What items should be included in an anaphylaxis kit and what is the proper emergency management protocol?

Anaphylaxis Kit Contents and Emergency Management

An anaphylaxis emergency kit must contain intramuscular epinephrine as the primary life-saving medication, with additional supplies for airway management, IV access, and adjunctive medications—epinephrine autoinjectors (0.15 mg for children <25 kg, 0.3 mg for those ≥25 kg) are the cornerstone, and all other interventions are secondary. 1

Essential Kit Components

Primary Medication (Life-Saving)

• Epinephrine autoinjectors: Stock both 0.15 mg and 0.3 mg doses
  • 0.15 mg for children weighing <25 kg
  • 0.3 mg for children/adults ≥25 kg and teenagers
  • Alternative: Epinephrine 1:1000 solution with syringes for IM injection (0.01 mg/kg, max 0.3 mg prepubertal, 0.5 mg teenager/adult) 1

Adjunctive Medications (Second-Line)

• Diphenhydramine (H1-antihistamine): 1-2 mg/kg or 25-50 mg parenterally 2
• Ranitidine (H2-antihistamine): 1 mg/kg IV (diluted in D5W, given over 5 minutes)—combination with diphenhydramine is superior to diphenhydramine alone 2
• Albuterol for nebulization: 2.5-5 mg in 3 mL saline for bronchospasm resistant to epinephrine 2
• Methylprednisolone or equivalent corticosteroid: 1-2 mg/kg/day IV (may prevent biphasic reactions but no acute benefit) 2

Refractory Anaphylaxis Medications

• Glucagon: 1-5 mg IV (20-30 mcg/kg in children, max 1 mg) for patients on beta-blockers 2
• Dopamine: 400 mg in 500 mL D5W for hypotension refractory to epinephrine and fluids 2

Equipment and Supplies

• Oxygen delivery system with high-flow capability
• IV access supplies: Catheters, normal saline or lactated Ringer's for rapid volume expansion
• Airway management: Bag-valve-mask, oral/nasal airways
• Blood pressure cuff and stethoscope (or automated BP monitor)
• Pulse oximeter
• Syringes and needles for medication administration
• Written anaphylaxis emergency action plan posted visibly 1

Emergency Management Protocol

Immediate Actions (First 60 Seconds)

1. Recognize anaphylaxis using clinical criteria—look for acute onset (minutes to hours) involving ≥2 organ systems:

   • Skin: Urticaria, angioedema, flushing, pruritus
   • Respiratory: Dyspnea, wheeze, stridor, hypoxemia, throat tightness
   • Cardiovascular: Hypotension, tachycardia, syncope, chest pain
   • Gastrointestinal: Cramping, vomiting, diarrhea
   • Neurologic: Confusion, sense of doom, altered mental status 1

2. Call for help immediately: 911/EMS in community settings, resuscitation team in healthcare facilities 1

3. Inject epinephrine IM in mid-outer thigh (vastus lateralis) without delay—this is the single most important intervention 1

4. Position patient appropriately:

   • Supine with legs elevated (improves venous return)
   • If respiratory distress/vomiting: position of comfort
   • Never allow standing, walking, or sitting upright—sudden postural changes can precipitate cardiovascular collapse 1

Subsequent Management (Minutes 1-15)

1. Assess airway, breathing, circulation continuously

   • Administer high-flow oxygen (8-10 L/min via face mask)
   • Establish IV access and begin rapid fluid resuscitation with 20 mL/kg bolus of normal saline if hypotensive 2

2. Repeat epinephrine at 5-15 minute intervals if:

   • Inadequate response to first dose
   • Symptoms progress or recur
   • 6-19% of pediatric patients require a second dose 1

3. Administer adjunctive medications (only after epinephrine):

   • Diphenhydramine + ranitidine (H1 + H2 blockade)
   • Nebulized albuterol if bronchospasm persists
   • Corticosteroids for patients with asthma or severe/prolonged reactions 2

Refractory Anaphylaxis Management

1. For hypotension unresponsive to 2-3 epinephrine doses + fluids:

   • Start dopamine infusion (2-20 mcg/kg/min, titrate to BP)
   • Consider epinephrine infusion (1 mg in 250 mL D5W at 1-4 mcg/min) with continuous hemodynamic monitoring 2

2. For patients on beta-blockers:

   • Administer glucagon 1-5 mg IV over 5 minutes, followed by infusion
   • Watch for nausea/vomiting (aspiration risk) 2

Observation and Disposition

1. Monitor for biphasic reactions: Observe 4-12 hours depending on severity and risk factors (asthma, delayed epinephrine, severe initial presentation) 3, 4

2. Discharge planning:

   • Prescribe epinephrine autoinjectors (≥2 devices)
   • Provide written anaphylaxis emergency action plan
   • Refer to allergist for trigger identification and immunotherapy consideration
   • Education on autoinjector technique and when to use 1

Critical Pitfalls to Avoid

• Delaying epinephrine administration: Fatal anaphylaxis is strongly associated with delayed or absent epinephrine—inject at first recognition 1
• Using antihistamines or corticosteroids as first-line treatment: These have slow onset (hours) and do not treat life-threatening symptoms 2
• Allowing patient to stand or walk: Sudden postural changes can trigger fatal cardiovascular collapse 1
• Inadequate observation period: Biphasic reactions occur in up to 20% of cases, typically within 4-12 hours 3
• Subcutaneous or IV epinephrine in stable patients: IM route in thigh provides optimal absorption; IV epinephrine reserved for cardiac arrest or profound shock with continuous monitoring 2