Emergency Management of Anaphylaxis
emupdates.com/anaphylaxis
Concern for severe allergic reaction or angioedema
Non-allergic angioedema? Remove stimulus
Asymmetric mucosal edema, absence of hives/pruritus suggests non-allergic Remove stinger
Stop medication infusion
Unless certainly non-allergic, start treatment as allergic Consider rinsing mouth/brushing teeth if food trigger
If certainly non-allergic or failing allergic treatment, proceed to purple box
airway signs
change in voice, drooling, stridor, posturing
no breathing signs
Secondary care Insult to Airway, Breathing, or Circulation? wheezing, dyspnea
circulation signs
hypotension, syncope, hypoperfusion
yes
if uncertain whether or not to treat with epi, treat with epi
0.3 mg (300 mcg) for smaller patient/less severe reaction
0.5 mg (500 mcg) for larger patient/more severe reaction
preferred location is anterolateral thigh
Epinephrine 0.3 mg - 0.5 mg IM (0.01 mg/kg in children, max 0.5 mg)
1 mg/mL concentration (1:1000) is best IV, O2, Monitor
0.1 mg/mL (1 mg in 10 mL, 1:10,000) is OK
avoid 1:1000 and 1:10000 terminology–causes errors
Does airway require management?
yes Assume cricothyrotomy will be necessary
Improved? If laryngoscopy or flexible endoscopy attempted,
double setup with full cric readiness
no
Secondary Care Hypotensive?
Crystalloid bolus
H1 and H2 blockers, steroids Epinephrine 0.3 mg - 0.5 mg IM
Observation
Start epinephrine drip Wheezing?
Discharge with epinephrine auto-injector Asthma therapy
informal epi drip: 1 mg in 1 liter NS, start at 2 drops per second
Auto-injector instructions, allergic precautions formal epi drip: start at 10 mcg/min or 0.1 mcg/kg/min
Referral to allergy/immunology nebulized epinephrine if laryngeal involvement
Duration of observation based on
Severity of reaction
Speed with which reaction developed yes
Capacity of patient to self-treat with epinephrine Improved?
Capacity of patient to immediately access emergency care
no Glucagon 1 mg IV if beta blocker
If anaphylaxis persistently epinephrine-refractory:
Methylene blue 100 mg IV
Vasopressin 5 u IV
ECMO {scant evidence for these therapies}
Non-allergic/bradykinin mediated angioedema
h/t: @ibookcc
ACE inhibitor or ARB related
Hereditary angioedema/C1 esterase deficiency
tPA related
Empiric treatment: 1 g TXA over 10 minutes and 2 units FFP
C1 inhibitor concentrate is first line treatment for hereditary angioedema
May be used in other forms of bradykinin mediated angioedema
Very expensive and often not immediately available
Berinert 20 u/kg, Ruconest 50 u/kg, Cinryze 1000 u
Bradykinin/kallikrein modifiers (ecallantide, icatibant, lanadelumab) poorly supported by evidence
