What is the recommended order of treatment for an anaphylactic (severe allergic) reaction?

Treatment Order for Anaphylactic Reaction

The correct order of treatment for anaphylactic reaction is epinephrine 1:1000, followed by hydrocortisone, then promethazine (option B). 1

Primary Treatment: Epinephrine

Epinephrine is universally recommended as the first-line treatment for anaphylaxis and should be administered immediately upon recognition of anaphylactic symptoms:

• Administer epinephrine 1:1000 (1 mg/mL) intramuscularly into the anterolateral thigh at a dose of 0.01 mg/kg, up to 0.5 mg in adults and 0.3 mg in children 1
• There are no absolute contraindications to epinephrine use in anaphylaxis 1
• Additional doses may be administered every 5-15 minutes if symptoms persist 1

Why epinephrine first?

• Epinephrine is both inotropic and a bronchodilator
• It reduces further mediator release from mast cells
• Delays in epinephrine administration may be fatal 2
• Antihistamines or corticosteroids should never be administered before or in place of epinephrine 1, 3

Secondary Treatments

After administering epinephrine, the following adjunctive therapies should be provided in this order:

Hydrocortisone (second)

• Administer hydrocortisone 200 mg IV (adult dose) 1
• While glucocorticoids have a slow onset of action and no proven role in acute anaphylaxis management, they are commonly used as adjunctive therapy 1

Promethazine/Antihistamines (third)

• Administer antihistamines such as promethazine or chlorphenamine (10 mg IV for adults) 1
• Antihistamines are appropriate for managing cutaneous symptoms but have no effect on respiratory or cardiovascular manifestations 1
• They should not be relied upon to prevent biphasic anaphylaxis 1

Additional Management Steps

1. Position the patient in a recumbent position with elevated lower extremities if cardiovascular symptoms are present 1
2. Establish and maintain airway - provide oxygen to patients with respiratory distress 1
3. Administer IV fluids (normal saline) early with the first epinephrine dose for patients with cardiovascular involvement 1
4. Monitor for biphasic reactions - observe patients for 4-12 hours, particularly those with severe reactions or who required multiple doses of epinephrine 1, 4

Common Pitfalls to Avoid

• Delaying epinephrine administration - this is the most common and dangerous error in anaphylaxis management 3
• Using subcutaneous instead of intramuscular route for epinephrine - IM administration into the anterolateral thigh provides faster and more reliable absorption 1
• Relying solely on antihistamines - they do not relieve or prevent serious complications such as airway obstruction, hypotension, and shock 5
• Using epinephrine 1:100 concentration (option D is incorrect) - the appropriate concentration for IM administration is 1:1000 1
• Starting with hydrocortisone or promethazine (option C is incorrect) - this delays the administration of life-saving epinephrine 1, 3

Remember that the benefits of prompt epinephrine administration far outweigh the risks of transient side effects such as pallor, tremor, anxiety, and palpitations 3.