Anaphylaxis (peds) - Revision history

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← Older revision		Revision as of 09:28, 22 March 2026
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	==Management==		==Management==
	*~~'''~~[[Epinephrine]]~~'''~~		*[[Epinephrine]]
	**1:1000 '''IM''' 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes<ref>Dhami S. et al. Management of anaphylaxis: a systematic review. Allergy. 69 (2014) 168–175. http://onlinelibrary.wiley.com/store/10.1111/all.12318/asset/all12318.pdf?v=1&t=hrspdbpk&s=8067bfd5903c7ffebf4a274f062a71633ebe0507</ref><ref>Sheikh A, Shehata YA, Brown SGA, Simons FER. '''Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock.''' ''Cochrane Database of Systematic Reviews'' 2008, Issue 4. Art. No.: CD006312. DOI:10.1002/14651858.CD006312.pub2</ref>		**1:1000 '''IM''' 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes<ref>Dhami S. et al. Management of anaphylaxis: a systematic review. Allergy. 69 (2014) 168–175. http://onlinelibrary.wiley.com/store/10.1111/all.12318/asset/all12318.pdf?v=1&t=hrspdbpk&s=8067bfd5903c7ffebf4a274f062a71633ebe0507</ref><ref>Sheikh A, Shehata YA, Brown SGA, Simons FER. '''Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock.''' ''Cochrane Database of Systematic Reviews'' 2008, Issue 4. Art. No.: CD006312. DOI:10.1002/14651858.CD006312.pub2</ref>
	**Give as soon as possible		**Give as soon as possible
	**Always IM initially <ref>Simons FER, Gu X, Simons KJ. ~~'''~~[[Epinephrine]]absorption in adults: Intramuscular versus subcutaneous injection,~~'''~~ ''J Allergy Clin Immunol'' 2001;108:871-3 </ref>		**Always IM initially <ref>Simons FER, Gu X, Simons KJ. [[Epinephrine]]absorption in adults: Intramuscular versus subcutaneous injection, ''J Allergy Clin Immunol'' 2001;108:871-3 </ref>
	**If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min		**If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min
	**~~'''~~How to make a quick epinephrine drip:~~'''~~ ''Take your code-cart epinephrine (it does not matter if it is 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS. Final concentration is 1mcg/ml. Run at 1cc/min and titrate to effect''.		**How to make a quick epinephrine drip: ''Take your code-cart epinephrine (it does not matter if it is 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS. Final concentration is 1mcg/ml. Run at 1cc/min and titrate to effect''.
	*Pediatric: [[Epinephrine]] ~~'''~~1:1000 0.01mg/kg (max 0.5mg) IM~~'''~~ every 5 to 15 minutes		*Pediatric: [[Epinephrine]] 1:1000 0.01mg/kg (max 0.5mg) IM every 5 to 15 minutes
	**IV infusion: 0.05 - 1 mcg/kg/min		**IV infusion: 0.05 - 1 mcg/kg/min
	*~~'''~~Supplemental oxygen~~'''~~		*Supplemental oxygen
	**''Consider [[Intubation\|endotracheal intubation]] if airway edema present''		**''Consider [[Intubation\|endotracheal intubation]] if airway edema present''
	*~~'''~~Normal saline bolus~~'''~~		*Normal saline bolus
	**If unresponsive to [[epinephrine]] assume distributive [[Shock\|shock]] and give 1 - 2 liters of normal saline		**If unresponsive to [[epinephrine]] assume distributive [[Shock\|shock]] and give 1 - 2 liters of normal saline
	*~~'''~~Also consider~~'''~~		*Also consider
	**[[Albuterol]] for bronchospasm resistant to IM epinephrine		**[[Albuterol]] for bronchospasm resistant to IM epinephrine
	**[[Antihistamines]] (for symptom control AFTER hemodynamically stable)		**[[Antihistamines]] (for symptom control AFTER hemodynamically stable)
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	***If taking beta-blocker AND unresponsive to [[Epi\|epinephrine]]		***If taking beta-blocker AND unresponsive to [[Epi\|epinephrine]]
	**Consider adding additional pressor support if persistent hypotension present		**Consider adding additional pressor support if persistent hypotension present
	***For example: ~~'''~~[[vasopressin]]~~'''~~ 2-8 units for persistent refractory shock (case series only)<ref>Schummer et al. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 620-624.</ref><ref>Dünser et al. Treatment of Anaphylactic Shock: Where Is the Evidence? Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 359-361</ref>		***For example: [[vasopressin]] 2-8 units for persistent refractory shock (case series only)<ref>Schummer et al. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 620-624.</ref><ref>Dünser et al. Treatment of Anaphylactic Shock: Where Is the Evidence? Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 359-361</ref>
	***[[Norepinephrine]] 0.05 to 0.5 mcg/kg per minute		***[[Norepinephrine]] 0.05 to 0.5 mcg/kg per minute

Ostermayer at 21:00, 17 January 2026

2026-01-17T21:00:13Z

← Older revision		Revision as of 21:00, 17 January 2026
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	{{~~Peds top~~}}~~[[Anaphylaxis]].''~~		{{PediatricPage\|Anaphylaxis}}
	==Background==		==Background==
	*Type I [[Hypersensitivity Reaction\|hypersensitivity reaction]] that is either severe in nature or having two or more organ systems involved.		*Type I [[Hypersensitivity Reaction\|hypersensitivity reaction]] that is either severe in nature or having two or more organ systems involved.

Rossdonaldson1 at 17:31, 11 March 2024

2024-03-11T17:31:31Z

← Older revision		Revision as of 17:31, 11 March 2024
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	{{Peds top}}Anaphylaxis ~~(peds)~~.''		{{Peds top}}[[Anaphylaxis]].''
	==Background==		==Background==
	*Type I [[Hypersensitivity Reaction\|hypersensitivity reaction]] that is either severe in nature or having two or more organ systems involved.		*Type I [[Hypersensitivity Reaction\|hypersensitivity reaction]] that is either severe in nature or having two or more organ systems involved.

Rossdonaldson1: Created page with "{{Peds top}}Anaphylaxis (peds).'' ==Background== Type I hypersensitivity reaction that is either severe in nature or having two or more organ systems involved. Clinically Anaphylaxis and its treatment is virtually identical whether it is the traditional IgE dependent anaphylaxis reaction (vast majority), or the IgE independent ''anaphylactoid'' reaction *Precipitants Food (most common) Medications Insect stings Latex **Aerobic..."

2024-03-11T17:30:37Z

Created page with "{{Peds top}}Anaphylaxis (peds).'' ==Background== *Type I hypersensitivity reaction that is either severe in nature or having two or more organ systems involved. *Clinically Anaphylaxis and its treatment is virtually identical whether it is the traditional IgE dependent anaphylaxis reaction (vast majority), or the IgE independent ''anaphylactoid'' reaction *Precipitants **Food (most common) **Medications **Insect stings **Latex **Aerobic..."

New page

{{Peds top}}Anaphylaxis (peds).''
==Background==
*Type I [[Hypersensitivity Reaction|hypersensitivity reaction]] that is either severe in nature or having two or more organ systems involved.
*Clinically [[Anaphylaxis]] and its treatment is virtually identical whether it is the traditional IgE dependent anaphylaxis reaction (vast majority), or the IgE independent ''anaphylactoid'' reaction
*Precipitants
**Food (most common)
**Medications
**Insect stings
**Latex
**Aerobic exercise
**Idiopathic (rare)

==Clinical Features==
[[File:Hives2010.jpg|thumbnail|Raised [[urticaria]]]]
[[File:Angioedema2013.jpg|thumbnail|[[Angioedema]] of tongue]]
[[File:Angioedema2010.jpg|thumb|Angioedema of face.]]
*Cutaneous symptoms (90%)
**[[Hives]]
**[[Angioedema]]
**Itching
**Morbilliform rash
*Respiratory symptoms (70%)
**[[Wheezing]]
**[[Shortness of breath]]
**Throat itching or tightness
**Hoarseness
**Stridor
**Hypoxia, cyanosis
*Gastrointestinal symptoms (40%)
**Abdominal pain
**Nausea, vomiting
**[[Diarrhea]]
*Cardiovascular symptoms (35%)
**[[Hypotension]]
**Chest pain
**Palpitations
*Central Nervous System
**Uneasiness
**Altered mental status
**Headache, dizziness, confusion
**Syncope

===Expected Course===
====Uniphasic (80-90%)====
*Symptoms peak within 30 minutes to 1 hour after onset, resolve within 30 minutes to 1 hour of receiving treatment<ref>Ewan PW. '''ABC of allergies – Anaphylaxis,''' ''BMJ'' 1998; 316: 1442-1445 </ref>
====Biphasic (10-20%)====
''Biphasic reactions are rare and can occur anywhere from 10 minutes up to six days after an initial reaction.''<ref> Milne K. Biphasic Allergic Reactions: Observation, Treatment Guidelines http://www.acepnow.com/article/biphasic-allergic-reactions-observation-treatment-guidelines/</ref>
*Uniphasic response, followed by asymptomatic period of hour or more, then return of symptoms
*The second phase does not necessarily resemble the first!
*More likely with a severe initial presentation or repeated epinephrine doses. Additionally hypotension, widened pulse pressure, unknown trigger, and drug trigger in children<ref>Ellis AK, Day JH: Incidence and characteristics of biphasic anaphylaxis: A prospective evaluation of 103 patients. Ann Allergy Asthma Immunology. 2007; 98:64-69</ref><ref name="aaaai"/>
*Little evidence to support the use of discharge steroids to prevent a biphasic reaction
*0.4% of patients with anaphylaxis had a rebound event while in the ED<ref name="biphasic"/>

==Differential Diagnosis==
{{Acute Allergic DDX}}
{{Shock DDX}}
{{Erythematous rash DDX}}

==Evaluation==
''[[Anaphylaxis]] is highly likely when ANY ONE of the following criteria is fulfilled''<ref>Brown SGA, Mullins RJ and Gold MS. '''Anaphylaxis: diagnosis and management,''' ''MJA'' 2006; 185: 283–289 </ref><ref>Lieberman P et al. '''The diagnosis and management of anaphyalxis: An updated practice parameter,''' ''J Allergy Clin Immunol'' 2005;115;3:S483-S523 </ref>

===Criterion 1 (90% of patients)===
*Acute onset of an illness involving the skin, mucosal tissue, or both AND at least one of the following:
**Respiratory Compromise
**Reduced blood pressure or associated symptoms ([[Syncope]], [[Dizziness]])

===Criterion 2 (10-20% of patients)===
*TWO OR MORE of the following that occur rapidly after exposure to a LIKELY allergen for that patient
**Involvement of the skin-mucosal tissue (hives, swollen lips-tongue-uvula)
**Respiratory compromise
**[[Reduced BP|Hypotension]] or associated symptoms
**Persistent gastrointestinal symptoms: ([[Vomiting|vomiting]], [[Diarrhea|diarrhea]], crampy [[Abd Pain|abdominal pain]])

===Criterion 3===
*[[Reduced BP|Hypotension]] after exposure to a KNOWN allergy for that patient (minutes to hours):
**Adults: systolic blood pressure (SBP) <90 mmHg or >30% reduction from baseline
**Pediatrics
***1 month - 1 year: SBP <70 mmHg
***1 year - 10 years: SBP <(70 mmHg + [2 x age])
***11 years - 17 years: SBP <90 mmHg

==Management==
*'''[[Epinephrine]]'''
**1:1000 '''IM''' 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes<ref>Dhami S. et al. Management of anaphylaxis: a systematic review. Allergy. 69 (2014) 168–175. http://onlinelibrary.wiley.com/store/10.1111/all.12318/asset/all12318.pdf?v=1&t=hrspdbpk&s=8067bfd5903c7ffebf4a274f062a71633ebe0507</ref><ref>Sheikh A, Shehata YA, Brown SGA, Simons FER. '''Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock.''' ''Cochrane Database of Systematic Reviews'' 2008, Issue 4. Art. No.: CD006312. DOI:10.1002/14651858.CD006312.pub2</ref>
**Give as soon as possible
**Always IM initially <ref>Simons FER, Gu X, Simons KJ. '''[[Epinephrine]]absorption in adults: Intramuscular versus subcutaneous injection,''' ''J Allergy Clin Immunol'' 2001;108:871-3 </ref>
**If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min
**'''How to make a quick epinephrine drip:''' ''Take your code-cart epinephrine (it does not matter if it is 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS. Final concentration is 1mcg/ml. Run at 1cc/min and titrate to effect''.
*Pediatric: [[Epinephrine]] '''1:1000 0.01mg/kg (max 0.5mg) IM''' every 5 to 15 minutes
**IV infusion: 0.05 - 1 mcg/kg/min
*'''Supplemental oxygen'''
**''Consider [[Intubation|endotracheal intubation]] if airway edema present''
*'''Normal saline bolus'''
**If unresponsive to [[epinephrine]] assume distributive [[Shock|shock]] and give 1 - 2 liters of normal saline
*'''Also consider'''
**[[Albuterol]] for bronchospasm resistant to IM epinephrine
**[[Antihistamines]] (for symptom control AFTER hemodynamically stable)
***[[Diphenhydramine]]: 25 to 50mg IV (1mg/kg in children)
***[[Ranitidine]]: 50mg IV (0.5mg/kg in children) (has been found to improve urticaria but not angioedema at 2 hours<ref>Lin, RY et al. Improved Outcomes in Patients With Acute Allergic Syndromes Who Are Treated With Combined H1 and H2 Antagonists. Annals of Emergency Medicine. 36:5 NOVEMBER 2000.</ref>)
***AVOID promethazine as this can worsen hypotension
**Glucocorticoid
***MAY blunt biphasic reaction although little evidence to support usage<ref>Choo KJ, Simons E, Sheikh A: Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2010; 65:1205-1211.</ref>
***[[Methylprednisolone]]: 125mg IV (2mg/kg in children)
***[[Dexamethasone]]: 10mg IV or PO (0.6mg/kg in children)
**[[Glucagon]]
***1 - 5mg IV over 5 minutes followed by infusion of 5 - 15 µg/min<ref>Campbell RL, et al. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014; 113:599e608.</ref>
***If taking beta-blocker AND unresponsive to [[Epi|epinephrine]]
**Consider adding additional pressor support if persistent hypotension present
***For example: '''[[vasopressin]]''' 2-8 units for persistent refractory shock (case series only)<ref>Schummer et al. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 620-624.</ref><ref>Dünser et al. Treatment of Anaphylactic Shock: Where Is the Evidence? Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 359-361</ref>
***[[Norepinephrine]] 0.05 to 0.5 mcg/kg per minute

==Disposition==
===Admit===
*Severe and moderate presentations, especially if symptoms did not respond promptly to epinephrine or required repeat dosing
*Labs that may be requested by allergist/admitting team if uncertain diagnosis
**Histamine level - serum elevation 30-60 min following anaphylaxis, window easily missed
**Tryptase - peaks at 2-4 hrs, remains elevated 6-12 hrs

===Discharge===
*Consider discharge after 1 hour observation, if no severe symptoms and no repeat epinephrine doses (AAAAI recommendations)<ref name="aaaai">Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol 2020; 145:1082. https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Professional%20Education/Podcasts/Anaphylaxis-2020-grade-document.pdf</ref>
**NPV of 1-hour observation was 95%, with NPV for biphasic anaphylaxis after >6 hours of observation of 97.3% <ref>Shaker M, Wallace D, Golden DBK, Oppenheimer J, Greenhawt M. Simulation of health and economic benefits of extended observation of resolved anaphylaxis. JAMA Netw Open 2019;2:e1913951.</ref>
*Send home with an [[epinephrine]] autoinjector! (Epi-Pen)
**Up to 6% of the people with anaphylaxis have a repeat ED visit for anaphylaxis within 7 days<ref name="biphasic">Grunau BE et al. Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients With Allergic Reactions or Anaphylaxis. Ann Emerg Med. 2013 Nov 13</ref>

==See Also==
*[[Allergic Reaction]]
*[[Angioedema]]

==External Links==

==References==
<references/>

[[Category:Critical Care]]