Pediatric emergency medicine trisk 1676 1676
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providers should anticipate upper airway edema and the need to use two-person
bag-mask ventilation, the need to downsize the caliber of the endotracheal tube,
and potential to need airway adjuncts (nasal and oral airways, supraglottic
devices). If these interventions are unsuccessful, cricothyrotomy (in an older
child) or a percutaneous needle airway (younger child) may provide a lifesaving
alternative to bypass upper airway obstruction. For intubated patients with severe
bronchospasm and refractory hypoxemia, avoid the impulse to extubate the
airway if endotracheal tube placement is confirmed by visualizing the tube pass
between the vocal cords and using end-tidal capnography; instead, treatments
should focus on optimizing oxygenation and ventilation, minimizing barotrauma,
and reversing bronchospasm.
Maintenance of Circulation
Children with hypotension should be placed in the Trendelenburg position,
immediate IV access obtained, and rapid boluses of 20 mL per kg of a crystalloid
solution administered and repeated as necessary. Significant fluid resuscitation
may be required secondary to decreased plasma volume from fluid leak as well as
profound vasodilation with resultant increased intravascular capacity. Patients
with refractory hypotension despite multiple doses of IM epinephrine and fluid
boluses should be started on a continuous epinephrine infusion as previously
described. Other vasopressors (e.g., dopamine, norepinephrine) may be
considered for refractory shock. Patients on β-blockers may also benefit from
anticholinergics and glucagon.
Adjunctive Therapies
There have been no randomized controlled studies evaluating the efficacy of
adjunctive therapies (e.g., systemic glucocorticoids, inhaled beta agonists, or
antihistamines) to treat and prevent severe anaphylactic reactions (including
biphasic reactions). As adjunctive therapies, antihistamines have a role in treating
local symptoms including angioedema, pruritus, and urticaria. Second-generation
H1 antihistamines such as cetirizine (2.5 mg to 10 mg orally once daily) may
have therapeutic advantages over first-generation H1 antihistamines such as
diphenhydramine (1 to 1.25 mg per kg, maximum 50 mg; routes: oral, IM, or
intravenously) because they have fewer central nervous system side effects and
are longer acting. Although H2-blocking antihistamines such as ranitidine (1 to 2
mg per kg; maximum 50 mg) may offer additional relief for urticaria or
gastrointestinal symptoms, their use should not delay treatment with epinephrine.
