What are the next steps for a 14-year-old patient who received two EpiPens (epinephrine) in the field and continues to have retractions?

Management of Anaphylaxis in a 14-Year-Old with Persistent Retractions After Two Epinephrine Doses

For a 14-year-old patient with persistent retractions despite receiving two doses of epinephrine in the field, you should immediately administer a third dose of epinephrine (0.01 mg/kg up to 0.3 mg) intramuscularly, provide supplemental oxygen, establish IV access for fluid resuscitation, and consider inhaled beta-2 agonists for bronchospasm. 1

Immediate Actions

• Administer a third dose of epinephrine 0.01 mg/kg (maximum 0.3 mg) intramuscularly into the vastus lateralis (mid-outer thigh) if retractions persist, as epinephrine should be given every 5-15 minutes when anaphylaxis signs or symptoms persist 1

• Provide supplemental oxygen at 6-8 L/min to address respiratory distress 1

• Position the patient in a way that optimizes breathing - typically sitting up if respiratory symptoms predominate 1

• Establish intravenous access immediately for fluid administration 1

• Begin fluid resuscitation with normal saline; children can receive up to 30 mL/kg in the first hour 1

Respiratory Support

• For persistent retractions and lower respiratory symptoms, administer inhaled beta-2 agonists (albuterol/salbutamol) following epinephrine 1

• Continue to monitor oxygen saturation, respiratory rate, and work of breathing 1

• Prepare for potential airway intervention if retractions worsen despite treatment 2

Ongoing Management

• Monitor vital signs continuously, including heart rate, blood pressure, respiratory rate, and oxygen saturation 1

• Consider adjunctive therapy with H1-antihistamines (diphenhydramine 1-2 mg/kg or 25-50 mg) for cutaneous symptoms only, but never in place of epinephrine 1

• Consider H2-blockers such as ranitidine (1 mg/kg) as adjunctive therapy 1

• Glucocorticoids may be administered to potentially prevent biphasic reactions, though evidence for their effectiveness is limited 1

Risk Assessment for Biphasic Reactions

• This patient is at high risk for biphasic anaphylaxis due to:

  • Requiring multiple doses of epinephrine 1
  • Persistent respiratory symptoms 1
  • Adolescent age group 1

• Extended observation (minimum 4-6 hours, potentially longer) in a setting capable of managing recurrent anaphylaxis is essential 1

Special Considerations for Adolescents

• Adolescents are at particularly high risk for fatal anaphylaxis due to:
  • Tendency to engage in risky behaviors 1
  • Potential failure to recognize triggers 1
  • Possible denial of symptoms 1
  • Reluctance to carry or use emergency medications 1

Common Pitfalls to Avoid

• Do not delay additional epinephrine doses when symptoms persist - this is associated with increased morbidity and mortality 2

• Do not rely solely on antihistamines or glucocorticoids - they should never be used instead of epinephrine and have no proven role in treating acute respiratory symptoms 1

• Do not discharge the patient too early - extended observation is necessary due to the risk of biphasic reactions, especially after multiple epinephrine doses 1

• Do not place the patient in a standing position as this can worsen hypotension and compromise circulation 1

• Do not assume the reaction is resolving based on improvement of cutaneous symptoms alone - respiratory and cardiovascular symptoms determine severity 1