Allergic Reaction/Anaphylaxis 

Patient Care Goals

Identify anaphylaxis (life-threatening allergic reactions) quickly to prevent cardiorespiratory collapse. Anaphylaxis is defined as two or more of the following symptoms: skin (hives/itching), GI symptoms (nausea/vomiting/diarrhea), respiratory symptoms (chest tightness/wheezing/shortness of breath), swelling (tongue/face/lips), difficulty swallowing, hypotension. Early epinephrine should be considered for anyone with signs of anaphylaxis, or anyone with concern for anaphylaxis with hypotension and/or facial swelling.

Assessment

Pediatric Pearls: Signs & Symptoms: Differential: 
□ Fluids and medications titrated to maintain SBP > 70 + (age x 2) mmHg  
□ Do not hesitate to give epinephrine for anaphylaxis
□ Epinephrine dosing		□ Edema / Voice Changes  
□ Itching or Hives  
□ Coughing / Wheezing or Respiratory Distress  
□ Chest or Throat Constriction / Tightness  
□ Difficulty Swallowing  
□ Hypotension or Shock  
□ Vomiting / Diarrhea		□ Urticaria (rash only)  
□ Anaphylaxis (systemic effect)  
□ Shock (vascular effect)  
□ Angioedema (drug induced)  
□ Aspiration / Airway Obstruction  
□ Vasovagal event  
□ CHF  
□ Asthma or COPD  
□ Anxiety  

Clinical Management Options

EMT-B
• Place in position of comfort
• Oxygen target SpO2 92% – 96%  
• Cold pack to insect bite or sting site and remove bee stinger if present. 
Basic airway management as needed
Consider ALS intercept for any evidence of anaphylaxis or respiratory distress
Paramedic
• IM Epinephrine, up to 3 additional doses q5 minutes as needed for continued symptoms
Consider Albuterol for wheezing, chest tightness, shortness of breath
Consider CPAP, if refractory to Albuterol 
Diphenhydramine for Allergic Reaction or Dystonia 
IV / IO access as appropriate for patient condition 
IV fluid therapy with Isotonic Crystalloid, titrated to Adult SBP > 100 mmHg      
Consider Push dose Epinephrine IV/IO for hypotension 
Monitor ETCO2 in patients with respiratory distress
Consider ECG
Consult Online Medical Control as Needed

Pearls

  • Epinephrine is the single most important intervention in this setting and has small risk for high benefit.
  • Hives + vomiting is anaphylaxis and should be treated with epinephrine
  • Skin symptoms (hives) may be missing in up to 40% of patients
  • Continuous reassessment for lack of improvement or rebound reaction with need for additional epinephrine. 
  • Lung should be assessed between each dose of Albuterol prior to additional nebulizers. 
  • Any patient with respiratory symptoms or extensive reaction should receive IV/IO or IM Diphenhydramine. 
  • The shorter the onset from exposure to symptoms, the worse the reaction.