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Table 2 Clinical Scenarios for Epinephrine Use Outside of a Medical Facility

From: Epinephrine: The Drug of Choice for Anaphylaxis--A Statement of the World Allergy Organization

For Discussion Purposes
Clinical Findings Use of Epinephrine?
Generalized urticaria develops in a 28-yr-old fire ant-allergic individual stung by ant while playing in the yard. Currently receives ant immunotherapy based on positive skin test response to fire ant whole body extract but is not yet at maintenance dosage (6 wk of therapy on conventional\buildup schedule). Pro: inject immediately; past anaphylaxis and current findings away from medical facility
Con: do not inject immediately; wait for symptoms involving another organ system
A 45-yr-old yellow jacket-allergic farmer has just been stung after disturbing nest with tractor. History of hypotension and rapid syncope in past stings. Currently receives venom immunotherapy but is not yet at maintenance (last dose was 1 mL [L]). No current symptoms. Pro: inject immediately in view of past severe anaphylaxis; low risk of serious side effects from injected epinephrine; some risk of severe symptoms because he has not reached maintenance
Con: do not inject immediately; wait for symptoms
A 17-yr-old individual develops paroxysmal sneezing within 5 min of receiving allergen immunotherapy injection Pro: inject immediately; rapid onset of symptoms may be associated with severe anaphylaxis; low risk of serious side effects from injected epinephrine; antihistamines are second-line agents in anaphylaxis
Con: do not inject immediately; wait for other symptoms if suspect sneezing could be due to transient respiratory irritant exposure or seasonal allergy exacerbation if it occurs during pollen season of a pollen-allergic individual.
A 7-yr-old child with mild persistent asthma and clinical history of peanut allergy (wheeze, hives that "get better after vomiting") experiences sudden cough and wheeze while playing outside 15 min after eating a cookie in school cafeteria; has no other symptoms; has albuterol metered-dose inhaler and epinephrine autoinjector available Pro: inject immediately; history is strongly suggestive of past anaphylaxis; safety of cookie is uncertain; signs and severity of anaphylaxis can vary from episode to episode in the same individual; delayed treatment or treating anaphylaxis with salbutamol (albuterol) alone could have adverse outcome; low risk of serious side effects from injected epinephrine
Con: do not inject immediately; for possible asthma (eg, exercise-induced or pollen exposure), assess response to salbutamol first.
  1. Anaphylaxis occurs as part of a continuum, and delaying treatment until multiorgan dysfunction is present is risky. The recommendations in this table apply regardless of comorbid conditions because there is no absolute contraindication to epinephrine administration during anaphylaxis. Physicians and other health care professionals should instruct patients at risk for anaphylaxis outside of a medical facility to err on the side of caution and self-administer epinephrine if there is any doubt anaphylaxis is either present or imminent.
  2. Adapted from Sicherer and Simons[65].