Anaphylactic Shock

Anaphylactic Shock is an acute, life-threatening hypersensitivity disorder, with a generalized, rapidly evolving, multi-systemic allergic reaction (IgE-mediated disorder). If not treated rapidly can become fatal.

Scott Weingart, MD put together  a manual titled the Resuscitation Crisis Manual, which in short, is composed of two-page protocols for various situations that involve crashing patients.  On the 1st page are the immediate actions that must be taken to stabilize a crashing patient.  The second page includes additional information and less critical steps.  Anand Swaminathan, MD and I wrote the anaphylactic shock chapter and with Scott’s permission are publishing it here as FOAM.  We both highly recommend this manual and will put a link at the bottom of the post for you to consider buying it.

Immediate Steps:

1. Remove any triggers and call for assistance
2. Consider early intubation for airway compromise or impending obstruction as edema can progress rapidly
3. Give high-flow oxygen
4. Place 2 large bore IVs and infuse at least 20mL/kg of crystalloid
5. Administer epinephrine
6. If symptoms persist start an IV epinephrine infusion and consider an arterial line placement
7. If failure to respond try alternative agents listed in section below
8. Start adjunctive therapy once patient is hemodynamically stable

Additional Information:

• Intubation
  • Be prepared to perform emergent cricothyrotomy before attempting intubation (double set up)
  • Consider awake intubation if time permits
• Epinephrine
  • Nebulized: 5mg standard epinephrine (5mLs of 1mg/mL) nebulized if patient has stridor
  • IM Bolus: 0.3 to 0.5mg (1mg/mL)
  • IV Bolus: 5 to 20mcg (10mcg/mL)
  • IV Infusion: 1 to 20mcg/min
• If Poor Response to Conventional Therapy Consider
  • Epinephrine 100mcg IV bolus
  • Norepinephrine infusion 0.1mcg/kg/min
  • Vasopressin 0.01 to 0.04 U/min or 2U bolus (0.03U/kg)
  • Glucagon 1mg IV over 5 min (beta blocker reversal), may also start drip at 5 to 15mcg/min if needed (common side effect of nausea/vomiting)
  • Methylene blue 1.5 to 2mg/kg IV bolus followed by a continuous infusion of 0.5mg/kg/hr in refractory cases
• Adjunctive Therapy When Hemodynamically Stable
  • PO prednisone 1mg/kg (maximum of 50mg) or IV hydrocortisone 2 to 4 mg/kg (maximum 200mg) or IV dexamethasone 0.2 to 0.4 mg/kg (maximum 10mg) or IV methylprednisolone 125gm
  • Diphenhydramine 1 to 2mg/kg (up to 50mg)
  • H2 Blocker: Cimetidine 300mg or ranitidine 50mg PO or IV

Buy the Resuscitation Crisis Manual by Clicking on the Image Below

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)