Immunotherapy Safety for the Primary Care ... - U.S. Coast Guard

J ALLERGY CLIN IMMUNOL
VOLUME 115, NUMBER 3
Lieberman et al S491
FIG 3. Anaphylaxis treatment record.
soning, hypoglycemia, and seizure disorder. Specific
signs and symptoms of anaphylaxis might present singly
in other disorders. Examples are urticaria-angioedema,
hereditary angioedema, and asthma.
Annotation 5. Immediate intervention
The clinician should remember that anaphylaxis occurs
as part of a continuum. Symptoms not immediately lifethreatening
might progress rapidly unless treated
promptly. Treatment recommendations are subject to
physician discretion, and variations in sequence and
performance rely on physician judgment. Additionally,
a determination of when a patient should be transferred to
an emergency or intensive care facility depends on
available resources and the skill, experience, and clinical
decision making of the individual physician.
1. Assess airway, breathing, circulation, and level of
consciousness (altered mentation might suggest the
presence of hypoxia).
2. Administer epinephrine. Aqueous epinephrine
1:1000 dilution (1 mg/mL), 0.2 to 0.5 mL (0.01
mg/kg in children, maximum 0.3-mg dosage) intramuscularly
or subcutaneously every 5 minutes, as
necessary, should be used to control symptoms and
increase blood pressure. Consider dose-response
effects. Note: If the clinician deems it appropriate,
the 5-minute interval between injections can be
liberalized to permit more frequent injections. Intramuscular
epinephrine injections into the thigh
have been reported to provide more rapid absorption
and higher plasma epinephrine levels in both children
and adults than intramuscular or subcutaneous
injections administered in the arm. However, similar
studies comparing intramuscular injections with subcutaneous
injections in the thigh have not yet been
done. Moreover, these studies were not performed in
patients experiencing anaphylaxis. For this reason,
the generalizability of these findings to the clinical
setting of anaphylaxis has not been established.
Although intuitively more rapid absorption and
higher epinephrine levels would seem desirable, the
clinical significance of this finding is not known. No
data support the use of epinephrine in anaphylaxis
through a nonparenteral route. However, alternative
routes of administration have been anecdotally