What is the management policy for Anaphylaxis?

From the Guidelines

Anaphylaxis management should prioritize immediate administration of epinephrine as the first-line treatment, without delay, to minimize morbidity and mortality. According to the most recent guidelines, administering epinephrine promptly is crucial, as delaying its administration may be associated with higher morbidity and mortality 1. The recommended dose of epinephrine for anaphylaxis is not explicitly stated in the most recent guideline, but previous studies suggest administering 0.3-0.5 mg of epinephrine intramuscularly in the mid-outer thigh for adults, and 0.15 mg for children weighing less than 30 kg and 0.3 mg for those over 30 kg 1.

Key Considerations

• Administer epinephrine as the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis, without delay 1
• Position the patient lying flat with legs elevated unless they are experiencing respiratory distress
• Provide supplemental oxygen if available and establish IV access for fluid resuscitation with normal saline
• Second-line medications include antihistamines and corticosteroids, though these do not replace epinephrine
• All patients experiencing anaphylaxis should be monitored for at least 4-6 hours after symptom resolution, with severe cases requiring 24-hour observation

Post-Treatment Care

After diagnosis and treatment of anaphylaxis, all patients should be kept under observation in a setting capable of managing anaphylaxis until symptoms have fully resolved 1. Upon discharge, patients should be prescribed an epinephrine auto-injector, provided with training on its use, and referred to an allergist to identify triggers. The most recent guidelines emphasize the importance of education on anaphylaxis, including avoidance of identified triggers, presenting signs and symptoms, biphasic anaphylaxis, treatment with epinephrine, and the use of epinephrine auto-injectors 1.

Recent Guidelines

The 2024 American Heart Association and American Red Cross guidelines for first aid also emphasize the importance of prompt epinephrine administration in the treatment of anaphylaxis, highlighting its role as the mainstay of immediate treatment 1. However, the most recent and highest quality study, published in 2020, provides the most comprehensive guidance on anaphylaxis management, including the importance of prompt epinephrine administration and post-treatment care 1.

From the FDA Drug Label

1 INDICATIONS & USAGE Adrenalin® is available as a single-use 1 mL vial and a multiple-use 30 mL vial for intramuscular and subcutaneous use. Emergency treatment of allergic reactions (Type I), including anaphylaxis, which may result from allergic reactions to insect stings, biting insects, foods, drugs, sera, diagnostic testing substances and other allergens, as well as idiopathic anaphylaxis or exercise-induced anaphylaxis.

5 WARNINGS AND PRECAUTIONS 5. 1 Incorrect Locations of Injection Injection into the anterolateral aspect of the thigh (vastus lateralis muscle) is the most appropriate location for administration because of its location, size, and available blood flow.

The management policy for anaphylaxis involves the administration of epinephrine (IM). Key points to consider are:

• Administration location: Inject into the anterolateral aspect of the thigh (vastus lateralis muscle) for optimal absorption and effectiveness.
• Contraindications and precautions: Use with caution in patients with heart disease, hyperthyroidism, Parkinson's disease, diabetes mellitus, pheochromocytoma, elderly individuals, and pregnant women 2 2.
• Allergic reactions: Be aware of the potential for allergic reactions to sulfite in susceptible individuals, but do not let this preclude the use of epinephrine in life-threatening situations.
• Signs and symptoms of anaphylaxis: Include flushing, apprehension, syncope, tachycardia, thready or unobtainable pulse associated with hypotension, convulsions, vomiting, diarrhea and abdominal cramps, involuntary voiding, airway swelling, laryngospasm, bronchospasm, pruritus, urticaria or angioedema, swelling of the eyelids, lips, and tongue.

From the Research

Anaphylaxis Management Policy

• Anaphylaxis is a life-threatening systemic reaction that requires immediate treatment with epinephrine 3, 4, 5, 6
• The administration of epinephrine should be prompt, with a dose of 0.3 to 0.5 mL of 1:1000 dilution intramuscularly for adults and 0.01 mg/kg for children, given in the lateral thigh 3, 4
• Patients with known anaphylactic reactivity should be prescribed an epinephrine auto-injector to be carried at all times for treatment of potential recurrences 3, 4, 5
• Education of the patient or parent regarding the proper use of the epinephrine auto-injector is crucial 3, 4, 5

Treatment Approach

• Epinephrine is the cornerstone of anaphylaxis management and should be administered immediately upon evidence of anaphylaxis 3, 4, 6
• Adjunct medications, such as histamine H1 and H2 antagonists, corticosteroids, beta2 agonists, and glucagon, should only be considered after epinephrine administration 5, 6
• Corticosteroids may be beneficial in reducing the length of hospital stay, but there is no compelling evidence to support or oppose their use in emergency treatment of anaphylaxis 7

Patient Care

• Patients should be monitored for a biphasic reaction (i.e., recurrence of anaphylaxis without reexposure to the allergen) for four to 12 hours, depending on risk factors for severe anaphylaxis 5
• Patient observation and disposition should be individualized, as there is no well-defined period of observation after resolution of signs and symptoms 6
• All patients at risk for anaphylaxis should carry 2 epinephrine autoinjectors and be taught and able to demonstrate how to use them 4