Anaphylaxis Recognition and Treatment

Definition and Mechanism

Anaphylaxis is a life-threatening allergic emergency that requires rapid recognition and treatment, with allergen aggregation of IgE molecules on mast cells and basophils leading to mediator release, and distinction between allergic (IgE-dependent) and anaphylactoid (IgE-independent) reactions, as defined by the American Academy of Allergy, Asthma, and Immunology 1

Common triggers of anaphylaxis include medications, stinging insect venoms, foods (especially peanuts, tree nuts, fish, shellfish, milk, and eggs), latex, exercise, and idiopathic (unknown cause in up to 20% of cases), as noted by the American Academy of Allergy, Asthma, and Immunology 1
Symptoms of anaphylaxis can be graded, with Grade I: Skin and mucosal signs, Grade II: Moderate multi-organ involvement, Grade III: Life-threatening mono- or multi-organ involvement, and Grade IV: Cardiac or respiratory arrest, as classified by the American Academy of Allergy, Asthma, and Immunology 2

The American College of Allergy, Asthma, and Immunology recommends epinephrine as the first-line treatment for anaphylaxis, which should be administered immediately at the onset of symptoms, with a dosing of 0.3-0.5 mg (0.3-0.5 mL of 1:1000 solution) for adults, and may be repeated every 5-15 minutes if symptoms persist, as recommended by the American College of Allergy, Asthma, and Immunology 1
Adrenaline dose for children:
Age Dose
>12 years 500 μg (0.5 ml of 1:1000 solution)
6-12 years 300 μg (0.3 ml of 1:1000 solution)
<6 years 150 μg (0.15 ml of 1:1000 solution)
Between 8-28% of patients with anaphylaxis may require two or more doses of adrenaline, and a second dose should be considered if symptoms do not respond to the initial dose and emergency services will be delayed, as recommended by the American Heart Association 4

The American Academy of Pediatrics recommends age-appropriate dosing for medications, pediatric equipment availability, and family education for patients with anaphylaxis, as well as prescription for epinephrine auto-injector, training on auto-injector use, written emergency action plan, medical identification jewelry, and referral to allergist 5
In case of anaphylactic reaction, administer adrenaline (epinephrine) intramuscularly as first-line treatment, followed by antihistamines, corticosteroids, and hemodynamic support as needed, according to the American Heart Association guidelines 4
Administer chlorphenamine intravenously: adults 10 mg, children 6-12 years 5 mg, children <6 years dose adjusted according to weight, as recommended by the American Society of Anesthesiologists 3
Administer hydrocortisone intravenously: adults 200 mg, children 6-12 years 100 mg, children <6 years 50 mg, as recommended by the American Society of Anesthesiologists 3
Consider intravenous adrenaline infusion if hypotension persists despite adrenaline administration, as recommended by the American Society of Anesthesiologists 3
Consider alternative vasopressors such as metaraminol, as recommended by the American Society of Anesthesiologists 3
Administer salbutamol inhalation or infusion for persistent bronchospasm, as recommended by the American Society of Anesthesiologists 3

Clinics should maintain a comprehensive emergency box containing essential medications, equipment, and supplies, including oral airways, bag-valve-mask devices, portable oxygen, and suction equipment, to manage life-threatening emergencies until EMS arrives, as recommended by the American Academy of Pediatrics 6
The emergency box should include epinephrine 1:1000 (1mg/mL) in vials or auto-injectors, with adult dose: 0.3-0.5 mL (0.3-0.5 mg) IM and pediatric dose: 0.01 mg/kg up to 0.3 mg IM, as recommended by the Journal of Allergy and Clinical Immunology 1
Basic equipment should include a first aid kit, CPR barrier devices, portable oxygen, blood pressure monitoring equipment, pulse oximeter, and Automated External Defibrillator (AED), as recommended by 7
Clinics should ensure appropriate equipment is available, including pediatric-sized airway equipment, BP cuffs, medication dosing charts, and pediatric AED pads (or adult pads with pediatric dose attenuator if available), as recommended by 8

All clinical staff should be trained in Basic Life Support (BLS) and consider Advanced Cardiac Life Support (ACLS) training for physicians and advanced practice providers, as recommended by the American Heart Association 6
Staff should be trained to recognize signs of common emergencies, such as cardiac arrest, anaphylaxis, respiratory distress, seizures, and severe bleeding, as recommended by 7
Clinics should conduct unannounced emergency drills at least quarterly, using simulation manikins to practice CPR and AED use, and debrief after each drill to identify areas for improvement, as recommended by 9, 7
Clinics should establish clear protocols for activating emergency medical services (EMS), designate staff responsible for calling 9-1-1, and assign staff to meet EMS at entrance and guide them to the patient, as recommended by 7
Emergency response plans should be reviewed annually, updated after any actual emergency event, and revised based on changes in staff composition, patient population, facility layout, or current medical guidelines, as recommended by 9