Anaphylaxis v6.2: ED Higher Initial Clinical Concern Approval & Citation Summary of Version Changes Explanation of Evidence Ratings Inclusion Criteria > 3 months with suspected anaphylaxis Exclusion Criteria • Blood transfusion reactions that are not anaphylaxis • Symptoms clearly attributable to other causes High clinical Go to concern for NO Lower Clinical anaphylaxis? Concern YES • Give epinephrine 0.01mg/kg IM (max 0.3mg) in lateral thigh • Repeat every 5 min as needed (can give more frequently if symptoms are severe) • Place on monitors, vitals every 5 minutes Symptoms Suggestive of Anaphylaxis • Place patient supine if tolerated • Avoid sudden changes in position, Mild Symptoms: especially to standing • Generalized erythema, hives, angioedema • Administer O2 until O2 Sat is known, and to Moderate Symptoms: keep O2 saturation > 90% • Chest or throat tightness • Dyspnea, stridor, wheeze • If MAP <5th %ile → place IV and • Nausea, vomiting, abdominal pain administer N/S 20 cc/kg • Dizziness (presyncope), diaphoresis • If bronchospasm→ place IV and Severe Symptoms: • Cyanosis, saturation <= 92% give albuterol 20 mg / hr or 8 puffs • Hypotension, collapse • Confusion, LOC Observe for 5-10 mins • Incontinence Continue monitoring with vitals every 5 minutes Risk Factors for Anaphylaxis • Possible exposure to know allergen • Home anaphylaxis management plan Adapted from Brown, 2004 Has patient improved? YES NO Go to Historical factors that increase risk and warrant a lower threshold for epinephrine: • prior anaphylaxis involving respiratory distress Go to Go to • hypoxia Moderate - • hypotension Mild • neurologic compromise Severe From Wang 2017 For questions concerning this pathway, Last Updated: June 2021 contact: [email protected] Next Expected Review: August 2022 © 2021 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Anaphylaxis v6.2: ED Lower Initial Clinical Concern Approval & Citation Summary of Version Changes Explanation of Evidence Ratings Inclusion Criteria > 3 months with suspected Symptoms Suggestive of Anaphylaxis anaphylaxis Mild Symptoms: Exclusion Criteria • Generalized erythema, hives, • Blood transfusion reactions • Blood transfusion reactions angioedema that are not anaphylaxis Moderate Symptoms: • Symptoms clearly • Chest or throat tightness attributable to • Dyspnea, stridor, wheeze other causes • Nausea, vomiting, abdominal pain • Dizziness (presyncope), diaphoresis Severe Symptoms: • Cyanosis, saturation <= 92% Lower • Hypotension, collapse clinical concern • Confusion, LOC for anaphylaxis? • Incontinence Risk Factors for Anaphylaxis • Possible exposure to know allergen YES • Home anaphylaxis management plan Adapted from Brown, 2004 Use the Anaphylaxis Score Assisting Providers (ASAP) Score Score 1-4 >5 Rapid symptom Epinephrine is progression or likely indicated. YES epinephrine indicated per Huddle with team patient action plan? to discuss • Give epinephrine 0.01mg/kg IM (max 0.3mg) in lateral thigh NO • Repeat every 5 mins as needed (can give more frequently if symptoms are severe) Go to Mild Has patient YES NO improved? Go to Go to Mild Moderate - Severe For questions concerning this pathway, Last Updated: June 2021 contact: [email protected] Next Expected Review: August 2022 © 2021 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Anaphylaxis v6.2: ED Management – Mild Approval & Citation Summary of Version Changes Explanation of Evidence Ratings Resolved after epinephrine or no epinephrine given Inclusion Criteria > 3 months with suspected anaphylaxis Exclusion Criteria • BloodBlood transfusion transfusion reactions thatreactions are not anaphylaxisthat are not • Symptoms clearly attributable to other causes Use “ED Anaphylaxis Panel” if patient has received epinephrine, or has cutaneous symptoms: • Cetirizine PO • H2 receptor blocker PO Assess for risk factors • History of biphasic or severe reaction • History of asthma or wheezing • Time from exposure to symptom onset delayed > 1 hour or unknown ! Steroids Symptoms resolved AND Symptoms persist OR with risk factors absent risk factors present immunotherapy No steroids dexamethasone PO Evaluate and score hourly and with symptom change NOT worse or Epinephrine is worse or score likely indicated. score >5 Huddle with team 1-4 to discuss. Go to Go to ED Disposition Moderate - Severe For questions concerning this pathway, Last Updated: June 2021 contact: [email protected] Next Expected Review: August 2022 © 2021 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Anaphylaxis v6.2: ED Management – Moderate/Severe Approval & Citation Summary of Version Changes Explanation of Evidence Ratings Epinephrine given Inclusion Criteria > 3 months with suspected anaphylaxis Exclusion Criteria • BloodBlood transfusion transfusion reactions thatreactions are not anaphylaxisthat are not • Symptoms clearly attributable to other causes Epinephrine has been given YES & observed for 5-10 mins Score patient using ASAP Go to NOT improved or Mild Improved or score score 1-4 >5 Give epinephrine 0.01mg/kg IM (max 0.3mg) in lateral thigh Use “ED Anaphylaxis Panel” • Place IV (if not already done) • Cetirizine PO (unless unable to tolerate PO, then diphenhydramine IV) • H2 Blocker IV • MethylPrednisolone IV ! Steroids with Observe for 5-10 min immunotherapy -continue monitoring, vitals every 5 minutes NOT Improved improved or or score score 1-4 >5 • Consider epinephrine 0.01mg/kg IM (max Go to 0.3mg) in lateral thigh ED Disposition • Repeat every 5 min as needed (can give more frequently if symptoms are severe) • Start epinephrine drip after 3rd IM dose • PICU consult, admit to PICU For questions concerning this pathway, Last Updated: June 2021 contact: [email protected] Next Expected Review: August 2022 © 2021 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Anaphylaxis v6.2: ED Disposition Approval & Citation Summary of Version Changes Explanation of Evidence Ratings Urgent Care Transfer Recommendations Transfer patients who have received IM Epinephrine to the Emergency Department ! • Patients should be transported by ALS (or an ambulance crew If not who is able to give IM epienphrine) improving, consider • Patients who have low BP or require more than one dose of alternate diagnoses epinephrine, consider calling 911 (or Code Blue) • Patient requiring observation after 1 hour- transfer to ED Patient NO received YES • Observe for 1 hour if symptoms are stable, or 1 epinephrine? hour after any symptom progression. • If anaphylaxis high risk by history: observe for 4 Meets hours from either exposure or any symptom admission progression. NO Criteria? High risk by history: YES: Acute Care • History of anaphylaxis • History of life-threatening allergies (versus environmental) • Two systems involved at any point Assessment Acute Care Observe for 4 hours from the latest of: Admit Criteria exposure, epinephrine administration, or any • Persistent symptoms worsening of symptoms beyond rash or score > 5 after 2 epinephrine Discharge Criteria Observe for 3 hours “LIKE A ROSE” patients • Persistent wheeze or • Score 1-4, no symptom meeting all these criteria : bronchospasm after progression during • ASAP – max 2, points for exposure only 1 epinephrine observation period • No hypotension or syncope during event • Biphasic reaction • Teaching completed • No wheeze, stridor or resp distress during event • Tolerating PO intake • No URI symptoms even if baseline • No sleepiness even if late in day • No history of biphasic reactions YES: PICU • Reaction to a food, not a medication or a sting • Parents comfortable with early discharge Discharge Instructions • Epinephrine auto-injector in hand • Provide anaphylaxis discharge materials e.g. FARE Field Guide and Anaphylaxis Emergency Care Plan • Rx epinephrine auto-injector and provide training PICU Criteria • RASH Hx, discharge with • Persistent MAP <5% ile - Cetirizine prn • Altered mental status after 1 epinephrine - H2 receptor blocker PRN • > 3 doses of epinephrine given with persistent symptoms x3 days beyond rash/ angioedema • No RASH Hx, discharge with no • Persistent cardiovascular compromise meds • Persistent respiratory distress • Recommend allergist referral • Continuous albuterol for > 1 hour • F/U PCP within 3 days For questions concerning this pathway, Last Updated: June 2021 contact: [email protected] Next Expected Review: August 2022 © 2021 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Anaphylaxis v6.2: Inpatient Continued Management Approval & Citation Summary of Version Changes Explanation of Evidence Ratings Use “Anaphylaxis for Inpatient” Panel Symptoms Suggestive of Anaphylaxis Inclusion Criteria > 3 months with suspected Patients to receive adjunctive medications below: Mild Symptoms: anaphylaxis • Prednisone/prednisolone daily • Generalized erythema, hives, Exclusion Criteria • If persistent cutaneous symptoms: angioedema •• BloodBlood transfusion transfusion reactions - Cetirizine PRN Moderate Symptoms: thatreactions are not anaphylaxisthat are not - H2 receptor blocker • Chest or throat tightness • Symptoms clearly PRN medications: • Dyspnea, stridor, wheeze attributable to • Epinephrine 0.01mg/kg IM (max 0.3mg) in lateral • Nausea, vomiting, abdominal pain other causes thigh for anaphylaxis • Dizziness (presyncope), diaphoresis • Albuterol 8 puffs for bronchospasm Severe Symptoms: • Ondansetron for nausea or vomiting • Cyanosis, saturation