Anaphylaxis Clinical Pathway – All Settings

Clinical Pathway for Evaluation/Treatment of Children with Anaphylaxis

Goals and Metrics
Patient Education
Provider Resources
Child with Suspected Anaphylaxis
 
 
ED Triage
Primary Care Guidance for
Home Management of Suspected Anaphylaxis
 
 

Team Assessment

  • Review clinical criteria
  • Confirm anaphylaxis
  • Administer epinephrine IM immediately
  • Repeat as clinically indicated q5–15min
  • Emergency Activation per location
Emergency Activation/Plan per Location
Non-ICU Inpatients
  • Administer epinephrine
  • Call Code Blue
  • Oncology Day Medicine or Oncology Inpatients on 3E/3S
  • Buerger Allergy Clinic
  • Administer epinephrine
  • Call Code Blue with 2nd epinephrine dose
Food Challenge Call Code Blue with 3rd epinephrine dose given
  • All Outpatients in PHL Campus
    (ED excluded)
  • Administer epinephrine
  • Call Code Blue
Primary Care Offices, Ambulatory Medical Clinics off PHL Campus
Urgent Care
  • Administer epinephrine
  • Monitor as per pathway
  • Transfer to ED as clinically indicated
Summary of Evidence
  • Epinephrine treats all symptoms of anaphylaxis and prevents progression of symptoms
  • IM is preferred, being faster and safer
  • Use of adjunctive medications should not delay epinephrine administration
Epinephrine Dosing—IM
< 5 kg 0.01 mg/kg Epinephrine IM
0.1 mg/mL solution
5–24 kg 0.15 mg Epinephrine autoinjector
≥ 25 kg 0.3 mg Epinephrine autoinjector
 
 

History and Physical

Manifestations of Anaphylaxis
 
 
  • Assess, manage ABC's
    • Mental status abnormality
    • Upper, lower airway obstruction
    • Circulatory abnormality
  • IV Access/NS bolus as indicated

Tryptase Testing

  • May help when no known anaphylaxis trigger
  • Obtain within 3 hrs of symptoms
 
 

Readminister epinephrine IM as indicated Adjunctive Medications
Antihistamine, respiratory, circulatory

 
 
Reassess child’s symptoms, physical exam, VS
 
 
 
 
 
 
Symptoms resolved with 1 dose of epinephrine
Rash excluded
Symptoms resolved with 2 doses of epinephrine
Rash excluded
Need for 3rd dose of epinephrine
Consider refractory anaphylaxis
Discharge
Admit
  • Discharge Medications, Teaching
  • Discharge with epinephrine auto-injector in hand
  • If known allergen, follow up with allergist as indicated
  • If no known allergen, refer to Allergy between 4–8 wks
    • If trigger identified enter into EHR
Consult allergy for all admissions
 
 
 
 
 
 
Clinical Criteria for Diagnosing Anaphylaxis
Anaphylaxis is highly likely when one of the following 3 criteria is fulfilled,
usually within minutes to 2–3 hrs following possible allergen exposure.
Criteria 1
  • Acute onset of an illness with involvement of the skin, mucosal tissue, or both
    • e.g., generalized hives, pruritus or flushing, swollen lip-tongue-uvula
  • And at least one of the following:
    • Respiratory compromise
    • Reduced BP or associated symptoms of end-organ dysfunction
    • GI symptoms, such as abdominal pain and/or vomiting
Criteria 2
  • Two or more of the following that occur rapidly after exposure to a likely allergen for that child:
    • Involvement of the skin-mucosal tissue
    • Respiratory compromise
    • Reduced BP or associated symptoms
    • GI symptoms, such as abdominal pain and/or vomiting
Criteria 3 Reduced BP after exposure to known allergen for that child