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a pratice parameter
Adapted from: Ronna L. Campbell M.D. and the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology.
Diagnosis of anaphylaxis is clinical
Base the diagnosis of anaphylaxis on the history and physical examination, using scenarios described by the National Institutes of Allergy and Infectious Disease (NIAID) but recognizing that there is a broad spectrum of anaphylaxis presentations that require clinical judgment. Do not rely on signs of shock for the diagnosis of anaphylaxis. (Strong Recommendation; C Evidence)
Triage patients as priority one
Carefully and immediately triage and monitor patients with signs and symptoms of anaphylaxis in preparation for epinephrine administration. (Strong Recommendation; D Evidence)
Keep patients supine
In general, place patients in a supine position to prevent or counteract potential circulatory collapse. Place pregnant patients on their left side. (Moderate Recommendation; C Evidence)
Give oxygen
Administer oxygen to any patient exhibiting respiratory or cardiovascular symptoms or patients with decreased oxygen saturation and consider for all patients experiencing anaphylaxis regardless of their respiratory status. (Moderate Recommendation; D Evidence)
Consider alternative diagnosis
Expeditiously consider conditions other than anaphylaxis that might be responsible for the patient’s condition. Obtain a serum tryptase level to assist in this regard after effective treatment has been rendered. (Moderate Recommendation; C Evidence)
Risk stratify for fatal anaphylaxis
Determine whether the patient has risk factors for severe and potentially fatal anaphylaxis, such as delayed administration of epinephrine, asthma, a history of biphasic reactions, or cardiovascular disease, and consider these in the management and/or disposition of all patients with anaphylaxis. (Moderate Recommendation; B Evidence)
Immediate IM epinephrine
Administer epinephrine intramuscularly in the anterolateral thigh as initial treatment for acute anaphylaxis immediately after the diagnosis of anaphylaxis is made. The first line of treatment for patients experiencing anaphylaxis is epinephrine. (Strong Recommendation; B Evidence)
If refractory to IM epinephrine administer epinephrine infusion
If the patient is not responding to epinephrine injections, administer an IV infusion of epinephrine in a monitored setting. (Moderate Recommendation; C Evidence)
If no IV access go ahead with IO
If IV access is not readily available in patients experiencing anaphylaxis, obtain IO access and administer epinephrine by this route. (Moderate Recommendation; D Evidence)
Prepare for and establish an airway
Prepare for airway management, including intubation if necessary, if there is any suggestion of airway edema (eg, hoarseness or stridor) or associated respiratory compromise. (Moderate Recommendation; C Evidence)
Proceed with aggressive volume resuscitation
For patients with circulatory collapse from anaphylaxis, aggressively administer large volumes of IV or IO normal saline through large-bore catheters. (Strong Recommendation; B Evidence)
Administer glucagon if patient is not responding
Administer glucagon (especially if the patient is receiving b-blockers) if parenteral epinephrine and fluid resuscitation fail to restore blood pressure. (Moderate Recommendation; B Evidence)
Give Beta-agonist if bronchospasm
Administer an inhaled b-agonist if bronchospasm is a component of anaphylaxis. (Moderate Recommendation; B Evidence)
Consider ECMO in patients unresponsive to resuscitation
Consider extracorporeal membrane oxygenation in patients with anaphylaxis who are unresponsive to traditional resuscitative efforts. (Moderate Recommendation; D Evidence)
Antihistamines and steroids are only adjunctive therapy
Do not routinely administer antihistamines or corticosteroids instead of epinephrine. There is no substitute for epinephrine in the treatment of anaphylaxis. Administration of H1 and/or H2 antihistamines and corticosteroids should be considered adjunctive therapy. (Strong Recommendation; B Evidence)
Try to identify triggers
Identify triggers of anaphylaxis and consider obscure and less common triggers. (Moderate Recommendation; C Evidence)
Observe patients, particularly those with risk factors for severe anaphylaxis
Strongly consider observing patients who have experienced anaphylaxis for at least 4 to 8 hours and observe patients with a history of risk factors for severe anaphylaxis (eg, asthma, previous biphasic reactions, or protracted anaphylaxis) for a longer period. (Moderate Recommendation; C Evidence)
Prescribe auto injectable epinephrine and teach patient how to use it
Prescribe auto-injectable epinephrine for patients who have experienced an anaphylactic reaction and provide patients with an action plan instructing them on how and when to administer epinephrine. (Moderate Recommendation; C Evidence)
Give patients appropriate follow-up
Instruct patients who have experienced anaphylaxis when discharged from the ED to see an allergistimmunologist in a timely fashion. (Moderate Recommendation; C Evidence)
Management Anaphylaxis
Images 1 and 4  from Campbell, Ronna L., et al. "Emergency department diagnosis and treatment of anaphylaxis: a practice parameter." Annals of Allergy, Asthma & Immunology 113.6 (2014): 599-608. Image 2 from Greg Friese (flickr) under Creative Commons License. Image 3 from Cove and MacLaren Critical Care 2010 14:235. Clip art from