From the Guidelines
Immediate management of anaphylaxis in pediatric patients in the emergency department requires prompt administration of epinephrine as the first-line treatment, with a recommended dose of 0.01 mg/kg (maximum 0.5 mg) of 1:1000 (1 mg/mL) solution intramuscularly in the mid-outer thigh, as supported by the American Academy of Pediatrics 1. This approach is crucial in reducing hospitalizations, morbidity, and mortality associated with anaphylaxis. The administration of epinephrine should be repeated every 5-15 minutes if needed, and for patients with persistent hypotension, consideration should be given to IV epinephrine infusion at 0.1-1 mcg/kg/min, as outlined in guidelines for anaphylaxis management 1.
Key Considerations in Anaphylaxis Management
- Remove the triggering agent if possible and place the patient in a supine position with legs elevated unless respiratory distress is present.
- Secure the airway and provide high-flow oxygen (10-15 L/min) via face mask.
- Establish IV access and administer fluid resuscitation with normal saline 20 mL/kg boluses for hypotension.
- Second-line medications include H1 antihistamines like diphenhydramine (1 mg/kg, max 50 mg IV/IM), H2 blockers such as ranitidine (1 mg/kg, max 50 mg IV), and corticosteroids like methylprednisolone (1-2 mg/kg IV) to prevent biphasic reactions.
- For bronchospasm, consider albuterol nebulization (2.5-5 mg).
Monitoring and Follow-Up
Continuous monitoring of vital signs, cardiac rhythm, oxygen saturation, and end-tidal CO2 is essential. All pediatric patients should be observed for at least 4-6 hours after symptom resolution due to the risk of biphasic reactions, with severe cases requiring admission. Before discharge, provide education on trigger avoidance and prescribe an epinephrine auto-injector with proper training, emphasizing the importance of prompt recognition and management of anaphylaxis in the community, as highlighted by the American Academy of Pediatrics 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.
For the management of anaphylaxis in the emergency department (ED) in a pediatric patient, epinephrine (IM) is indicated for emergency treatment. The signs and symptoms of anaphylaxis that may be treated with epinephrine 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 2
From the Research
Anaphylaxis Management in ED in Pediatric Patients
- Anaphylaxis is a potentially life-threatening event in children, commonly encountered in the prehospital and emergency department settings 3.
- The management of anaphylaxis in pediatric patients involves prompt recognition and treatment with epinephrine, as well as attention to airway patency, breathing, circulation, and mental status 4.
- A study of pediatric anaphylaxis in the prehospital setting found that the incidence of anaphylaxis is increasing, with common suspected allergens including nuts and dairy/milk formula 5.
- In the emergency department, anaphylaxis management may include:
- It is essential to prescribe self-injectable epinephrine and provide an action plan to patients with anaphylaxis, as well as to inform their schools and communities about the possible occurrence of reactions and the appropriate avoidance and rescue measures 4.
- The administration of epinephrine is critical for survival, and any delays in recognition or initiation of therapy can result in unnecessary increases in patient morbidity and mortality 7.