Anaphylaxis Management: Clinical Chess, Not a Checklist

The Problem

Anaphylaxis is often approached as a checklist, recognise the reaction, give intramuscular adrenaline, and call for help.

These actions are essential. However, they do not reflect the reality of managing anaphylaxis in practice.

Anaphylaxis management is more like a game of clinical chess than a checklist.

The opponent is anaphylaxis itself, with each change in the patient’s condition representing a move that must be recognised and interpreted. These changes need to be understood in terms of the foundations of anaphylaxis as well as the underlying pathophysiology.

A Different Way to Think About It

Management is not a single action, but a sequence of decisions made as the clinical situation evolves.

The Starting Point

Recognising anaphylaxis is not as simple as identifying a “classic case.”

ASCIA defines anaphylaxis as:

Anaphylaxis is a potentially life threatening systemic allergic reaction which is usually rapid in onset and can present with:

• typical skin (urticarial rash or erythema/flushing, and/or angioedema), plus involvement of respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms;

or

• Any acute onset of hypotension or respiratory impairment (bronchospasm, upper airway obstruction) where anaphylaxis is considered possible, even if typical skin features are not present.”

In this “clinical game of chess,” anaphylaxis has many and varied presentations as described in the definition. These are the opening moves. If you do not recognise the opening move, you are already behind the game.
 

The Foundations

To recognise and manage anaphylaxis effectively, we need an underlying level of knowledge.

This includes an understanding of the foundations of anaphylaxis as well as the underlying pathophysiology, and how this gives rise to the clinical features seen in practice.

The foundational knowledge includes:

1. Understanding what anaphylaxis is
2. The triggers of anaphylaxis
3. How it is mediated via the mediators of inflammation
4. Summation anaphylaxis
5. The importance of co-morbidities

This knowledge allows us to understand the “how and why” of anaphylaxis.

The pathological processes involved include:

1. Increased capillary permeability
2. Arteriole vasodilatation
3. Smooth muscle contraction
4. Increased mucosal secretion

An understanding of how these processes manifest in the clinical scenario, both initially and as it progresses, is required.

The ASCIA Acute Management of Anaphylaxis Guidelines for Health Professionals assume a lot of this underlying knowledge, as all peak body guidelines naturally do.

The ASCIA guideline document is substantial at 11 pages and provides the definition and clinical diagnostic criteria, outlines the signs and symptoms of allergic reactions, and elaborates on the 7 steps of management.

In this way, the ASCIA guidelines and the underlying clinical knowledge form the “rules” of the game and assist healthcare professionals to interpret and respond to each move as it occurs.

A Spectrum of Presentation

At one end of the spectrum, anaphylaxis may present with a rash, tightness in the throat, and resolve with a single dose of intramuscular adrenaline.

At the other end, it may progress to overwhelming anaphylaxis, with cardiac arrest occurring within minutes and requiring complex resuscitation.

Most patients fall somewhere between these two extremes.

This is the middle ground of anaphylaxis, where ongoing assessment, interpretation and management is required.

The ASCIA guidelines provide us with the roadmap of the 7 steps.

However, it is always up to us as healthcare professionals to apply clinical judgement.

This is where many healthcare professionals can become overwhelmed as the situation begins to spiral away from them.

The 7 Steps

The 7 steps of anaphylaxis management are outlined in the Australian Prescriber “Anaphylaxis: emergency management for health professionals” wall chart:

This wall chart is endorsed by ASCIA, the Australasian College for Emergency Medicine, the Royal Australasian College of Physicians, and other peak bodies.

The 7 steps are:

1. Immediate Action
2. Intramuscular Adrenaline
3. Call for Help
4. Supportive Management
5. Additional Measures
6. Observation
7. Follow-up Care

These steps provide the structure for management.

Some are immediate and non-negotiable. Others require clinical judgement and adaptation based on the patient’s presentation and response.

What are the 5 possible clinical pathways for a patient with anaphylaxis?

Within this clinical space, patients may progress along one of several clinical pathways, and these pathways may be crossed as the situation evolves.

The five clinical pathways are:

1. Self-limiting anaphylaxis
2. Simple anaphylaxis
3. Refractory anaphylaxis
4. Overwhelming anaphylaxis
5. Biphasic anaphylaxis

I have explored these pathways in more detail in my article, “What are the 5 possible clinical pathways for a patient with anaphylaxis?”

Who Wins the Game of Clinical Chess?

From the above, it becomes clear that anaphylaxis has earned its name as the quintessential medical emergency (Professor Anthony Brown, Professor of Emergency Medicine, Queensland University).

The challenge for us as healthcare professionals is that we may be called to play a game of clinical chess with anaphylaxis at any time.

It may occur infrequently, but this does not mean never.

As with every other emergency we need to be prepared.

The preparation we undertake today may very well determine who wins the match

How well do I know the rules of the game?

This is not a rhetorical question.

It has significant clinical, accreditation and medicolegal implications.

The required answer is:

“Well.”

Clinical, Accreditation and Medicolegal Context

The Australian Commission on Safety and Quality in Health Care (ACSQHC), through the Acute Anaphylaxis Clinical Care Standard (AACCS), expects all healthcare professionals who may need to treat a patient with anaphylaxis to be fully conversant with the ASCIA guidelines and the AACCS.

It also expects health service organisations that care for patients with anaphylaxis to ensure that appropriate systems, clinical pathways, and clinician competence are in place.

This standard states on p4 that applies across:

• Hospitals (public and private, subacute facilities, day procedure services and outpatient clinics)
• Emergency and ambulance services
• Radiology and imaging services
• General practice
• Community pharmacies and other primary healthcare settings, including Aboriginal Controlled Health Services

In the glossary the AACCS adds in

• Patient's homes
• Community settings and 
• Clinicians' rooms (which includes specialist consulting rooms)

And to all clinicians involved in patient care, including:

• Nurses and midwives
• Medical practitioners
• Allied health practitioners
• Paramedics
• Community and hospital pharmacists
• Students providing healthcare under supervision

In the glossary the AACCS adds in 

• employees
• contractors
• credentialed healthcare providers and 
• other professionals involved in healthcare delivery

Where to Next

For those looking to understand how to manage anaphylaxis effectively, click here to enroll and learn more about my Anaphylaxis Management Courses. These online, guideline-based courses provide in-depth training from first principles, practical strategies and real case studies to better equip you with the knowledge needed to respond to the many clinical challenges that anaphylaxis presents.

There are multiple courses available, each one tailored to a specific healthcare professional cohort.

Dr Sue Flanagan

28th May 2026