(a)  Assess rapidly.  Alert emergency personnel.

(b)  Place patient in a recumbent or trendelenburg position.

(c)  Place a tourniquet above injection/sting site(s) to delay absorption of the antigen.  Release the tourniquet for 1 to 2 minutes, every 10 minutes.

(d)  Establish an airway and provide supplemental oxygen. Inject epinephrine (1:1000) 0.01 ml/kg (max. 0.3 to 0.5 cc) subcutaneously opposite the site of injection every 20 minutes x 3.  If asthma or wheezing is present, use 0.5 cc.  Some have advocated injection of    0.1 to 0.2 cc of epinephrine into the site of the inoculation or sting.  Do not consider this procedure if the allergic response site is on the head, neck, hands, or feet.  Prompt recognition of anaphylaxis and use of epinephrine is critical.  Epinephrine treatment delay can lead to the risk of fatality.

For pediatric patients administer epinephrine according to weight as follows: 

Continuously monitor vital signs, maintain an open airway, establish intravenous (IV) access, and attach a cardiac monitor.  Treat for shock if present.

(e)  Give IV Ringer's Lactate: 1 to 2 liters (or 20 ml/kg for children.

(f)  Give dopamine 2 - 20 mg/kg/min, only if there is difficulty in maintaining an adequate blood pressure.

[Mix 800 mg in 500 cc D5W to make solution of 1600 mg/ml.  For a 50 kg patient:

• 5   mg/kg/min = 9.4 microdrops/min,

• 10 mg/kg/min = 19 microdrops/min,

• 15 mg/kg/min = 28 microdrops/min,

• 20 mg/kg/min = 37.5 microdrops/min.

(g) Other recommendations as needed include the following:

• Give Diphenhydramine (Benadryl), 1.25 mg/kg (max. 50 mg) IV over 3 to 5 minutes.  THIS IS NOT A SUBSTITUTE FOR EPINEPHRINE.

• Give Cimetidine (Tagamet), 5 mg/kg (maximum 300 mg) IV over 3 to 5 minutes.

• Give Aminophyline, 5 mg/kg IV over 20 minutes.  Then give 0.5 to 1.0 mg/kg/hr for severe bronchospasm, if blood pressure (BP) and pulse are stable.

(h)  Glucagon

• 1 to 2 mg IV bolus, with continuous infusion of 1 to 5 mg per hour if the patient is not responding to epinephrine due to beta-blocker use.

(4) Late phase reactions

(a)  It is important to realize that some patients will resolve their anaphylaxis only to have a spontaneous recurrence 8 to 24 hours later.

• Bronchodialators prevent the early phase, not the late phase.

• Corticosteroids may prevent the late, but not the early phase.

• Cromolyn prevents the early and late phases.

(b)     Corticosteroids given during the initial phase of anaphylaxis does not prevent the appearance of recurrent or protracted anaphylaxis.  Steroids may lessen the chances or decrease the intensity of recurrence, but cannot be relied upon to eliminate this response.  However, in severe reactions, it is reasonable to start steroids early to modify or perhaps prevent protracted or recurrent symptoms.  The dose for Methylprednisolone is 2 mg/kg, followed by 1 mg/kg every 6 hours.

(c)  Individuals who have experienced an anaphylactic episode require 12 to 24 hours of observation.

(d)  All persons with known or suspected anaphylactic episodes require a careful history and clinical evaluation in consultation with Internal Medicine or Allergy.  Patients should carry epinephrine and Medic Alert identification.

Submitted by CAPT Jay R. Montgomery, MC, USN, MED-22, Surface Warfare Medicine, BUMED, Washington, D.C. (1999).  Revised by CAPT J.E. Murnane III, MC, USN, Allergy/Immunology Specialty Leader, Allergy/Immunology Clinic, Naval Medical Center Portsmouth, Portsmouth, VA  (1999).