Anaphylaxis
Emergency management of anaphylaxis with epinephrine-first approach
Overview
- Emergency management of anaphylaxis with epinephrine-first approach
Protocol steps
- id: 1; title: Recognize Anaphylaxis; detail: Urticaria/angioedema + hypotension or airway compromise after trigger exposure. Two or more organ systems involved (skin, respiratory, cardiovascular, GI).; time: ; drugs:
- id: 2; title: Epinephrine IM — GIVE NOW; detail: Lateral thigh (vastus lateralis). This is the PRIORITY action — do NOT delay for IV access or other interventions.; time: ; drugs: name: Epinephrine; dose: 0.3mg IM; interval: may repeat q5-15min
- id: 3; title: Position Patient; detail: Supine with legs elevated if hypotensive. Upright/sitting if respiratory distress predominates. Do NOT have patient stand or sit up suddenly.; time: ; drugs:
- id: 4; title: Call for Help + IV Access; detail: Activate code/rapid response team. Establish large-bore IV access (18G or larger). Place on continuous monitoring (SpO2, BP, ECG).; time: ; drugs:
- id: 5; title: H1 + H2 Blockade; detail: Adjunctive therapy — NOT a substitute for epinephrine.; time: ; drugs: name: Diphenhydramine; dose: 50mg IV; name: Famotidine; dose: 20mg IV
- id: 6; title: IV Fluid Bolus; detail: If hypotension present, give 1-2L NS wide open. May need 5-10L total in severe anaphylactic shock. Use pressure bags if needed.; time: ; drugs:
- id: 7; title: Refractory — Epinephrine Drip; detail: If no response to IM epinephrine and fluids. Prepare for intubation if airway edema progressing. Have surgical airway equipment ready.; time: ; drugs: name: Epinephrine drip; dose: 0.1-0.5 mcg/kg/min IV; interval: titrate to response
- id: 8; title: Methylprednisolone IV; detail: Prevents biphasic reaction (occurs in 1-20% of cases, typically 4-12 hours after initial reaction). Not immediately life-saving.; time: ; drugs: name: Methylprednisolone; dose: 125mg IV
- id: 9; title: Observation Period; detail: Observe minimum 4-6 hours. Extend to 24 hours if: severe initial reaction, required multiple epinephrine doses, biphasic risk factors, or refractory symptoms.; time: ; drugs:
- id: 10; title: Discharge Planning; detail: Prescribe epinephrine auto-injector (EpiPen). Refer to allergist/immunologist. Educate on trigger avoidance and action plan. Consider medical alert bracelet.; time: ; drugs:
Source and review
- WAO Anaphylaxis Guidelines 2020; Lieberman et al., JACI 2015; ACEP Clinical Policy. Last reviewed: 2024-11-01