Allergic Reaction / Anaphylaxis
History
Signs and Symptoms
Differential
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·
·
·
·
·
·
·
·
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·
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Onset and location
Insect sting or bite
Food allergy / exposure
Medication allergy / exposure
New clothing, soap, detergent
Past history of reactions
Past medical history
Medication history
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·
·
·
·
Itching or hives
Coughing / wheezing or respiratory
distress
Chest or throat constriction
Difficulty swallowing
Hypotension or shock
Edema
N/V
I
IV Procedure
P
Cardiac Monitor
Urticaria (rash only)
Anaphylaxis (systemic effect)
Shock (vascular effect)
Angioedema (drug induced)
Aspiration / Airway obstruction
Vasovagal event
Asthma or COPD
CHF
Symptom Severity
MILD
SEVERE
Hives, Flushing, Itching
I
Diphenhydramine
25 - 50 mg IV / IM
if not already given
B
Monitor and Reassess
Monitor for Worsening
Signs and Symptoms
Dyspnea, Wheezing, Hypoxia
+
OR
Dyspnea, Wheezing, Hypoxia
Angioedema
OR
OR
Nausea, vomiting, abdominal pain
Nausea, vomiting, abdominal pain
WITH
WITH
Normal Blood Pressure
Hypotension / Poor Perfusion
Airway Protocol
if indicated
Epinephrine 1:1000
Auto-Injector IM
if available
I
I
Epinephrine 1:1000
Auto-Injector IM
if available
Epinephrine 1:1000
0.3 – 0.5 mg IM
Repeat in 5 minutes if
no improvement
Epinephrine 1:1000
0.3 – 0.5 mg IM
I
Diphenhydramine
25 - 50 mg IV / IM
if not already given
Histamine-2 Blocker
I
Albuterol 2.5 – 5 mg
+/- Ipratropium 0.5 mg
Nebulizer
Repeat as needed x 3
P Solumedrol 125 mg IV
YES
Normal Saline
Bolus 500 mL IV / IO
Repeat as needed
Maximum 2 liters
Improving
NO
I
P
Notify Destination or
Contact Medical Control
Medical Protocols
Diphenhydramine
50 mg PO
+
Hives, Flushing, Itching,
Angioedema
Normal Blood Pressure
B
Hives, Flushing, Itching
MODERATE
WITH
Epinephrine 1:100,000
Administer
1 mL every minute over
10 minutes IV / IO
Solumedrol 125 mg IV
Protocol 16
Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS
2012
Allergic Reaction / Anaphylaxis
Allergic reactions occur when a patient is exposed to an allergen (pollen, insect, medication, food, etc.) causing the body to respond
by releasing specific immunoglobulins such as histamine which causes hives, itching and capillary leaking leading to edema. Most
allergic reactions are mild and involve only the skin such as erythema, hives and / or itching and are usually resolved with an
anti-histamine like diphenhydramine.
Anaphylaxis is a severe form of an allergic reaction and recent studies show it is under-recognized and under-treated.
Anaphylaxis is likely present when any 1 of the 3 criteria below are present:
1. Acute onset of illness (minutes to hours) with skin involvement: Hives, erythema, itching and / or angioedema.
PLUS
Dyspnea, wheezing, stridor or hypoxemia.
OR
Hypotension, poor perfusion, shock, incontinence, syncope.
2. Acute onset of illness (minutes to hours) with 2 or more of the following are present:
a. Hives, erythema, itching and / or angioedema.
b. Dyspnea, wheezing, stridor or hypoxemia.
c. Hypotension, poor perfusion, shock, incontinence
d. Nausea, vomiting and / or abdominal pain / cramping.
The main point is that anaphylaxis does not mean the patient must be in shock. Patients who demonstrate skin involvement plus a
respiratory complaint have anaphylaxis. Patients who have skin involvement and GI symptoms such as nausea or abdominal
cramping have anaphylaxis. And finally a patient may have anaphylaxis and have no skin findings such as rash or erythema.
Epinephrine:
Epinephrine should be given in all but the most mild allergic reactions. Epinephrine is the first line drug in anaphylaxis and should be
given intramuscularly (NOT SUBCUTANEOUSLY.) For patients older than 50 or when the heart rate is 150 or greater give one half
the dose, 0.15 to 0.25 mg of 1:1000, and repeat in 5 to 10 minutes if no improvement.
Epinephrine 1:100,000:
In the patient with severe anaphylaxis who is not responding to Epinephrine IM and fluid resuscitation, IV Epinephrine should be
administered. Take your Epinephrine 1:10,000 and draw out 1 mL which equals 0.1 mg of epinephrine. Dilute this 1 mL with 10 mL
of Normal Saline in a separate syringe to yield a concentration of 1:100,000 (0.1 mg in 10 mL of Normal Saline.) Administer 1 mL
each minute over 10 minutes or until symptoms resolve.
Medical Protocols
3. Acute onset of illness (minutes to hours) with hypotension, poor perfusion, syncope, incontinence after exposure to known
allergen.
Pearls
· Recommended Exam: Mental Status, Skin, Heart, Lungs
· Patients who are >50 years of age, have a history of cardiac disease, take Beta-Blockers or patient's who have heart
rates >150 give one-half the dose of epinephrine (0.15 – 0.25 mg of 1:1000.) Epinephrine may precipitate cardiac
ischemia. These patients should receive a 12 lead ECG.
· Any patient with respiratory symptoms or extensive reaction should receive IV or IM diphenhydramine.
· The shorter the onset from symptoms to contact, the more severe the reaction.
Protocol 16
Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS
2012