Pediatric emergency medicine trisk 1675 1675
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routine measurement is not recommended secondary to suboptimal sensitivity and
specificity. Elevated PAF and other biologic mediators have been associated with
severe anaphylactic reactions and may eventually be used to risk stratify patients;
however, they are currently experimental and have not been incorporated into
clinical care guidelines.
Management
Life-threatening anaphylactic reaction requires rapid evaluation and management
of the airway, breathing, and circulation, including immediate administration of
IM epinephrine and removal of the offending trigger. Epinephrine is the first-line
therapy for children with confirmed or suspected anaphylaxis; there are no
absolute contraindications for its use. Epinephrine’s α-adrenergic agonist effects
lead to vasoconstriction, increased blood pressure, and decreased capillary
leakage. Through its β-adrenergic agonist effects, it stimulates bronchial smooth
muscle relaxation, increased cardiac output, and inhibits further mediator release.
Epinephrine should be administered IM (peak plasma levels are higher via the IM
route compared to subcutaneous administration) in the thigh at a dose of 0.01 mg
per kg (1 mg/mL concentration; maximum 0.5 mL in adults, 0.3 mL in children).
Some centers use automated epinephrine auto-injectors (e.g., EpiPen Jr 0.15 mg
and EpiPen 0.3 mg) to prevent dosing errors and familiarize families around
administration. Epinephrine doses may be repeated every 5 to 15 minutes for
persistent, recurrent, or worsening reactions.
Patients with refractory hypotension, signs of impaired end organ perfusion, or
who require multiple doses of IM epinephrine should be started on an epinephrine
infusion and titrated to effect (staring dose 0.1 μg/kg/min, maximum dose of 1
μg/kg/min). Inhaled epinephrine does not achieve adequate plasma levels and
should not replace IM dosing. Patients should be monitored for complications
from epinephrine administration including arrhythmias, pulmonary edema, and
hypertensive crisis.
Maintenance of the Airway
Patients with hypoxemia, respiratory distress, or signs of shock should receive
supplemental oxygen. Bag-mask ventilation should be initiated for patients with
hypoventilation or refractory respiratory distress and hypoxemia. Clinicians
should observe for signs of impending upper airway obstruction (e.g., refractory
stridor, intraoral mucosal or tongue edema, symptoms of airway closure, and
respiratory distress) and be prepared to perform immediate endotracheal
intubation for patients with refractory symptoms. When preparing for intubation
