7-11
loose tourniquet proximal to injection/bite/sting site and place injection site in a dependant position to reduce
venous/lymphatic circulation. Apply ice to, and consider injecting small dose of epinephrine (0.1-0.2 ml
1:1,000) into, the injection site, unless contraindicated. If due to bee/wasp sting(s), carefully remove all
stingers. Avoid applying pressure to venom sac while stinger is inserted in patient. If due to an ingested
food/drug, give activated charcoal (50 gm for adults).
Recommended: Evaluate for common causes of anaplylactic shock.
A. Any food can contain an allergen that could cause anaphylaxis
B. Any drug is capable of causing anaphylaxis
C. Insect bites and stings - biting flies, and stinging insects - most types
D. Latex allergy - contact reactions that get progressively worse among medical personnel
Treatment
NOTE: IV administration of epinephrine (adrenaline) is DANGEROUS if it is given in too large a dose, if
given too quickly IV, and/or if given unnecessarily. DO NOT USE IV epinephrine to treat a simple allergic
reaction without signs of shock and/or severe bronchospasm and/or stridor - give either subcutaneously, or
intramuscularly.
Epinephrine: WARNING: Use only 1:10,000 concentration for IV - if only 1:1,000 concentration is available
dilute to 1:10,000 before using.
Dose: 0.1ml/kg 1:10,000 slow IV (up to 5 ml total dose for adults) given over 15-20 minutes in 1 ml
increments every 3-5 minutes. Give epinephrine endotracheally if necessary to treat severe hypotension
and bronchospasm. If unable to obtain an IV and patient is not intubated, epinephrine may be given
intraosseously or deep IM (avoid SC administration in hypotensive patients due to poor absorption).
Bronchospasm: Treat with inhaled beta agonists (i.e., albuterol or epinephrine)
Benadryl 50-100 mg IV over 3 minutes. Consider adding cimetidine 300 mg IV q 6 hr
Solu-Medrol (methylprednisolone 125-250 mg q 6 hr)
Trendelenburg position
Oxygen
Crystalloid (saline) fluid bolus IV, titrated to restore and maintain blood pressure
Apply PASG (MAST) if available and if hypotension is unresponsive to epinephrine and fluids
Patient Education
General: Activity: Following resuscitation, inform patient that he/she has experienced a life threatening
allergic reaction. If the triggering allergen is known, warn patient to avoid any future exposure.
Diet: Avoidance of allergen if known
Medications: Anaphylaxis kit (Epi-Pen autoinjector; Ana-Kit) for use in the event of recurrence. Albuterol
(or other beta-agonist) inhaler if bronchospasm was a prominent symptom (be sure to properly teach patient
how to use inhaler with spacer).
Prevention and Hygiene: Avoid circumstances in which recurrent exposure is possible/likely
No Improvement/Deterioration: Return immediately for any recurrence of symptoms after first self-adminis-
tering anaphylaxis kit.
Follow-up Actions
Return evaluation: Return for repeat evaluation/treatment if fainting/near fainting occur; if difficulty breathing
does not resolve with treatment
Consultation Criteria: If cause of allergic reaction is unknown, patient should be advised to seek allergist
in an effort to isolate cause
Shock: Hypovolemic
COL Clifford Cloonan, MC, USAIntroduction: Hypovolemic shock is usually caused by hemorrhage but may also be caused by burns,