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Managing Anaphylaxis in the Emergency Department Contents

“last update: 28 Oct 2024” Download Guideline

– Executive Summary

This guideline is the key for the initial management of anaphylaxis (a life-threatening condition compromising the airway, breathing, and/or circulation) in the emergency department (ED), to be used by emergency physicians and any physician who works in the ED, whatever the specialty. It has been made in a simple concise way to go through in a quick stepping manner giving the clues to most critical points of such a critical condition in the ED.

The guideline was developed through adoption and adaptation methodology by a consensus of expert field group, Guideline Development Group (GDG) of the Egyptian National Clinical Guidelines Centre, supporting the 2021 update of the Resuscitation Council United Kingdom (RCUK). Because of lacking randomized clinical trials, the certainty of evidence for these recommendations was moderate or less.

We recommend	Strength
1- giving adrenaline as the first line of treatment	Strong
2- early administration of adrenaline once symptoms of anaphylaxis are recognized or suspected	Weak
3- giving adrenaline by intramuscular route as the initial treatment of anaphylaxis	Strong
4- following the list of adrenaline doses according to age	Strong
5- repeating intramuscular adrenaline every 5-15 min in cases of refractory anaphylaxis	Weak
6- iv bolus of crystalloid in case of hemodynamic instability and in refractory anaphylaxis	Weak
7- against using antihistamines as initial treatment of anaphylaxis	Weak
8- against using corticosteroids in initial treatment of anaphylaxis	Weak
9 – giving inhalational beta2 agonist as part of treatment in the presence of wheezy chest	Weak
10- a minimum of 6 hours of observation after resolution of symptoms for all patients with a confirmed diagnosis.	Weak

CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF MILD HEAD INJURY (MHI) IN ADULTS

“last update: 4 Jan 2026” Download Guideline

– Executive Summary

These recommendations promote selective CT imaging and safe disposition in adult mild head injury, and standardizing care with clear admission/discharge criteria.

No.	Recommendations	Strength of recommendation
1.	We recommend the Canadian CT Head Rule (CCHR) to guide CT use in adults with mild head injury not on anticoagulants or antiplatelets, to minimize unnecessary imaging. If CT imaging is not available, refer to an appropriate facility. CT is indicated if any of the following are present: · Failure to reach a GCS score of 15 within 2 hours of injury. · Suspected open skull fracture. · Signs of basal skull fracture. · Vomiting more than once. · Age > 64 years. The Canadian CT Head Rule (CCHR) is not applicable to patients younger than 16 years, those receiving anticoagulant therapy (blood thinners), or patients who experience a post-traumatic seizure.	Strong
2.	We recommend performing a non-contrast head CT in patients over 60 years old who are present with loss of consciousness or post traumatic amnesia. If CT imaging is not available, refer to an appropriate facility.	Strong
3.	We recommend performing a non-contrast head CT in intoxicated patients with mild head trauma who present with loss of consciousness or posttraumatic amnesia. If CT imaging is not available, refer to an appropriate facility.	Strong
4.	We recommend performing a non-contrast head CT in anticoagulated patients with mild head injury, rather than relying solely on clinical decision tools to exclude imaging. If CT imaging is not available, refer to an appropriate facility.	Strong
5.	We advise against routine repeating a non-contrast head CT in adults with mild head injury on anticoagulants or antiplatelets who remain at baseline neurologic assessment, if the initial CT is negative for hemorrhage.	Conditional
6.	We recommend admitting patients with mild head injury to hospital if clinical assessment identifies any risk factors or concerning features that warrant close observation or further management. Admission is advised when one or more of the established admission criteria for mild head injury are present: · New, clinically important abnormalities on imaging (An isolated simple linear non-displaced skull fracture is unlikely to be clinically important unless the patient is taking anticoagulant or antiplatelet medication.) · GCS score did not return to 15 (or pre-injury baseline) after imaging, regardless of the imaging results. · Indications for CT scanning are present, but scanning cannot be performed within the appropriate time period, either because CT is unavailable or because the person is not sufficiently cooperative to allow scanning. · Continuing worrying symptoms of concern to the clinician, such as persistent vomiting, severe headaches, or seizures. · Other sources of clinician concern, including but not limited to drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak, or suspicion of ongoing post-traumatic amnesia.	Good Practice Statement
7.	We recommend discharging patients with mild head injury when clinical assessment and investigations identify no evidence of clinically important brain or cervical spine injury, provided that: · CT scan of the head and/or cervical spine is not indicated or has shown normal findings, and the Glasgow Coma Scale (GCS) has returned to 15 or the pre-injury baseline. · There are no other factors that would warrant hospital admission. (refer to recommendation number 6) · There is appropriate supervision at home or a suitable environment for continued observation in the community.	Good Practice Statement
8.	We advise against routine hospital admission in anticoagulated or antiplatelet-treated patients with mild head injury who have a normal neurological exam, a normal initial CT, and lack criteria warranting extended monitoring. The criteria warranting extended monitoring and hospital admission are the same as those for patients who are not taking anticoagulant or antiplatelet therapy.	Conditional
9.	We recommend providing written discharge instructions outlining red-flag symptoms and follow-up guidance to adults with mild head injury to improve early recognition of complications. A. Discharge instructions should include advice to: · Avoid activities that may increase the risk of recurrent head injury. · Maintain social contact and communicate with family or friends about recovery symptoms. · Use only medications approved by the treating physician for symptom control. · Limit screen time and exposure to loud noise before sleep, keep a consistent sleep schedule, and rest in a quiet, dark environment. B. Inform a trusted person about the injury and the warning signs to monitor for, as they may recognize symptoms before the patient does. C. Arrange a follow-up visit within 48 hours of discharge. On discharge you should inform the patient and his/her companion about red-flag symptoms: · A headache that gets worse and does not go away. · Significant nausea or repeated vomiting. · Unusual behavior, increased confusion, restlessness, or agitation. · Drowsiness or inability to wake up · Slurred speech, weakness, numbness, or decreased coordination. · Convulsions or seizures (shaking or twitching). · Loss of consciousness (passing out)

THE MANAGEMENT OF MASSIVE BLEEDING IN POLYTRAUMA PATIENTS

“last update: 9 Feb 2026” Download Guideline

– Executive Summary

This guideline provides standardized, evidence‑based recommendations for the recognition and management of massive bleeding in trauma patients.

Key Principles

Early Recognition & Immediate Control: Rapid identification of haemorrhage and prompt surgical or interventional bleeding control is essential.
Damage Control Resuscitation (DCR): Adopted globally over the past decade, DCR emphasizes:
- Permissive hypotension until bleeding is controlled.
- Balanced blood‑product transfusion (plasma, platelets, red cells).
- Restricted crystalloid use to avoid dilutional coagulopathy.
- Early correction of coagulopathy.
Multidisciplinary Approach: Integration of emergency medicine, surgery, anaesthesia, and intensive care teams to deliver coordinated haemostatic resuscitation tailored to patient physiology.

1. Minimize Time to Bleeding Control

We recommend that the time between injury and bleeding control be minimized. (Strong recommendation)

2. Local Compression of Open Wounds

We recommend local compression of open wounds to limit life-threatening bleeding. (Strong recommendation)

3. Tourniquet Use for Extremity Injuries

We recommend adjunct tourniquet use to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting. (Strong recommendation)

4. Follow the C-ABCDE Approach

We recommend Following the C-ABCDE approach in the management of polytraumatized patients with massive bleeding. (Strong recommendation)

5. Clinical Assessment of Traumatic Haemorrhage

We recommend that the physician should clinically assess the extent of traumatic hemorrhage using a combination of patient vital signs, anatomical injury pattern, mechanism of injury and the patient response to initial resuscitation. (Strong recommendation)

6. Use of Shock Index (SI) and narrowed pulse pressure (PP)

We recommend that the Shock Index (SI) and/or Pulse Pressure (PP) be used to assess the degree of hypovolemic shock and transfusion requirements. (Strong recommendation)

7. Immediate Bleeding Control

We recommend that patients with an obvious bleeding source and those presenting with haemorrhagic shock in extremities and a suspected source of bleeding undergo an immediate bleeding control procedure, if not available transfer patient to the nearest appropriate facility after stabilization. (Strong recommendation)

8. Investigation of Unidentified Bleeding Source

We recommend that patients with an unidentified source of bleeding should undergo immediate further investigation to determine the bleeding source.
(Strong recommendation)

9. Use of Point-of-Care Ultrasonography (POCUS)

We suggest the use of point-of-care ultrasonography (POCUS), including eFAST, in patients with thoracoabdominal injuries if feasible (Conditional recommendation)

10. Early Whole-Body CT (WBCT)

We suggest early imaging using contrast-enhanced whole-body CT (WBCT) for detection and identification of injury type and bleeding source after patient stabilization, if available. (Conditional recommendation)

11. Repeated Haemoglobin/Haematocrit Monitoring

during resuscitation, we recommend repeating Hb and/or Hct measurements within 30 – 60 minutes, as initial normal values may mask early bleeding. (Strong recommendation)

12. Lactate and Base Deficit Monitoring

We suggest measurement of blood lactate as a sensitive test to estimate and monitor the extent of bleeding and tissue hypoperfusion; In the absence of lactate measurements, base deficit may represent a suitable alternative. If available. (Conditional recommendation)

13. Monitoring of Haemostasis

We recommend the early and repeated monitoring of haemostasis, using an international normalised ratio (INR), and platelet count. (Strong recommendation)

14. Restricted Volume Replacement and Blood Pressure Targets

We recommend the use of a restricted volume replacement strategy in the absence of clinical evidence of brain injury with a target systolic blood pressure of 80–90 mmHg (mean arterial pressure 50–60 mmHg) In the initial phase following trauma, until major bleeding has been stopped. (Strong recommendation)

15. In patients with severe TBI (GCS ≤ 8)

we recommend maintaining mean arterial pressure ≥ 80 mmHg. (Strong recommendation)

16. Use of Noradrenaline When Restricted Volume Replacement Fails

we recommend the administration of noradrenaline to maintain target arterial blood pressure, if a restricted volume replacement strategy does not achieve the target blood pressure. (Strong recommendation)

17. Choice of Crystalloid Solutions

We recommend that fluid therapy using a 0.9% sodium chloride and/or ringer lactate or balanced crystalloid solution be initiated in the hypotensive bleeding trauma patient. (Strong recommendation)

18. Avoidance of Hypotonic Solutions in TBI

We recommend against hypotonic solutions during resuscitation of patients with haemorrhagic shock and traumatic brain injury. (Strong recommendation)

19. Restriction of Colloid Use

We suggest restricting the use of colloids due to their adverse effects on haemostasis. (Conditional recommendation)

20. Target Haemoglobin After Bleeding Control

We recommend a target haemoglobin of 7–9 g/dL after controlling the source of bleeding. (Strong recommendation)

21. Prevention and Management of Hypothermia

We recommend early application of measures such covering the patient and warm fluids to reduce heat loss and warm the hypothermic patient to achieve and maintain normothermia. (Strong recommendation)

22. Damage Control Surgery

We suggest damage control surgery in the severely injured patient if the definitive surgery to control the source of bleeding is complicated and time-consuming (>90 minutes) in the presence of severe persistent coagulopathy, severe acidosis with base deficit >15 mmol/L or lactate >5 mmol/L, hypothermia <34°C, or signs of ongoing bleeding despite the initial attempts of bleeding control with systolic BP persistently <90 mmHg. (Conditional recommendation)

23. Pelvic Binder Use

We recommend the adjunct use of a pelvic binder or pelvic sheet to limit life threatening bleeding in the presence of a suspected pelvic fracture. (Strong recommendation)

24. Topical Haemostatic Agents

We suggest the use of topical haemostatic agents with packing for venous or moderate arterial bleeding associated with parenchymal injuries. (Conditional recommendation)

25. Tranexamic Acid (TXA)

We recommend TXA administration in trauma patients who are bleeding or at risk of significant bleeding, as soon as possible and within 3 hours of injury at a loading dose of 1 g IV over 10 min, followed by 1 g IV infusion over 8 h.
(Strong recommendation)

26. Balanced Blood Product Transfusion

We recommend transfusion of pRBCs: FFP: Platelets in ratio following the massive transfusion protocols, In the initial management of patients with suspected massive haemorrhage. (Strong recommendation)

27. Calcium Monitoring and Supplementation

We recommend that ionised calcium levels be monitored and maintained within the normal range following major trauma and especially during massive transfusion. We recommend the administration of calcium to correct hypocalcaemia. (Strong recommendation)

28. Reversal of Vitamin K Antagonists (VKA)

We recommend the emergency reversal of vitamin K-dependent oral anticoagulants in the bleeding trauma patient with the early use of 5–10 mg I.V. phytomenadione (vitamin K1) in addition to FFP. (Strong recommendation)