Table 2. Summary of the Pharmacologic Management of Anaphylaxis (continued)
In the Hospital-Based Setting
ÎFirst-line treatment: > Epinephrine IM as in the outpatient setting Note: consider continuous epinephrine infusion for persistent hypotension (ideally with continuous noninvasive monitoring of blood pressure and heart rate); alternatives are endotracheal or intra-osseous epinephrine
ÎAdjunctive treatment: > Bronchodilator (β2
> H1
▶ MDI (child: 4-8 puffs; adult: 8 puffs) or ▶ Nebulized solution (child: 1.5 mL; adult: 3 mL) every 20 minutes or continuously as needed
-agonist): albuterol
▶ 1-2 mg/kg per dose ▶ Maximum dose, 50 mg IV or oral (oral liquid is more readily absorbed than tablets)
antihistamine: diphenhydramine > H2
▶ Alternative dosing may be with a less-sedating second generation antihistamine antihistamine: ranitidine
> Corticosteroids ▶ Prednisone at 1 mg/kg with a maximum dose of 60-80 mg oral or ▶ Methylprednisolone at 1 mg/kg with a maximum dose of 60-80 mg IV
▶ 1-2 mg/kg per dose ▶ Maximum dose, 75-150 mg oral and IV
> Vasopressors (other than epinephrine) for refractory hypotension, titrate to effect > Glucagon for refractory hypotension, titrate to effect
> Atropine for bradycardia, titrate to effect > Supplemental oxygen therapy > IV fluids in large volumes if patient presents with orthostasis, hypotension, or incomplete response to IM epinephrine
▶ Child: 20-30 mcg/kg ▶ Adult: 1-5 mg ▶ Dose may be repeated or followed by infusion of 5-15 mg/min
Therapy for the Patient at Discharge ÎFirst-line treatment:
> Epinephrine auto-injector prescription (2 doses) and instructions > Education on avoidance of allergen > Follow-up with primary care physician > Consider referral to an allergist
ÎAdjunctive treatment: > H1
> H2
antihistamine: diphenhydramine every 6 hours for 2-3 days; alternative dosing with a nonsedating second generation antihistamine antihistamine: ranitidine twice daily for 2-3 days > Corticosteroid: prednisone daily for 2-3 days
9
> Place the patient in recumbent position if tolerated, with the lower extremities elevated
