Anaphylaxis Management

ANAPHYLAXIS MANAGEMENT
OUTPATIENT SETTING
First-line Treatment

•  EPINEPHRINE, IM; auto-injector or 1:1000 solution

  º  Weight 10–25kg: 0.15mg epinephrine autoinjector, IM (anterior-lateral thigh)

  º  Weight>25kg: 0.3mg epinephrine autoinjector, IM (anterior-lateral thigh)

  º  Epinephrine (1:1000 solution) IM, 0.01mg/kg per dose; max 0.5mg per dose (anterior-lateral thigh)

  º  May need to repeat epinephrine dose every 5–15min

Adjunctive Treatment

•  Bronchodilator (β2-agonist): ALBUTEROL

  º  MDI (Children: 4–8 puffs; Adults: 8 puffs) or

  º  Nebulized solution (Children: 1.5mL; Adults: 3mL) every 20min or continuously as needed

•  H1 antihistamine: DIPHENHYDRAMINE

  º  1–2mg/kg per dose; max 50mg IV or PO (oral liquid is more readily absorbed than tablets)

  º  Alternative dosing may be used with a less-sedating second generation antihistamine

•  Supplemental oxygen therapy

•  IV fluids in large volumes if patient presents with orthostasis, hypotension, or incomplete response to IM epinephrine

•  Place the patient in recumbent position if tolerated, with the lower extremities elevated

HOSPITAL-BASED SETTING
First-line Treatment

•  EPINEPHRINE IM (as above, outpatient setting), consider continuous epinephrine infusion for persistent hypotension (ideally with continuous non-invasive monitoring of blood pressure and heart rate); alternatives are endotracheal or intra-osseous epinephrine

Adjunctive Treatment

•  Bronchodilator (β2-agonist): ALBUTEROL

  º  MDI (Children: 4–8 puffs; Adults: 8 puffs) or

  º  Nebulized solution (Children: 1.5mL; Adults: 3mL) every 20min or continuously as needed

•  H1 antihistamine: DIPHENHYDRAMINE

  º  1–2mg/kg per dose; max 50mg IV or PO (oral liquid is more readily absorbed than tablets)

  º  Alternative dosing may be used with a less-sedating second generation antihistamine

•  H2 antihistamine: RANITIDINE

  º  1–2mg/kg per dose; max 75–150mg PO and IV

•  Corticosteroids

  º  PREDNISONE: 1mg/kg; max 60–80mg PO or

  º  METHYLPREDNISOLONE: 1mg/kg; max 60–80mg IV

•  Vasopressors (other than epinephrine) for refractory hypotension, titrate to effect

•  GLUCAGON for refractory hypotension, titrate to effect

  º  Children: 20–30mcg/kg

  º  Adults: 1–5mg

  º  May repeat dose or followed by infusion of 5–15mcg/min

•  ATROPINE for bradycardia, titrate to effect

•  Supplemental oxygen therapy

•  IV fluids in large volumes if patient presents with orthostasis, hypotension, or incomplete response to IM epinephrine

•  Place the patient in recumbent position if tolerated, with the lower extremities elevated

THERAPY AT DISCHARGE
First-line Treatment

•  EPINEPHRINE, auto-injector prescription (2 doses) and instructions

•  Education on avoidance of allergen

•  Follow-up with primary care physician

•  Consider referral to an allergist

Adjunctive Treatment

•  H1 antihistamine: DIPHENHYDRAMINE every 6hrs for 2–3 days; alternative dosing with a non-sedating second generation antihistamine

•  H2 antihistamine: RANITIDINE twice daily for 2–3 days

•  Corticosteroid: PREDNISONE daily for 2–3 days

NOTES

These treatments often occur concomitantly, and are not meant to be sequential, with the exception of epinephrine as first-line treatment.

REFERENCES

Adapted from Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report. J Allergy Clin Immunol 2010; 126(6):1105–18. http://www.niaid.nih.gov/topics/foodAllergy/clinical/Documents/
FAGuidelinesExecSummary.pdf

(Rev. 7/2015)

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