Table 1 Physician-Supervised Management of Anaphylaxis

   a. Assessment of airway, breathing, circulation, and adequacy of mentation

   b. Administer aqueous epinephrine 1:1,000 dilution, 0.2-0.5 mL (0.01 mg/kg in children; maximum dose 0.3 mg) intramuscularly every 5 min, as necessary, to control symptoms and blood pressure.

II. Possibly appropriate, subsequent measures depending on response to epinephrine

   a. Place patient in a recumbent position and elevate the lower extremities.

   b. Establish and maintain an airway.

   c. Administer oxygen.

   d. Establish venous access.

   e. Normal saline IV for fluid replacement.

III. Specific measures to consider after epinephrine injections, where appropriate

   a. An epinephrine infusion might be prepared. Continuous hemodynamic monitoring is essential. (See Lieberman et al [1] for specific details.)

   b. Diphenhydramine. In the management of anaphylaxis, a combination of diphenhydramine and ranitidine is superior to diphenhydramine alone.

   c. For bronchospasm resistant to epinephrine, use nebulized albuterol.

   d. For refractory hypotension, consider dopamine, 400 mg in 500 mL D₅W, administered intravenously at a rate of 2-20 μg/kg/min titrated to maintain adequate blood pressure. Continuous hemodynamic monitoring is essential.

   e. Where use of β-blockers complicates therapy, consider glucagon, 1-5 μg (20-30 mg/kg [maximum 1 mg in children]), administered intravenously over 5 min followed by an infusion, 5-15 μg/min. Aspiration precautions should be observed.

   f. For patients with a history of asthma and for those who experience severe or prolonged anaphylaxis, consider methylprednisolone (1.0-2.0 mg/kg/d).

   g. Consider transportation to the emergency department or an intensive care facility.

IV. Interventions for cardiopulmonary arrest occurring during anaphylaxis High-dose epinephrine and prolonged resuscitation efforts are encouraged, if necessary, since efforts are more likely to be successful in anaphylaxis where the patient (often young) has a healthy cardiovascular system. (See Lieberman et al [1] for specific details.)

VI. Observation and subsequent outpatient follow-up

Observation periods after apparent resolution must be individualized and based on such factors as the clinical scenario, comorbid conditions, and distance from the patient's home to the closest emergency department. After recovery from the acute episode, patients should receive epinephrine syringes and be instructed in proper technique. Everyone postanaphylaxis requires a careful diagnostic evaluation in consultation with an allergist-immunologist.