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Case 3

Acute Anaphylaxis in Surgery

Summary

Video consultation following incidental genomic finding of MYH7 pathogenic variant associated with hypertrophic cardiomyopathy. Asymptomatic but anxious. Requests urgent clarification and referral. 

Past medical history

  • Severe Peanut Allergy
  • Mild Asthma

DH

  • Salbutamol inhaler PRN
  • Adrenaline auto-injector
Background

The patient lives with her partner. She works as a marketing executive. She has a history of severe peanut allergy diagnosed in childhood and has had one prior anaphylactic reaction requiring hospital admission. No safeguarding concerns are recorded.  

Examination findings

The patient was assessed immediately by Nurse Hannah Carter, Practice Nurse, who recorded BP 88/54 mmHg, pulse 124 regular, RR 28, SpO₂ 93% on air. Widespread urticaria was noted. Hoarse voice and difficulty swallowing were observed. 

Patient
Laura Mitchell
Age 30
Observations

BP

88/54 mmHg

BMI

23

Smoking

non-smoker

Alcohol

occasional

Allergies

Peanut (anaphylaxis)

Patient history

You are a 30-year-old woman who attended the surgery for a routine appointment and suddenly developed symptoms in the waiting room 10 minutes ago after eating a chocolate bar that may have contained nuts. You have a known severe peanut allergy and normally carry an adrenaline auto-injector, but you left it at home today. You now feel your throat tightening, difficulty swallowing, itching all over, and a widespread raised rash over your arms and chest. You feel lightheaded and slightly short of breath. No chest pain. No vomiting yet, but you feel nauseated. 

You are frightened and struggling to speak in full sentences. If asked directly, you confirm a known peanut allergy diagnosed in childhood. 

Impact on life & function

You are acutely unwell and unable to stand without support. You feel your symptoms worsening quickly. 

Ideas

You believe you are having another allergic reaction. 

Concerns

You are scared that your throat will close completely. 

Expectations

You expect immediate treatment. 

Red flag symptoms and occupational hazards

Rapid onset airway symptoms, urticaria, lightheadedness following allergen exposure. High suspicion of anaphylaxis. Safeguarding consideration as patient forgot to carry prescribed adrenaline auto-injector. No occupational hazards. 

Tick the indicators you would have demonstrated

Grading: Clear pass = 3 · Marginal pass = 2 · Marginal fail = 1 · Clear fail = 0 

Case Title: Anaphylaxis – Immediate Recognition and Safeguarding Discussion

Data-gathering, technical and assessment skills

Score: 0/3

  • Positive indicators
  • Rapidly recognises signs of airway compromise
  • Identifies likely allergen exposure appropriately
  • Performs an effective ABC assessment
  • Recognises hypotension and tachycardia as features of anaphylaxis
  • Differentiates anaphylaxis from a mild allergic reaction
  • Appropriately prioritises emergency management and escalation
  • Negative indicators
  • Fails to recognise anaphylaxis promptly
  • Delays administration of adrenaline
  • Performs an inadequate ABC assessment
  • Minimises the severity of the presentation
  • Demonstrates poor clinical prioritisation during emergency management
Clinical Management Skills

Score: 0/3

  • Positive indicators
  • Diagnoses anaphylaxis promptly and appropriately
  • Administers intramuscular adrenaline immediately
  • Calls an emergency ambulance without delay
  • Positions the patient appropriately and administers oxygen
  • Monitors vital signs continuously throughout management
  • Provides safeguarding and follow-up advice regarding carrying an adrenaline auto-injector and ongoing allergy management after stabilisation
  • Negative indicators
  • Delays administration of adrenaline
  • Fails to arrange emergency ambulance transfer
  • Treats the reaction with antihistamines alone
  • Provides inadequate monitoring during the acute episode
  • Fails to provide appropriate safety-netting or allergy management advice
Interpersonal skills

Score: 0/3

  • Positive indicators
  • Calm but decisive
  • Reassures patient while acting urgently
  • Provides clear communication with the team
  • Remains supportive after stabilisation
  • Negative indicators
  • Panic
  • Disorganised
  • Dismissive
  • Poor leadership
  • Inadequate reassurance
1
Acute anaphylaxis following allergen exposure
Relevance

Recognising life-threatening anaphylaxis with airway compromise and hypotension requiring immediate emergency treatment. 

Curriculum mapping

Care of Acutely Ill People; Allergy and Immunology. 

2
Emergency management in primary care setting
Relevance

Demonstrates prompt ABC assessment, intramuscular adrenaline administration and urgent ambulance escalation in primary care emergencies. 

Curriculum mapping

Emergency and Urgent Care; Clinical Management and Patient Safety. 

3
Long-term allergy safety and prevention
Relevance

Highlights patient education on carrying adrenaline auto-injectors and preventing future severe allergic reactions. 

Curriculum mapping

Health Promotion and Prevention; Person-Centred Care. 

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