Anaphylaxis Counselling #1

Introduction
Patient script
Additional notes

PATIENT INFORMATION

Julie has presented to the ED with her 3-year-old daughter, Mikaela, who has had her first anaphylactic reaction. This has been treated successfully, but Julie would like a further explanation of what happened and what anaphylaxis is.

CANDIDATE INSTRUCTIONS

You will have 9 minutes to perform the following:

Take a brief history from Julie based on Mikaela’s presenting complaint.
Counsel Julie on anaphylaxis and answer any questions she may have.

TASK – HISTORY (9 MINUTES)

Aboriginal/Torres StraitIslander

Opening statement

“I’d like to know what’s going on. Will Mikaela be alright?”

HOPC

Context/trigger: Ate some peanuts at a playmate’s house – witnessed by the friend’s dad
Symptoms: Told that she started having some difficulty breathing
- If asked to elaborate: Was also wheezing, and became very pale
Time course: Came on almost immediately
- Progression: They called the ambulance straight away – they came really quickly but it looked like she would’ve gotten worse
- Previous episodes: Nil
Relevant past medical history
- Allergies: Nil known
- History of atopy: Eczema as an infant – now outgrown; nil asthma/allergic rhinitis
- Family history: Dad allergic to peanuts and sesame

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Baseline understanding

Assess patient’s understanding:
- “It’s an allergic reaction, isn’t it? But how is it different from a normal allergic reaction?”
Give definition:
- Severe life-threatening allergic reaction that involves multiple body systems (e.g. circulation, breathing, skin)
- Not uncommon – 1 in 100 school-aged children

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Triggers

Food: e.g. egg, peanut, tree nut, cow’s milk, soywheat, fish, shellfish, sesame
Bites/stings: e.g. bee stings, insect bites
Medications: e.g. antibiotics, anaesthetics; latex

NB: Important to avoid anything containing the trigger(s)

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Symptoms and signs

As mentioned – multi-system reaction, so can present with:

CV: dizziness/collapse, palpitations, pale
Resp: SOB, wheeze, difficulty speaking/hoarse voice
GI: N/V, abdominal pain, diarrhoea
Skin: urticarial rash (red & lumpy)

The key is symptoms from ≥ 2 systems – but if worried or unsure, just call for help as you know your child best!

Management

Acute – Lie them down
Can allow to sit if difficulty breathing
Epipen (IM adrenaline 1:1000, 0.01mL/kg)
- Blue to the sky orange to the thigh
  - Lateral thigh (bigger muscle) – can go through one layer of clothing incl jeans, just don’t go through the seams
  - Push down and hold until you hear a click
  - Don’t put your thumb on top in case you’ve got it the wrong way!
- Wait 5 min – can give another if available
Call for help
- Even if you’ve given the Epipen and they look ‘fine’ – can have delayed reactionLong-term:
Anaphylaxis action plan (distribute to childcare/school etc.)
Avoid triggers

Resources

Online
Hard copy (e.g. give “pamphlet”)

Check understanding

Candidate should briefly summarise the above information and check Julie’s understanding.

QUESTIONS FOR THE CANDIDATE

These can be asked at any point during the OSCE, and can also be used to prompt the candidate further. e.g.

Will she ever outgrow this?
If she gets better after using the Epipen, do I still need to go to the hospital?
How do I use an Epipen?
Where and how do I store the Epipen?

Mark scheme

3 marks for addressing all of the above concerns
2 marks for addressing at least two, 1 mark for addressing 1, etc.

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Total:

NOTES

Information giving OSCEs:

A good way to structure an “information giving” OSCE is through the BUCES acronym. Remember that this information should be explained in laypeople’s terms (i.e. without unnecessary jargon).
- B – Brief history
  - Take a brief history of the presenting complaint. This should be concise, especially in an OSCE setting.
- U – Understanding
  - Assess the patient’s baseline understanding. For example: “What’s your understanding of what anaphylaxis is?’
- C – Concerns
  - Ask the patient about their concerns. This can help tailor your approach to providing information about their diagnosis.
- E – Explanation
  - Provide an explanation of what the disease is. A good approach to this is:
    - Explain normal anatomy/physiology
    - Explain the disease and what causes/triggers it
    - Explain common symptoms
    - Explain complications
      - Don’t forget to safety net, and highlight any red flags that should prompt the patient to seek medical attention
    - Explain management options – non-pharmacological (e.g. anaphylaxis management plan) and pharmacologicalS – SummariseEnsure the patient understands by summarising what you have told them, and supplementing this with additional resources for reference (e.g. pamphlets). Make sure all their questions have been answered!