Inpatient Clinical Pathway for Evaluation/Treatment
of Children with Anaphylaxis

  • Order epinephrine auto-injector on admission if:
    • Documented IgE-mediated food allergy and
    • History of severe reaction or anaphylaxis
Clinical Criteria for Diagnosing Anaphylaxis
Anaphylaxis is highly likely when ONE of the following 3 criteria are fulfilled 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, 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
    • 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

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
Patient meets one of the criteria listed above
  • Administer Epinephrine IM Immediately, Call Code Blue
    • Repeat dose as clinically indicated q 5-15 minutes
    • Additional auto-injectors are available at Pyxis™ MedStation™, code cart
Rapid Assessment, Manage ABCs
Mental Status Abnormality Oxygen
Upper Airway Obstruction Racemic epinephrine
Consider intubation
Lower Airway Symptoms Albuterol
Circulatory Abnormality Rapid infusion NS Epinephrine
  • 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®
Posted: February 2016
Revised: June 2022
Authors: J. Lee, MD; T. Brown-Whitehorn, MD; N. Tsarouhas, MD; J. Lamaina, RN, MSN; J. Molnar, CRNP; R. Sutton, MD; D. Davis, MD; M. Lewis, CRNP; C. Jacobstein, MD; J. Lavelle, MD; MK. Abbadessa, MSN