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

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; 2^nd-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 2^nd-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

3^rd-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