Pediatric emergency medicine trisk 1677 1677
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Similar to the care of children with asthma, it is reasonable to administer
inhaled β2 -agonists and glucocorticoids for children with wheezing as long as
administration does not delay treatment with IM epinephrine. Although the role
of glucocorticoids in preventing severe and biphasic reactions is unclear, they are
frequently recommended because of known efficacy for other allergic diseases.
For patients who can tolerate enteral medications prednisone (0.5 to 1 mg per kg
by mouth, maximum 60 mg) and dexamethasone (0.6 mg/kg, maximum 16 mg)
are reasonable options whereas methylprednisolone (1 to 2 mg per kg IV;
maximum 60 mg) can be administered for critically ill patients. Stress-dose
hydrocortisone should be considered for those with adrenal insufficiency or lifethreatening anaphylaxis.
In summary, there is no data supporting the use of antihistamines or
glucocorticoids to treat anaphylaxis, and, administration of these medications
should never precede treatment with IM epinephrine.
Disposition
The recommended period of observation after anaphylaxis should be
individualized and based upon initial reaction severity, risk factors for biphasic
reactions, and access to care. An observation period of 4 to 6 hours may be
appropriate for patients with mild to moderate episodes that resolve promptly
with therapy. Patients with severe reactions including upper airway obstruction,
refractory wheezing or respiratory distress, and shock should be hospitalized. The
reported incidence of biphasic reactions varies widely from 1% to 15%; potential
risk factors include delayed administered of IM epinephrine, respiratory
involvement (e.g., wheezing), history of asthma, and hypotension.
Discharge Considerations
Patients who are asymptomatic and fulfill discharge criteria after a period of ED
observation should be educated about allergen avoidance, anaphylaxis action
plans, and indications for out-of-hospital epinephrine administration. These
patients should be discharged with prescriptions for epinephrine autoinjectors, or
ideally the medication in hand. Providing hands-on instruction on proper use of
autoinjectors increases the likelihood of patients and families correctly
administering epinephrine during subsequent reactions. It is critical that families
receive specific instructions on different autoinjectors approved by the Food and
Drug Administration (FDA). Multiple online educational resources are available
for parents and patients with food allergies, some of which have been validated
through federal funding and are available free of charge.
