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Table 4 Standard protocol for anaphylaxis management

From: Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement

1. Initial steps
 • Call for assistance
 • Give epinephrine 1:1000 at a dose of 0.01 mg/kg IM in the lateral thigh (maximum 0.5 mg)
 • Lie patient flat with legs elevated unless this causes increased respiratory distress, in which case the patient may prefer to sit up. However, return to supine position if there is any deterioration in conscious state
 • Airway management (according to skills and equipment) if required
 • Document a simple systolic BP by palpation (radial/ brachial pulse) and then deflate the cuff to just below systolic pressure as a tourniquet and gain IV access. If equipment is available, start physiological monitoring (ECG, oxygen saturations, 5 minutely noninvasive BP) and give oxygen if severe respiratory distress and/or hypotension.
If the patient is hypotensive, also:
 b. Give IV normal saline bolus 20 mL/kg
 c. Gain additional wide bore IV access (14G or 16G in adults) and prepare to give additional fluid and/or adrenaline infusion if the patient does not respond to initial management
For upper airway obstruction/stridor, also:
 d. Continuous nebulization of epinephrine (5 mL of 1mg/ml)
2. If there is inadequate response, an immediate life-threatening situation or deterioration
 • Repeat IM epinephrine injection every 3–5 min as needed or start an IV epinephrine infusion as per hospital guidelines/protocol. Monitor BP closely. Nausea, vomiting, shaking, tachycardia or arrhythmias in the setting of normal or raised BP is likely to represent adrenaline toxicity rather than worsening anaphylaxis
If the patient remains hypotensive, also:
 • Further N/saline fluid boluses (up to 50 mL/kg in total) may be required in the first 20 min
 • In the hospital setting, consider adding a selective vasoconstrictor (see Table 1).
When indicated at any time, prepare to initiate cardiopulmonary resuscitation (CPR) including standard IV adrenaline dosing if the patient goes into cardiac arrest. Prolonged CPR is indicated because the arrest is usually sudden (no preceding hypoxia) and potentially reversible
3. Disposition
 • Consider to use systemic corticosteroids to prevent potential late phase reaction
Severe reactions should be monitored for a minimum 4 h after the last dose of adrenaline