Anaphylactic shock
Inject 1 mg of epinephrine 1:10,000 (one amp of crash cart epi) into a 1L bag of normal saline. Draw up 10mL from the 1L bag in a 10mL syringe (The concentration of epinephrine in the syringe is now 1 mcg/mL). Push Dose: 10 mL every 2-5 minutes (10 mcg) note that the onset = 1 minute and duration = 5-10 minutes. Dose of epinephrine given via infusion: 1mL/min (1 mcg/min) and titrate to a maximum of 20mL/min - Anton Helman
image by: Todd Mecklem
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Treatment of Anaphylaxis
You’ve administered multiple doses of IM epinephrine. You’re on your 3rd bolus of crystalloid. You’ve given antihistamines and glucocorticoids even though you know there’s no good data to support their use. Maybe you’re headed toward intubation for angioedema, waning mental status, or both. Your patient is still hypotensive. You’re getting out the central line kit. What now?
You’re now in the realm of anaphylactic shock. Anaphylactic shock is classically taught to be a distributive shock, but in reality, it is multifactorial. Peripheral vasodilation does indeed cause a distributive shock, but extremely leaky capillaries can also lead to a legitimate hypovolemic shock.
Resources
Management of severe anaphylaxis in the emergency department
My original plan was to make this a one word post: Epinephrine! However, there is probably a little more detail worth considering.
A Strange Itch, Trouble Breathing, Then Anaphylactic Shock
She had had this kind of allergic reaction twice before but never as severely. She knew from her own research that this was anaphylactic shock — a potentially deadly allergic reaction. After she got the medications, the woman’s symptoms resolved.
Anaphylaxis and Anaphylactic Shock
All patients who fulfill the criteria for anaphylaxis require the administration of epinephrine. Epinephrine is the only drug to show a mortality benefit in the management of anaphylaxis.
Steps for drawing up epinephrine for push dose epinephrine and epinephrine infusion
Inject 1 mg of epinephrine 1:10,000 (one amp of crash cart epi) into a 1L bag of normal saline. Draw up 10mL from the 1L bag in a 10mL syringe (The concentration of epinephrine in the syringe is now 1 mcg/mL). Push Dose: 10 mL every 2-5 minutes (10 mcg) note that the onset = 1 minute and duration = 5-10 minutes. Dose of epinephrine given via infusion: 1mL/min (1 mcg/min) and titrate to a maximum of 20mL/min.
Treatment of Anaphylaxis
MY PATIENT IS STILL HYPOTENSIVE – HELP! (ANAPHYLACTIC SHOCK) You’ve administered multiple doses of IM epinephrine. You’re on your 3rd bolus of crystalloid. You’ve given antihistamines and glucocorticoids even though you know there’s no good data to support their use. Maybe you’re headed toward intubation for angioedema, waning mental status, or both. Your patient is still hypotensive. You’re getting out the central line kit. What now?
EMCrit
Epinephrine is the only real disease-modifying medication for acute anaphylaxis. For example, antihistamines may make the patient less itchy, but they don't do much else. There is a high risk of hemodynamic collapse following intubation: start epinephrine & give fluid beforehand.
Life in the Fastlane
Persistant hypotension/bronchospasm -> repeat Adrenaline 0.5mg IM after 5 minutes; if still persists after 5 minutes start adrenaline infusion.
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