphylaxis mortality data. He carries additional modifiable risks: non-carrying of the device, a history of repeated reactions (a marker of recurrent exposure), alcohol use (which impairs recognition and judgement of a reaction), and an unstructured eating pattern at social events. The single most important teaching point is that the preventable cause of his death would be system failure, not biology — an absent or unused device at the moment of a reaction. [11]

Asthma optimisation (2 marks). His asthma is escalated to a preventer-based regimen with a written asthma action plan, and his control is formally reviewed, because uncontrolled asthma multiplies anaphylaxis fatality risk and because treating an allergic wheeze as asthma delays adrenaline. The crossover scenario is rehearsed: a wheeze after an allergen is treated with adrenaline first, salbutamol as adjunct. This is the intervention that most directly lowers his immediate fatal risk. [11]

The device-carrying problem (2 marks). The plan is rebuilt around his behaviour. He is prescribed a device that travels with him — compact, kept in a place he always carries (a pocket, a bag, a phone-case accessory), and a second device is kept at home or school as backup. The plan confronts the non-carrying behaviour directly and without stigma: the conversation is practical, not punitive, and frames the device as autonomy and freedom (he can go out safely) rather than restriction. He is taught to use it himself and to teach a friend. [4]

Adolescent-specific counselling (2 marks). He is counselled on alcohol (it impairs recognition and judgement of a reaction), eating out (choosing safe foods, carrying the device to restaurants, telling friends), and risk-taking — in a mental-health-aware way that addresses the behaviour rather than lecturing it. He is given increasing autonomy over the action plan and the device. The aim is a young person who carries the device, uses it, and tells someone — not a compliant child who relies on a parent who is no longer present. [11]

Transition (1 mark). A structured handover to an adult allergy service is planned before he leaves paediatric care, with his devices, plan, asthma control, and reaction history transferred, and an explicit appointment made with the adult service rather than an open referral. The two years before transition are used to build the self-management skills that will keep him safe in independent life. [4]