Outpatient setting
First-line treatment:

  • Epinephrine, IM; autoinjector or 1:1,000 solution

    22 to 56 lb (10 to 25 kg): 0.15-mg epinephrine autoinjector, IM (anterolateral thigh)

    > 56 lb: 0.3-mg epinephrine autoinjector, IM (anterolateral thigh)

    Epinephrine (1:1,000 solution), IM, 0.01 mg per kg per dose; maximal dose, 0.5 mg per dose (anterolateral thigh)

    Epinephrine doses may need to be repeated every 5 to 15 minutes

Adjunctive treatment:

  • Bronchodilator (beta2 agonist): albuterol

    Metered-dose inhaler (child: 4 to 8 puffs; adult: 8 puffs)

    or

    Nebulized solution (child: 1.5 mL; adult: 3 mL) every 20 minutes or continuously as needed

    Histamine H1 antagonist: diphenhydramine (Benadryl)

    1 to 2 mg per kg per dose; maximal dose, 50 mg IV or orally (liquid is more readily absorbed than tablets)

    Alternative dosing may be with a less-sedating second-generation antihistamine

    Supplemental oxygen therapy

    Fluids IV in large volumes if patient presents with orthostasis, hypotension, or incomplete response to epinephrine IM

    Place the patient in recumbent position if tolerated, with the lower extremities elevated

Hospital-based setting
First-line treatment:

  • Epinephrine IM as above, consider continuous epinephrine infusion for persistent hypotension (ideally with continuous noninvasive monitoring of blood pressure and heart rate); alternatives are endotracheal or intraosseous epinephrine

Adjunctive treatment:

  • Bronchodilator (beta2 agonist): albuterol

    Metered-dose inhaler (child: 4 to 8 puffs; adult: 8 puffs)

    or

    Nebulized solution (child: 1.5 mL; adult: 3 mL) every 20 minutes or continuously as needed

Adjunctive treatment:

  • H1 antagonist: diphenhydramine

    1 to 2 mg per kg per dose; maximal dose, 50 mg IV or orally (liquid is more readily absorbed than tablets)

    Alternative dosing may be with a less-sedating second-generation antihistamine

    Histamine H2 antagonist: ranitidine (Zantac)

    1 to 2 mg per kg per dose; maximal dose, 75 to 150 mg IV or orally

    Corticosteroids

    Prednisone, 1 mg per kg; maximal dose, 60 to 80 mg orally

    or

    Methylprednisolone (Solu-Medrol), 1 mg per kg; maximal dose, 60 to 80 mg IV

    Vasopressors (other than epinephrine) for refractory hypotension, titrate to effect

    Glucagon (Glucagen) for refractory hypotension, titrate to effect (child: 20 to 30 mcg per kg; adult: 1 to 5 mg)

    Dose may be repeated or followed by infusion of 5 to 15 mcg per minute

    Atropine for bradycardia, titrate to effect

    Supplemental oxygen therapy

    Fluids IV in large volumes if patients present with orthostasis, hypotension, or incomplete response to epinephrine IM

    Place the patient in recumbent position, if tolerated, with the lower extremities elevated

At discharge
First-line treatment:

  • Epinephrine autoinjector prescription (2 doses) and instructions

    Education on avoidance of allergen

    Follow-up with primary care physician

    Consider referral to an allergist

Adjunctive treatment:

  • H1 antagonist: diphenhydramine every 6 hours for 2 to 3 days; alternative dosing with a nonsedating second-generation antihistamine

    H2 antagonist: ranitidine twice daily for 2 to 3 days

    Corticosteroid: prednisone daily for 2 to 3 days