Emergency Department Clinical Pathway for
Evaluation/Treatment of Children with Anaphylaxis

CLINICAL CRITERIA FOR DIAGNOSING ANAPHYLAXIS
Anaphylaxis is highly likely when ONE of the following 3 criteria are fulfilled, usually within minutes to 2-3 hours following possible allergen exposure
CRITERIA 1

Acute onset of an illness with involvement of the skin, mucosal tissue, or both (e.g., generalized hives, pruritis or flushing, swollen lip-tongue-uvula)

AND AT LEAST ONE OF THE FOLLOWING

  • Respiratory compromise
  • Reduced BP or associated symptoms of end-organ dysfunction
  • Persistent GI Symptoms, Significant abdominal pain and/or significant vomiting
CRITERIA 2

Two or more of the following that occur rapidly after exposure to a LIKELY ALLERGEN for that patient:

  • Involvement of the skin-mucosal tissue
  • Respiratory compromise
  • Reduced BP or associated symptoms
  • Persistent gastrointestinal symptoms
CRITERIA 3 Reduced BP after exposure to KNOWN ALLERGEN for that patient

MD/CRNP/RN Rapid Assessment

  • Patient meets clinical criteria for Anaphylaxis listed below:
  • ADMINISTER EPINEPHRINE IM IMMEDIATELY
  • Repeat dose as clinically indicated q 5-15 minutes
  • Assess need for IV access
  • ASSESS, MANAGE ABC’S
    • Mental status abnormality
    • Upper airway obstruction
    • Lower airway symptoms
    • Circulatory abnormality
  • Respiratory Medications
  • IV Access, NS bolus as indicated
  • Vasopressors
  • Epinephrine treats all symptoms of anaphylaxis and can prevent the escalation 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 - 25 kg 0.15 mg EpiPen Jr®
> 25 kg 0.3 mg EpiPen®

Risk Factors for Biphasic Reaction

  • History of biphasic or severe reactions
  • Progression of / or persistent symptoms
  • History of severe asthma
  • Hypotension
  • Requires > 1 Epinephrine dose
  • Requires fluid bolus
  • Drug trigger
Reassess patient’s symptoms, PE, VS
Serious Symptoms Resolved with
1 dose of Epinephrine, excluding rash
Consider antihistamine for urticaria
Risk Factors for Biphasic Reactions
Posted: June, 2006
Revised: September 2011, October 2014, November 2016, January 2019, March 2020, June 2021, September 2021, November 2021
Authors: J. Lee, MD; T. Brown-Whitehorn, MD; N. Tsarouhas, MD; J. Molnar, CRNP; M. Lewis, CRNP; C. Jacobstein, MD;
J. Lavelle, MD; MK. Abbadessa, MSN