What should be included in an emergency box for managing vascular occlusion (VO) reactions and anaphylaxis, considering the backorder of Hyaluronidase (hyaluronidase) and the availability of an EpiPen (epinephrine auto-injector)?

Emergency Box Contents for Vascular Occlusion and Anaphylaxis Management

Your emergency box must contain epinephrine autoinjectors (EpiPen) as the absolute first-line treatment for anaphylaxis, with written step-by-step protocols immediately accessible for both vascular occlusion and anaphylaxis scenarios. 1, 2

Essential Medications and Equipment

For Anaphylaxis Management

Primary Medications:

• Epinephrine 1:1000 (1 mg/mL) solution for intramuscular injection - this is your life-saving first-line agent 1
• EpiPen autoinjectors (0.3 mg for adults, 0.15 mg for children <25 kg) - keep at least 2 doses available as 10-20% of patients require repeat dosing 1, 2
• Diphenhydramine 25-50 mg injectable (second-line only, never alone) 1
• Ranitidine 50 mg or famotidine injectable (H2-blocker, superior when combined with H1-antihistamine) 1, 2
• Hydrocortisone or methylprednisolone for IV injection (may prevent biphasic reactions) 1

Equipment:

• Stethoscope and sphygmomanometer 1
• Tourniquets, syringes, and large-bore needles (14-gauge) 1
• Oxygen delivery equipment with mask 1
• IV fluid setup with normal saline 1
• Nebulized albuterol 2.5-5 mg for refractory bronchospasm 1
• Pulse oximeter for continuous monitoring 1

For Vascular Occlusion Management

Hyaluronidase Supply:

• Given the 1500 U/2 mL backorder, your 2×150 U/10 mL vials are inadequate for true emergencies 3, 4
• High-dose pulsed hyaluronidase (HDPH) protocol requires 150-1500 units per treatment area, repeated hourly until resolution 3
• You need immediate access to additional hyaluronidase sources for emergencies - document your backup supplier contacts in writing 5, 3
• Reconstituted hyaluronidase remains stable and can be stored (consensus practitioners keep it longer than package inserts suggest) 6

Written Emergency Protocols Required

Anaphylaxis Protocol (Must Be Laminated in Emergency Box)

Immediate Recognition Criteria:

• Acute onset with skin/mucosal involvement (hives, swelling, itching) PLUS respiratory compromise (stridor, wheeze, dyspnea) OR hypotension/syncope 1, 2
• OR two or more organ systems involved: skin, respiratory, cardiovascular, gastrointestinal 1
• Critical: Skin signs absent in 10% of cases; isolated hypotension after allergen exposure = anaphylaxis 2

Step-by-Step Treatment Algorithm:

1. Call 911/activate emergency response immediately 1, 2

2. Inject epinephrine 0.3-0.5 mg IM (1:1000) into mid-outer thigh (vastus lateralis) immediately - achieves peak levels in 8 minutes vs 34 minutes subcutaneous 1, 2

3. Position patient supine with legs elevated - NEVER allow standing/walking as this increases mortality 1, 2

4. Repeat epinephrine every 5 minutes if symptoms persist or worsen - no maximum number of doses exists 2

   • 6-28% require second dose 1, 2
   • Continue until symptoms resolve 2
   • Maximum single dose: 0.5 mg regardless of weight 2

5. Administer oxygen via mask 1

6. Establish IV access with normal saline bolus 1-2 L for adults (30 mL/kg for children in first hour) 1

7. Give diphenhydramine 25-50 mg IV/IM PLUS ranitidine 50 mg IV (second-line, never alone) 1

8. Nebulized albuterol 2.5-5 mg if bronchospasm persists despite epinephrine 1

9. Consider hydrocortisone 100-200 mg IV for severe/prolonged reactions 1

10. Transport to emergency department even if symptoms resolve - observe 4-6 hours minimum for biphasic reactions 1

Critical Pitfall: Delayed epinephrine is the leading cause of anaphylaxis fatalities - inject immediately, not after antihistamines 1, 2

Vascular Occlusion Protocol (Must Be Laminated in Emergency Box)

Recognition Criteria:

• Immediate severe pain at injection site 3, 4
• Skin blanching, mottling, or livedo reticularis 3, 4
• Loss of capillary refill 3
• Dusky or white discoloration 3, 4

High-Dose Pulsed Hyaluronidase Protocol:

1. Stop injection immediately if vascular occlusion suspected 3, 4

2. Inject hyaluronidase 150-1500 units directly into ischemic tissue (dose varies with tissue volume affected) 3, 4

   • Use multiple injection points throughout affected area 3, 4
   • Inject along vessel distribution if known 3, 4

3. Repeat hyaluronidase injections hourly until resolution 3, 4

   • Monitor capillary refill, skin color, and pain 3
   • Continue until normal perfusion restored 3

4. If implemented within 2 days of onset, protocol prevents skin necrosis in most cases 3

5. Document your backup hyaluronidase sources with 24/7 contact numbers - 45.6% of California ERs lack immediate access 5

Your Current Supply Problem: With only 300 units total (2×150 U vials), you have enough for initial treatment of a small area but insufficient for the hourly repeat dosing required by evidence-based protocols 3, 4. This represents a significant patient safety gap that must be addressed immediately.

Additional Critical Considerations

Hyaluronidase Safety Profile

• Anaphylaxis to hyaluronidase is extremely rare (1% reported by practitioners) 6
• Do NOT perform routine skin testing - consensus experts avoid this practice 6
• Even patients with bee/wasp sting anaphylaxis history can receive hyaluronidase in emergencies 6
• Mild injection site reactions (redness, swelling) are common and expected 7, 8

Drug Interactions to Document

• Incompatible with hyaluronidase: furosemide, benzodiazepines, phenytoin, dopamine, alpha-agonists 7
• Reduce hyaluronidase effectiveness: salicylates, corticosteroids, antihistamines (may need higher doses) 7

Epinephrine Absolute Truths

• No absolute contraindication to epinephrine in anaphylaxis - even in elderly or cardiac patients, untreated anaphylaxis is more dangerous 1, 2
• Fatalities result from delayed epinephrine, not from multiple doses 2
• IV epinephrine reserved only for cardiac arrest or profound hypotension unresponsive to IM doses and fluids - carries significant arrhythmia risk 1, 2

Storage and Expiration Management

• Check autoinjector expiration dates monthly 1
• Store away from temperature extremes and direct sunlight 1
• Hyaluronidase degrades without visible discoloration 1

Bottom Line: Your emergency preparedness is incomplete without adequate hyaluronidase supply and laminated, step-by-step protocols immediately accessible in your treatment room. The written protocols eliminate decision-making paralysis during high-stress emergencies when cognitive load is maximal. 1