BNF for Children 2011-2012

160 3.4.3 Allergic emergencies BNFC 2011–20123 Respiratory systemrevised recommendations of the Working Group of theResuscitation Council (UK).Dose of intramuscular injection of adrenaline(epinephrine) for anaphylaxisAge range Dose Volume ofadrenaline1 in 1000(1 mg/mL)Under 6 years 150 micrograms 0.15 mL 16–12 years 300 micrograms 0.3 mL12–18 years 500 micrograms 0.5 mL 2These doses may be repeated several times if necessaryat 5-minute intervals according to blood pressure, pulse,and respiratory function.1. Use suitable syringe for measuring small volume2. 300 micrograms (0.3 mL) if child is small or prepubertalIntravenous adrenaline (epinephrine)Intravenous adrenaline should be given only by thoseexperienced in its use, in a setting where patients can becarefully monitored.Where the child is severely ill and there is real doubtabout adequacy of the circulation and absorption fromthe intramuscular injection site, adrenaline may be givenby slow intravenous injection. Children may respond toas little as 1 microgram/kg (0.01 mL/kg) of the dilute 1in 10 000 adrenaline injection by slow intravenousinjection repeated according to response. A singledose of adrenaline by intravenous injection should notexceed 50 micrograms; if multiple doses are requiredconsider giving adrenaline by slow intravenous infusion.Great vigilance is needed to ensure that the correctstrength of adrenaline injection is used; anaphylacticshock kits need to make a very clear distinction betweenthe 1 in 10 000 strength and the 1 in 1000 strength. It isalso important that, where intramuscular injectionmight still succeed, time should not be wasted seekingintravenous access.For reference to the use of the intravenous route foracute hypotension, see section 2.7.2.Self-administration of adrenaline(epinephrine)Children at considerable risk of anaphylaxis need tocarry (or have available) adrenaline at all times andthe child, or child’s carers, need to be instructed inadvance when and how to inject it; injection techniqueis device specific. Packs for self-administration need tobe clearly labelled with instructions on how to administeradrenaline (intramuscularly, preferably at the midpointof the outer thigh, through light clothing if necessary).It is important to ensure that an adequate supplyis provided to treat symptoms until medical assistance isavailable.Adrenaline for administration by intramuscular injectionis available in ‘auto-injectors’ (e.g. Anapen c , EpiPen cor Jext c ), pre-assembled syringes fitted with a needlesuitable for very rapid administration (if necessary by abystander or a healthcare provider if it is the onlypreparation available). A syringe delivering 300 microgramsof adrenaline is recommended for a child over30 kg. A syringe delivering 150 micrograms of adrenalineis recommended for a child 15–30 kg, but on thebasis of a dose of 10 micrograms/kg, 300 microgramsmay be more appropriate for some children.ADRENALINE/EPINEPHRINECautions for cautions in non-life-threatening situations,see section 2.7.2Interactions Severe anaphylaxis in children taking betablockersmay not respond to adrenaline calling for bronchodilatortherapy, see intravenous salbutamol (section3.1.1.1); furthermore, adrenaline may cause severe hypertensionand bradycardia in those receiving non-cardioselectivebeta-blockers. Other interactions, see Appendix 1(sympathomimetics).Renal impairment section 2.7.2Pregnancy section 2.7.2Breast-feeding section 2.7.2Side-effects section 2.7.2Licensed use auto-injector delivering 150-microgramdose of adrenaline not licensed for use inchildren body-weight under 15 kgIndication and doseEmergency treatment of acute anaphylaxis,angioedema. By intramuscular injection (preferably midpointin anterolateral thigh) of 1 in 1000 (1 mg/mL)solutionSee notes and table aboveAcute anaphylaxis when there is doubt as tothe adequacy of the circulation. By slow intravenous injection of 1 in 10 000(100 micrograms/mL) solution (extreme caution—specialistuse only)See notes aboveSafe PracticeIntravenous route should be used with extreme careby specialists only, see notes aboveCroup (section 3.1). By inhalation of nebulised solution of adrenaline1 in 1000 (1 mg/mL)Child 1 month–12 years 400 micrograms/kg(max. 5 mg), repeated after 30 minutes if necessaryAdministration For nebulisation, dilute adrenaline 1 in1000 solution with sterile sodium chloride 0.9% solutionAcute hypotension, low cardiac output section2.7.2Cardiopulmonary resuscitation section 2.7.3Intramuscular or subcutaneous1Adrenaline/Epinephrine 1 in 1000 (Non-proprietary)AInjection, adrenaline (as acid tartrate) 1 mg/mL, netprice 0.5-mL amp = 52p; 1-mL amp = 57pExcipients include sulphites1. A restriction does not apply to adrenaline injection1 mg/mL where administration is for saving life inemergency