13
8. Epinephrine intramuscular Repeat intramuscular epinephrine every 5-15
min for ≤3 injections if the patient is not
responding
9. EMS Activate EMS (call 911 or local rescue squad)
if no immediate response to first dose of
intramuscular epinephrine or if anaphylaxis is
moderate to severe (grade ≥2 on World Allerg y
Organization grading scale (Simons FE, Ardusso
LR, Bilo MB, et al. J Allerg y Clin Immunol.
2011;127:587e593.)
10. Intravenous fluids Establish intravenous line for venous access
and fluid replacement; keep open with 0.9%
(normal) saline, push fluids for hypotension or
failure to respond to epinephrine using 5-10 mL/
kg as quickly as possible and ≤30 mL/kg in first
hour for children and 1-2 L for adults
Additional measures
11. Albuterol Consider administration of 2.5-5 mg of
nebulized albuterol in 3 mL of saline for lower
airway obstruction; repeat as necessary every
15 min
12. Glucagon Patients on β-blockers who are not responding to
epinephrine should be given 1-5 mg of glucagon
intravenously slowly over 5 min because rapid
administration of glucagon can induce vomiting
13. Epinephrine infusion For patients with inadequate response to
intramuscular epinephrine and intravenous
saline, give epinephrine by continuous infusion
by micro-drip in office setting (infusion pump
in hospital setting ); add 1 mg (1 mL of 1:1,000)
of epinephrine to 1,000 mL of 0.9% (normal)
saline; start infusion at 2 μg/min (2 mL/min =
120 mL/h) and increase up to 10 μg/min (10
mL/min = 600 mL/h); titrate dose continuously
according to blood pressure, cardiac rate and
function, and oxygenation
14. Intraosseous access If intravenous access is not readily available in
patients experiencing refractory anaphylaxis,
obtain intraosseous access for administration of
intravenous fluids and epinephrine infusion
Table 8. Anaphylaxis Treatment Protocol in the Physician's
Office (cont'd)
