Anaphylaxis Summary

Acute onset of skin changes (urticaria, erythema/flushing and/or angioedema) AND at least one of the following: 

• Respiratory +/-
• Cardiovascular +/-
• GI symptoms
  OR
• Hypotension, bronchospasm or upper airway obstruction after exposure to known or highly probable allergen

0 to 5 MINUTES

• Place patient in supine position
• Assess ABCs, vital signs
• Provide O₂ 10-15 L/min by non-rebreather mask
• Identify and remove allergic trigger, if possible
• ADMINISTER IM EPINEPHRINE

DO NOT delay IM EPINEPHRINE administration

• Dose: 0.01mg/kg (1mg/ml), MAX 0.5mg
• Route: INTRAMUSCULAR (IM) in anterolateral thigh

• Never administer the IM preparation of epinephrine (1mg/mL) through IV/IO route
• Never give IV epinephrine bolus dose for initial anaphylaxis management, consider IV epinephrine infusion if no response after 3 doses of IM epinephrine
• REPEAT IM EPINEPHRINE every 5-10 min as needed (see below)

5 TO 10 MINUTES

Respiratory symptoms:

• Sitting position
• Administer high flow O₂, consider need for intubation
• If stridor or upper airway obstruction, give inhaled epinephrine
• If wheeze or lower airway obstruction, give inhaled salbutamol

Hypotension or Decreased Level Of Consciousness (LOC):

• Supine position
• Secure large bore IV or obtain intraosseous (IO) access
• Crystalloid NS or LR , 20 mL/kg IV/IO rapid push

If no improvement, give 2nd dose of IM EPINEPHRINE

10 to 15 MINUTES

Respiratory symptoms:

• Repeat inhaled epinephrine (upper airway obstruction)
  or salbutamol (lower airway obstruction)
• Prepare for difficult airway intubation

Hypotension or Decreased Level of Consciousness (LOC), persistent abdominal pain/vomiting:

• 2nd crystalloid NS or LR, 20 mL/kg IV/IO rapid push
• Prepare for possible IV epinephrine infusion

If no improvement, give 3rd dose of IM EPINEPHRINE

ALERT Pediatric Referral Center

15 to 20 MINUTES

Respiratory symptoms:

• Consider 3rd inhaled epinephrine or salbutamol
• Consider IV hydrocortisone for persistent shock, asthma or upper airway obstruction
• Proceed with intubation if no improvement

Hypotension or Decreased Level of Consciousness (LOC):

• Start IV epinephrine infusion 0.05 mcg/kg/min IV, titrate up by 0.02 mcg/kg/min to effect

ALERT Pediatric Referral Center

REFRACTORY ANAPHYLAXIS

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• Repeat boluses of Normal Saline (NS) 20 mL/kg
• Epinephrine Spritzer

Link: https://childhealthbc.ca/file/bc-childrens-hospital-epinephrine-spritzer-reconstitution-instructions 

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• Norepinephrine infusion (For persistent hypotension):Start at 0.05 mcg/kg/min IV, titrate by 0.02 mcg/kg/min to effect (MAX 2 mcg/kg/min) until adequate perfusion
• Glucagon bolus (For persistent anaphylaxis symptoms or patients on beta blockers) Dose: 20 - 30 mcg/kg/dose (MAX 1 mg) IV over 5 minutes, followed by infusion of 5 -15 mcg/min, titrated to clinical effect