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Table 4 Anaphylaxis treatment in healthcare settings: summary of collaborating organizations’ principal anaphylaxis guidelines 1

From: International consensus on (ICON) anaphylaxis

  WAO Guidelines AAAAI/ACAAI2Guidelines EAACI3Guidelines
Prompt initial treatment of anaphylaxis have a protocol; remove the trigger, if relevant, assess rapidly, promptly and simultaneously call for help, inject epinephrine IM, repeat in 5-15 min, position the patient supine (semi-reclining if dyspneic or vomiting) with lower extremities elevated; Tables 5, 6, 7; Figure 4 epinephrine IM is the initial medication of choice; repeat in 5+ min; have a protocol; remove exposure to the trigger; position the patient supine (semi-reclining if dyspneic or vomiting) with lower extremities elevated; call for help; Figures E2, E3 1st-line treatment: inject epinephrine IM; repeat in 10 min; 2nd-line treatment: inhaled beta-2 agonists for wheezing; inhaled adrenaline for stridor; remove the trigger, call for help, position the patient appropriately, high-flow oxygen, fluid support (crystalloid); Boxes 7, 8, 15; online supplement; Figure 2
Initial treatment (cont.) when indicated, give supplemental high-flow oxygen; IV fluids (crystalloid); start cardiopulmonary resuscitation with continuous chest compressions; H1- and H2-antihistamines, beta-2 agonists, and glucocorticoids are 2nd-line medications; Tables 5, 6, 7, 8; Figure 4 supplemental oxygen; IV fluid (crystalloid or colloid); cardiopulmonary resuscitation; H1- and H2-antihistamines, inhaled beta-2 agonists, and glucocorticoids are not initial medications of choice; Figures E2, E3 3rd-line interventions: H1- and H2-antihistamines, glucocorticoids; protocol for initial management includes cardiopulmonary resuscitation; systematic review of emergency management; Boxes 7, 15; online supplement; Figure 2
Management of refractory anaphylaxis intubation; ventilation; IV vasopressors; glucagon; anticholinergic; transfer to hospital (preferably to an emergency medicine, critical care medicine, or anesthesiology) team for ventilatory and inotropic support; checklist of needed items; Table 6 vasopressors; dopamine; give vasopressin if epinephrine injections and volume expansion fail to alleviate hypotension; transfer to hospital; glucagon; atropine; methylene blue; includes checklist of supplies and equipment; Figures E2, E3 glucagon
Observation and monitoring in healthcare settings observe for minimum 4 hrs; 8-10 hrs if respiratory or cardiovascular compromise; monitor BP, cardiac rate and function, respiratory status and oxygenation at frequent regular intervals, eg. 1-5 mins; continuous electronic monitoring if possible (essential if giving vasopressors); Table 5; Figure 4 individualize duration of observation; monitor BP and heart rate at frequent regular intervals (eg. 1 minute); continuous monitoring of BP, heart rate and function, and oxygenation, if possible; an example of a treatment record form for use in patients with anaphylaxis is provided; Figures E2, E4 minimum duration of observation 6-8 hrs for patients with respiratory symptoms and 12-24 hrs for those with hypotension or collapse; need for monitoring is highlighted; Box 7; online supplement; Figure 2
  1. 1For details, see ICON: Anaphylaxis text pages 5-8 and references 2, 3, and 4, including the tables, figures, boxes, and online supplemental materials from these references that are mentioned above in this Table.
  2. 2In the AAAAI/ACAAI Practice Parameters, one algorithm describes initial evaluation and management of a patient with a history of a previous episode of anaphylaxis and another algorithm describes treatment of an anaphylactic event in the outpatient setting.
  3. 3An evidence-based review of effectiveness of interventions for acute and long-term management is published separately.
  4. BP, blood pressure; IM, intramuscular; IV, intravenous.