Saunders, — Anaphylaxis may include any combination of common signs and symptoms Table 2. Gastrointestinal manifestations e. Headache, rhinitis, substernal pain, pruritus, and seizure occur less frequently. Symptom onset varies widely but generally occurs within seconds or minutes of exposure.

Rarely, anaphylaxis may be delayed for several hours. Anaphylaxis can be protracted, lasting for more than 24 hours, or recur after initial resolution. Anaphylaxis and anaphylactoid reactions. In: Middleton E, ed. Allergy: principles and practice.

Louis: Mosby, — Approximately one third of anaphylactic episodes are triggered by foods such as shellfish, peanuts, eggs, fish, milk, and tree nuts e. A patient may underestimate the importance of a food antigen, or the antigen may be one of many ingredients in a complex product. Some persons may react just by handling the culprit food. Another common cause of anaphylaxis is a sting from a fire ant or Hymenoptera bee, wasp, hornet, yellow jacket, and sawfly. Approximately 40 to deaths per year in the United States result from insect stings, and up to 3 percent of the U.

Aspirin and other nonsteroidal anti-inflammatory drugs NSAIDs may produce a range of reactions, including asthma, urticaria, angioedema, and anaphylactoid reactions. Overall, aspirin accounts for an estimated 3 percent of anaphylactic reactions.

Sensitive persons may have similar reactions to NSAIDs antigenically unrelated to aspirin and must take only acetaminophen for mild pain or fever. At one time penicillin was probably the most common cause of anaphylaxis. Between one and five per 10, patient courses with penicillin result in allergic reactions, with one in 50, to one in , courses having a fatal outcome, accounting for 75 percent of anaphylactic deaths in the United States. Latex allergy has become a significant problem since the widespread adoption of universal precautions against infection.

Eight to 17 percent of health care workers experience some form of allergic reaction to latex, although not all of these reactions are anaphylaxis. Latex is in gloves, catheters, and countless other medical supplies, as well as thousands of consumer products.

Persons allergic to latex also may be sensitive to fruits such as bananas, kiwis, pears, pineapples, grapes, and papayas. Allergy extracts, antilymphocyte and antithymocyte globulins, antitoxins, carboplatin Paraplatin , corticotropin H. Acthar , dextran, folic acid, insulin, iron dextran, mannitol Osmitrol , methotrexate, methylprednisolone Depo-Medrol , opiates, parathormone, progesterone Progestasert , protamine sulfate, streptokinase Streptase , succinylcholine Anectine , thiopental Pentothal , trypsin, chymotrypsin, vaccines.

Cryoprecipitate, immune globulin, plasma, whole blood. Cold temperatures, exercise. Finally, radiographic contrast media can result in severe adverse reactions at a rate of 0. When history of exposure to an offending agent is elicited, the diagnosis of anaphylaxis is often obvious. Cutaneous manifestations of urticaria, itching, and angioedema assist in the diagnosis by suggesting an allergic reaction.

However, when gastrointestinal symptoms predominate or cardiopulmonary collapse makes obtaining a history impossible, anaphylaxis may be confused with other entities. Some of these differential diagnoses are listed in Table 4. Vasovagal reaction. Cardiogenic shock. Hypovolemic shock. Asthma and chronic obstructive pulmonary disease exacerbation. Vocal chord dysfunction syndrome.

Monosodium glutamate ingestion. Sulfite ingestion. Scombroid fish poisoning. Postmenopausal hot flushes. Red man syndrome vancomycin [Vancocin]. Systemic mastocytosis. Hereditary angioedema. Leukemia with excess histamine production. If the diagnosis of anaphylaxis is not clear, laboratory evaluation can include plasma histamine levels, which rise as soon as five to 10 minutes after onset but remain elevated for only 30 to 60 minutes.

Urinary histamine levels remain elevated somewhat longer. Alternatively, serum tryptase levels peak 60 to 90 minutes after onset of anaphylaxis and remain elevated for up to five hours. Some patients have isolated abnormal tryptase or histamine levels without the other.

The initial management of anaphylaxis includes a focused examination, procurement of a stable airway and intravenous access, and administration of epinephrine. Examination may reveal urticaria, angioedema, wheezing, or laryngeal edema.

If the antigen was injected e. Epinephrine , dilution, 0. The site may be gently massaged to facilitate absorption. The dose may be repeated two or three times at 10 to 15 minutes intervals.

If severe hypotension is present, epinephrine may be given as a continuous intravenous infusion. Patients receiving intravenous epinephrine require cardiac monitoring because of potential arrhythmias and ischemia. If an intravenous line cannot be established, the intramuscular dose can be injected into the posterior one third of the sublingual area, or the intravenous dose may be injected into an endotracheal tube.

The patient should be placed supine or in Trendelenburg's position. Supplemental oxygen may be administered. Intravenous access should be obtained for fluid resuscitation, because large volumes of fluids may be required to treat hypotension caused by increased vascular permeability and vasodilation. While volume replacement is central to management of hypotension in anaphylaxis, other pressors such as dopamine Intropin , 2 to 20 mcg per kg per minute, may be required.

Thank you for explaining IV epinephrine treatment for it. I enjoyed reading it. We are the EMCrit Project , a team of independent medical bloggers and podcasters joined together by our common love of cutting-edge care, iconoclastic ramblings, and FOAM. This is part of the Bleeding Edge Series, which explores particularly controversial topics which are lacking in a strong evidentiary basis more on this here When treating anaphylaxis, epinephrine is generally given via an intramuscular IM route.

Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. Brown A. Anaphylaxis: quintessence, quarrels, and quandaries.

Emerg Med J. Managing acute anaphylaxis. Intravenous adrenaline should be considered because of the urgency of the condition. Pharmacokinetics of epinephrine in patients with septic shock: modelization and interaction with endogenous neurohormonal status.

Crit Care. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. Author Recent Posts. Social Me. Josh Farkas. Josh is the creator of PulmCrit. Latest posts by Josh Farkas see all. We may delete without a full, true name. Your Job i. Inline Feedbacks. What's Your Job? Reply to Peter. I think there is a role for our push dose epi here as well either while awaiting an epi gtt from pharmacy or to provide that initial loading dose What's Your Job?

Reply to Andrew. And if are treating sudden acute anaphylaxis in an ICU patient there is good chance its from rxn to an IV med, which have the most rapid onset and … Read more » What's Your Job?

Reply to phil. Zachary Davies. What do you think about the initiation of an infusion of adrenaline after giving IM adrenaline? Do not administer epinephrine to any other part of the body, including the:. A second dose of epinephrine should be injected if the initial anaphylaxis symptoms do not improve after 10 minutes of the first treatment. Due to the severity of anaphylaxis, it is critical that people with serious allergies keep their epinephrine injection device with them or accessible at all times.

Epinephrine should be injected as soon as you suspect you may be experiencing anaphylaxis symptoms. After injecting a dose of epinephrine, some solution will remain in the injection device. This is normal and does not mean that you did not receive the full dose. Take the used device with you to the emergency room or ask your doctor or pharmacist how to dispose of used infection devices safely.

While epinephrine helps treat serious allergic reactions, it does not take the place of professional medical treatment. Immediately following an epinephrine injection, call an ambulance or go to the hospital. Severe allergies are more than an inconvenience — they can be life-threatening.

Mahr, Stuart L. Abramson, Chitra Dinakar, Thomas A. Kim, Elizabeth C. Matsui; Epinephrine for First-aid Management of Anaphylaxis. Pediatrics March ; 3 : e Anaphylaxis is a severe, generalized allergic or hypersensitivity reaction that is rapid in onset and may cause death. Epinephrine adrenaline can be life-saving when administered as rapidly as possible once anaphylaxis is recognized.

This clinical report from the American Academy of Pediatrics is an update of the clinical report on this topic. It provides information to help clinicians identify patients at risk of anaphylaxis and new information about epinephrine and epinephrine autoinjectors EAs.

The report also highlights the importance of patient and family education about the recognition and management of anaphylaxis in the community. Anaphylaxis is defined as a serious, generalized allergic or hypersensitivity reaction that is rapid in onset and potentially fatal. Clinical presentation and severity can vary among patients and in the same patient from 1 anaphylactic episode to another.

Clinical criteria for anaphylaxis have been proposed and validated. These clinical criteria for the diagnosis of anaphylaxis have been validated in emergency department studies in children, teenagers, and adults.

They have high sensitivity Foods, especially peanut, tree nuts, milk, eggs, crustacean shellfish, and finned fish, are by far the most common triggers of anaphylaxis in the pediatric population. Cofactors that lower the threshold at which triggers can cause anaphylaxis include exercise, upper respiratory tract infections, fever, ingestion of nonsteroidal antiinflammatory drugs or ethanol, emotional stress, and perimenstrual status.

Epinephrine is the medication of choice for the first-aid treatment of anaphylaxis. Through vasoconstrictor effects, it prevents or decreases upper airway mucosal edema laryngeal edema , hypotension, and shock.

In addition, it has important bronchodilator effects and cardiac inotropic and chronotropic effects. Delayed epinephrine administration in anaphylaxis is associated with an increased risk of hospitalization 22 and poor outcomes, including hypoxic-ischemic encephalopathy and death.

Epinephrine can be life-saving when injected promptly by the intramuscular IM route in the mid-outer thigh vastus lateralis muscle as soon as anaphylaxis is recognized Table 1. Epinephrine autoinjectors EAs can be used in health care settings to deliver a 0.

Adapted from refs 1 , — 3 , 6. Note that only a few anaphylaxis symptoms may be present during an episode. Also, symptoms can differ among patients, and even in the same patient from 1 episode to the next. Typically, more than 1 body organ system is involved. If the response to the first epinephrine injection is inadequate, it can be repeated once or twice at 5- to minute intervals. Subsequent doses are typically given by a health care professional along with other interventions. The need for subsequent injections did not correlate with obesity or overweight status.

Subsequent epinephrine doses are needed for severe or rapidly progressive anaphylaxis and for failure to respond to the initial injection because of delayed injection of the initial dose, inadequate initial dose, or administration through a suboptimal route. Food-induced anaphylaxis is associated with biphasic anaphylaxis less often than is venom- or drug-induced anaphylaxis. Reluctance to inject epinephrine promptly at the onset of anaphylaxis symptoms is best overcome by awareness that the severity of an anaphylactic episode can differ from 1 patient to another and in the same patient from 1 episode to another.

These effects cannot be dissociated from the beneficial effects of epinephrine. Epinephrine given by IM injection achieves peak concentrations faster than that given by subcutaneous injection.

There is no absolute contraindication to epinephrine treatment in anaphylaxis. Only 2 premeasured, fixed doses of epinephrine, 0. These doses are optimal for many children but not necessarily for all children. The 0. However, dose preparation can take laypersons as long as 3 to 4 minutes; moreover, doses typically are inaccurate and can sometimes contain no epinephrine at all when the solution is ejected from the syringe along with the air.

After consideration of the aforementioned alternatives that potentially lead to delay in dosing, incorrect dosing, or no dose at all and consideration of the favorable benefit-to-risk ratio of epinephrine in young patients with anaphylaxis, many physicians recommend the use of the 0.

On the basis of a pharmacokinetic study 40 and expert consensus, it is appropriate to switch most children from the 0. Most anaphylaxis deaths occur in community settings rather than in health care settings 1 , 16 , — 18 ; yet, some physicians fail to prescribe EAs for their patients at risk of anaphylaxis in the community. In fact, some experts have suggested that consideration be given to prescribing EAs for all patients with immunoglobulin E—mediated food allergy, because it is difficult or impossible to predict the occurrence or severity of future reactions.

Guidelines recommend prompt epinephrine injection for the sudden onset of any anaphylaxis symptoms after exposure to an allergen that previously caused anaphylaxis in that patient.

Even physicians with years of experience in diagnosing and treating anaphylaxis cannot determine, at the onset of an episode, whether that episode will remain mild or escalate over minutes to become life-threatening. It is therefore important that physicians instruct patients and caregivers to err on the side of prompt epinephrine injection.

Many patients and caregivers fail to carry EAs consistently or to use them when anaphylaxis occurs, even for severe symptoms, including throat tightness, difficulty breathing, wheezing, and loss of consciousness.