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Table 5 Basic Management of Anaphylaxisa

From: World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis

Preliminary Steps
   1) Have a posted, written emergency protocol for recognition and treatment of anaphylaxis and rehearse the protocol regularlyb
   2) Remove exposure to the trigger if possible, eg. discontinue an intravenous diagnostic or therapeutic agent that seems to be triggering symptoms
   3) Assess circulation, airway, breathing, mental status, skin, and body weight (mass)c
Promptly and simultaneouslyd
   4) Call for help (resuscitation team in hospital or other healthcare setting, or emergency medical services in community setting), if available
   5) Inject epinephrine (adrenaline) intramuscularly in the mid-anterolateral aspect of the thigh, 0.01 mg/kg of a 1:1,000 (1 mg/mL) solution, to a maximum of 0.5 mg (adult) or 0.3 mg (childe); record the time of the dose and repeat it in 5-15 minutes, if needed; most patients respond to 1 or 2 doses
   6) Place patient on the back, or in a position of comfort if there is respiratory distress and/or vomiting; elevate the lower extremities; fatality can occur within seconds if a patient stands or sits suddenly
When indicated at any time during the episode
   7) Give high flow supplemental oxygen (6-8 L/min) by face mask or oropharyngeal airwayf
   8) Establish intravenous access using needles or catheters with wide-bore cannulae (14 or 16 gauge for adults). When indicated, give 1-2 litres of 0.9% (isotonic) saline rapidly. (eg. 5-10 mL/kg in the first 5-10 minutes to an adult; or 10 mL/kg to a child)
   9) When indicated at any time, prepare to initiate cardiopulmonary resuscitation with continuous chest compressionsg.
In addition
   10) At frequent and regular intervals, monitor patient's blood pressure, cardiac rate and function, respiratory status and oxygenation and obtain electrocardiograms; start continuous non-invasive monitoring, if possibleh
  1. aThese Guidelines are primarily intended to summarize the basic initial management of anaphylaxis for allergy/immunology specialists; however, they will likely also be of interest to a broader group of healthcare professionals.
  2. bThe written emergency protocol for anaphylaxis assessment and treatment should include drug dosages for adults and children, and telephone numbers and contact details for resuscitation team, emergency medical services, emergency department, etc. The protocol should also include flow charts (examples given in reference [24]) for recording the times of clinical observations and events, vital signs measurements, medications/doses administered, details of oxygen and intravenous fluid treatment, and times at which observations were made and interventions took place.
  3. cBody weight should be measured or estimated so that medication doses and intravenous fluid resuscitation can be calculated accurately.
  4. dSteps 4, 5, and 6 should be performed promptly and simultaneously as soon as anaphylaxis is diagnosed or strongly suspected. If precious minutes are lost early in the treatment of an acute anaphylactic episode, subsequent management can become more difficult.
  5. eChild is defined as a pre-pubertal patient weighing less than 35-40 kg; not defined by age.
  6. fSupplemental oxygen should be given to all patients with respiratory distress and those receiving repeated doses of epinephrine. It should also be considered for any patients with anaphylaxis who have concomitant asthma, other chronic respiratory disease, or cardiovascular disease.
  7. gInitiate cardiopulmonary resuscitation with chest compressions only (hands-only) before giving rescue breaths. In adults, chest compressions should be performed at a rate of 100-120/minute, and a depth of 5-6 cm. In children, the rate should be at least 100 compressions/minute at a depth of 5 cm (4 cm in infants). The compression/ventilation ratio performed by one rescuer should be 30:2.
  8. hDuration of monitoring should be individualized; for example, patients with moderate respiratory or cardiovascular compromise should be monitored in a medically supervised setting for at least 4 hours and if indicated, 8-10 hours or longer, and patients with severe or protracted anaphylaxis might require monitoring and interventions for days.
  9. Adapted from references [2, 2225, 32, 9399].