Anaphylaxis Management

Initial Assessment and Treatment

The American Heart Association recommends immediate administration of intramuscular epinephrine as the first-line treatment for anaphylaxis, with a dose of 0.15 mg (0.15 mL of 1:1000) for children under 6-12 years 1, 2, 4
Initial symptoms of anaphylaxis may include facial flushing, perioral tingling, and complaints of throat tightness, which can rapidly progress to generalized urticaria, audible wheezing, and severe respiratory distress 1, 2
Vital signs at 5 minutes may include blood pressure 65/40 mmHg, heart rate 145 bpm, respiratory rate 40/min, and oxygen saturation 88% on room air, indicating shock and respiratory compromise 3

The American College of Allergy, Asthma, and Immunology recommends assessing for rapidly progressive laryngeal edema and preparing for emergency airway management, including intubation if stridor worsens 2, 5
Early intubation should be considered if stridor worsens, as waiting too long may make intubation impossible and require emergency cricothyroidotomy 2, 5

The British Journal of Anaesthesia recommends establishing large-bore IV access and administering normal saline 0.9% rapid bolus 500 mL (20 mL/kg) for pediatric patients, with repeat boluses as needed for persistent hypotension 3, 5
IV epinephrine may be considered if shock persists despite IM epinephrine and fluid resuscitation, with a dose of 5-10 mcg bolus (0.05-0.1 mg) or an infusion of 0.05-0.1 mcg/kg/min 2, 3

The Journal of Allergy and Clinical Immunology recommends administering antihistamines, such as diphenhydramine 1 mg/kg IV or chlorphenamine 0.2 mg/kg IV, and H2-antihistamines, such as ranitidine 1 mg/kg IV or famotidine 0.25 mg/kg IV, after adequate epinephrine and fluid resuscitation 3, 5, 6
Corticosteroids, such as methylprednisolone 1-2 mg/kg IV or hydrocortisone 5 mg/kg IV, may be administered to prevent biphasic reactions, although evidence is limited 1, 5

The American Academy of Allergy, Asthma, and Immunology recommends obtaining serial mast cell tryptase levels to confirm anaphylaxis diagnosis, with samples taken as soon as feasible after resuscitation starts, 1-2 hours after symptom onset, and 24 hours later or at follow-up 1, 3
Patients should be observed in a monitored setting for a minimum of 6 hours or until stable and symptoms are regressing, and admitted to the pediatric intensive care unit given severity of initial presentation 3
Outpatient allergy referral and education on anaphylaxis action plans and medical alert bracelets are essential for preventing future reactions 4, 5, 7