Anaphylaxis Treatment Guidelines

Introduction to Anaphylaxis Treatment

Anaphylaxis is a severe, life-threatening allergic reaction that requires immediate medical attention, according to the American Heart Association and the American Academy of Allergy, Asthma, and Immunology guidelines 1, 2
The American Academy of Allergy, Asthma, and Immunology recommends that epinephrine should be administered promptly in cases of anaphylaxis, as delayed administration can result in increased risk of death 3
The American Academy of Pediatrics states that failure to administer epinephine within 5 minutes of the onset of severe respiratory symptoms can significantly increase the risk of death in cases of anaphylaxis 4

The American Heart Association recommends intramuscular (IM) epinephrine in the anterolateral thigh as the first-line approach, with adult dose: 0.3-0.5 mg (0.3-0.5 mL of 1:1000 solution), children ≥30 kg: 0.3-0.5 mg (0.3-0.5 mL of 1:1000 solution), and children <30 kg: 0.01 mg/kg (0.01 mL/kg), maximum 0.3 mg, which may be repeated every 5-15 minutes as needed 1
When IV access is available, the American Heart Association suggests IV bolus: 0.05-0.1 mg (0.5-1 mL of 1:10,000 solution), which is approximately 5-10% of the cardiac arrest dose 1
The American Academy of Pediatrics recommends IV infusion: 0.1-1.0 μg/kg/min, starting at the lowest dose and titrating to desired clinical effect, with doses up to 5 μg/kg/min may be necessary in refractory cases 5
Additional doses of epinephrine may be necessary every 5-15 minutes if symptoms persist or recur after the initial dose, as recommended by the American Academy of Allergy, Asthma, and Immunology 3, 2

Patients taking beta-blockers may have a diminished response to epinephrine and may require alternative treatment with glucagon, according to the American Academy of Allergy, Asthma, and Immunology 2
Anaphylaxis can occur without skin symptoms, particularly in severe cases, and diagnosis should not be ruled out based on the absence of skin symptoms alone, as warned by the American Academy of Pediatrics 4
Patients with asthma, particularly those with food allergies, are at higher risk of death from anaphylaxis, according to the American Academy of Pediatrics 4
Adolescents with risk factors such as denial of symptoms and failure to carry emergency medications are at increased risk of death from anaphylaxis, as highlighted by the American Academy of Pediatrics 4

Diphenhydramine (1-2 mg/kg or 25-50 mg parenterally) and ranitidine (1 mg/kg or 50 mg IV for adults) can be used as second-line medications, but never in place of epinephrine, as recommended by the Journal of Allergy and Clinical Immunology 2
The combination of H1 and H2 blockers is superior to H1 blockers alone for anaphylaxis treatment, according to the Journal of Allergy and Clinical Immunology guidelines 2
For bronchospasm resistant to epinephrine, nebulized albuterol (2.5-5 mg in 3 mL saline) can be used, repeated as necessary, as recommended by the Journal of Allergy and Clinical Immunology 2
For refractory hypotension, dopamine (400 mg in 500 mL D5W at 2-20 μg/kg/min) can be used, titrated to maintain systolic BP >90 mmHg, with continuous hemodynamic monitoring, according to the Journal of Allergy and Clinical Immunology guidelines 2

Aggressive fluid resuscitation with isotonic crystalloids is essential alongside epinephrine administration, with up to 7 L of crystalloids may be necessary in anaphylactic shock due to increased vascular permeability, as recommended by the American Academy of Allergy, Asthma, and Immunology 2
Adults should receive 1-2 L of normal saline at 5-10 mL/kg in the first 5 minutes, and children should receive up to 30 mL/kg in the first hour, according to the American Academy of Allergy, Asthma, and Immunology 2
Continuous hemodynamic monitoring is essential during IV epinephine administration, with monitoring for tachyarrhythmias, ectopic beats, hypertension, and hypotension, as recommended by the American Academy of Pediatrics 5

Close hemodynamic monitoring is essential after anaphylaxis treatment, as cardiovascular and respiratory status can change rapidly, and transportation to an emergency department or intensive care facility may be necessary for continued observation, as recommended by the Journal of Allergy and Clinical Immunology 2
The American Heart Association recommends immediately assessing for signs of airway compromise (hoarseness, stridor, lingual edema) 6
Early referral to a provider with advanced airway expertise is critical, according to the American Heart Association 1
Emergency cricothyroidotomy or tracheostomy may be required in cases of severe laryngeal edema, as suggested by the American Heart Association 1