Clinical Commander

All dossiers
allergy.anaphylaxis.v1

Anaphylaxis (acute resuscitation)

allergyacuteadultpediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is the canonical pilot — full 21/21 audit pass. Atoms split into assessment + treatment. Calculator gap: no anaphylaxis-specific severity score in registry (Sampson / Brown grade). Manifest references calc_news2 + calc_pulse_pressure as bedside surrogates; not yet wired through `calc.*` registry IDs. Sibling-engine gap: hereditary angioedema (HAE) and ACE-I-mediated angioedema have no dedicated dossiers yet — currently captured only as differential nodes. PMIDs corrected 2026-05-12 (B.5 ID/CC lane) — prior list (ProMISe 25776532 / POINT 29766750 / REDUCE 23900119) were copy-paste residue from scaffolding and matched none of the named guidelines. Replaced with WebSearch-verified anaphylaxis landmarks: Shaker JACI 2020 JTF Practice Parameter (32001253), Cardona WAO J 2020 (33204386). Additional landmarks (GA²LEN 2024 / Sampson 2006 / Brown 2004 / Simons 2001) routed to C.2 Provenance for downstream verification. No dedicated test file for anaphylaxis regimen — relies on shared regimen-builder safety harness. Per-setting playbooks added (ED + inpatient) covering immediate epinephrine cascade, biphasic observation, and discharge bundle; severity_triggers cover refractory/airway/biphasic/β-blocker/pregnancy/arrest phenotypes; action_plan green-yellow-red personalises trigger and epi-pen instructions.

Entry points (5)

  • symptom
    Urticaria + angioedema after exposure (Sampson 2006 NIAID criteria)
    urticaria_angioedema
  • symptom
    Stridor / throat tightness (WAO 2020 airway criterion)
    stridor_throat_tightness
  • symptom
    Acute dyspnea / wheeze (EAACI 2014 respiratory criterion)
    dyspnea_wheeze
  • vital_abnormality
    Hypotension after trigger exposure (Sampson 2006 circulatory criterion)
    hypotension_post_exposure
  • symptom
    Syncope after sting / drug / food (AAAAI/ACAAI 2020)
    syncope_post_sting

Required inputs (13)

  • sbprequired
    vital • used at RED_FLAGS
    Distributive shock; SBP <90 (adult) or age-adjusted threshold defines circulatory criterion (Sampson 2006 NIAID)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia + relative bradycardia (paradoxical) on epinephrine (WAO 2020)
  • spo2required
    vital • used at RED_FLAGS
    SpO2 <92% triggers high-flow O2 + early airway escalation (NICE 2020)
  • rrrequired
    vital • used at CONTEXT
    Tachypnea + accessory muscle use signals severe bronchospasm / impending failure (EAACI 2014)
  • trigger_exposurerequired
    symptom • used at ENTRY
    Food / drug / venom / latex exposure window anchors phenotype + duration of monitoring (WAO 2020)
  • symptom_onset_timingrequired
    symptom • used at CONTEXT
    Minutes-to-hours onset; alpha-gal delayed 3-6h; biphasic 1-72h (AAAAI/ACAAI 2020)
  • asthmarequired
    history • used at CONTEXT
    Asthma is single largest risk factor for fatal anaphylaxis (Pumphrey 2000)
  • beta_blockerrequired
    medication • used at CONTEXT
    Beta-blockade attenuates epinephrine response; glucagon adjunct indicated (AAAAI/ACAAI 2020)
  • ace_inhibitor
    medication • used at CONTEXT
    ACEi predisposes to refractory hypotension + bradykinin angioedema mimic (WAO 2020)
  • pregnancy_status
    demographic • used at CONTEXT
    Left lateral tilt; epinephrine still first-line; obstetric escalation (Simons JACI 2011)
  • weight
    demographic • used at TREATMENT
    Pediatric weight-based dosing (epi 0.01 mg/kg IM, NS 20 mL/kg) per AAAAI/ACAAI 2020
  • serum_tryptase
    lab • used at INITIAL_WORKUP
    Peak 1-2h post onset confirms mast-cell activation; baseline >11.4 ng/mL prompts mastocytosis workup (NICE 2020)
  • lactate
    lab • used at INITIAL_WORKUP
    Rules in distributive shock + sepsis mimic; trend on resuscitation (WAO 2020)

12-phase flow (11)

  1. 1FRAME
    Confirm acute multisystem hypersensitivity scope; exclude isolated urticaria, vasovagal, panic, ACE-i angioedema (Sampson 2006 NIAID criteria)
    inputs: symptom_onset_timing
    advance: multisystem involvement OR known trigger + airway/circulatory compromise (WAO 2020)
  2. 2ENTRY
    Recognise GA²LEN 2024 / Resus Council UK 3-criteria pattern (sudden onset + life-threatening A/B/C + skin/mucosal)
    inputs: trigger_exposure
    advance: one entry trigger present and patient on monitor (EAACI 2014)
  3. 3CONTEXT
    Capture vitals, asthma status, beta-blocker / ACEi exposure, prior reactions, pregnancy (AAAAI/ACAAI 2020)
    inputs: hr, rr, asthma, beta_blocker, ace_inhibitor, pregnancy_status
    advance: risk modifiers documented (WAO 2020)
  4. 4RED_FLAGS
    Airway swelling, stridor, severe bronchospasm, hypotension, hypoxia, LOC, no response to 2 IM epi → refractory phenotype (AAAAI/ACAAI 2020)
    inputs: sbp, spo2
    actions: calc.qsofa
    advance: red flags addressed; refractory cases routed to ICU (WAO 2020)
  5. 5INITIAL_WORKUP
    Acute tryptase 1-2h, ECG (ischemia from Kounis), CXR if persistent dyspnea, lactate (NICE 2020)
    inputs: serum_tryptase, lactate
    actions: panel.inflammation
    advance: tryptase drawn within 2h window; ECG reviewed (NICE 2020)
  6. 6DIFFERENTIAL
    Distinguish anaphylaxis from severe asthma, septic shock, ACS, vasovagal, scombroid, HAE, ACEi-AE, mastocytosis flare (WAO 2020)
    advance: mimics excluded or co-managed (WAO 2020)
  7. 7RISK_STRATIFICATION
    Severity grade (Sampson 2006 / Brown 2004), trigger class, response-to-epinephrine; flag biphasic risk factors
    inputs: sbp, spo2
    advance: severity + phenotype assigned (AAAAI/ACAAI 2020)
  8. 8TREATMENT
    IM epinephrine first-line (0.3-0.5 mg adult / 0.01 mg/kg ped) → repeat q5-15 min; remove trigger; high-flow O2; supine + leg-raise; IV NS bolus 1-2 L (20 mL/kg ped); H1/H2 + steroids adjunct only (Simons JACI 2011; AAAAI/ACAAI 2020)
    inputs: sbp, hr, weight
    advance: epinephrine given within 5 min of recognition; airway secured if indicated (WAO 2020)
  9. 9DISPOSITION
    Mild observed 4-6h; severe / 2 doses epi / biphasic risk → ≥12h obs; refractory → ICU; pediatric admit threshold lower (NICE 2020)
    inputs: sbp
    advance: observation period complete and stable (AAAAI/ACAAI 2020)
  10. 10MONITORING
    Continuous telemetry, q15min vitals during epi infusion; tryptase follow-up baseline at 24h-2 weeks if elevated acutely (NICE 2020)
    inputs: hr, sbp, spo2
    advance: no recurrence within observation period (WAO 2020)
  11. 11FOLLOWUP
    2x epi auto-injectors + written action plan + allergist referral 4-6 weeks; medical-alert bracelet; venom immunotherapy referral if hymenoptera (AAAAI/ACAAI 2020; EAACI 2014)
    advance: auto-injectors prescribed, action plan signed, allergist referral placed (NICE 2020)