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📝ED order for anaphylaxis
#Order
▪️Anaphylaxis (criteria)

▪︎Imp: Anaphylaxis
▪︎Cond: Emergency
▪︎Diet : NPO
▪︎Act: CBR and bed sides up
▪︎Position: recumbent, and elevate lower extremities (if tolerated )

▪︎CVS

▪︎CM and POM

▪︎oxygenation with nonrebreather mask 15L/min or commercial high-flow mask(at least 70-100% oxygen) if Sat<90

▪︎IV line fix

▪︎IV fluid 0.9% N.S 1-2L bolus and repeated as needed.
*in patient with hypotension or those requiring repeated dose of epinephrine .

▪︎Place the patient in recumbent, and elevate lower extremities (if tolerated )
* unless there is respiratory distress, in which case the patient should be seated. If vomiting occurs, turn the head to the side to prevent aspiration

▪︎ECG stat

▪︎Foley catheter( not routinely)
*Urine output should be monitored in patients receiving IV fluid resuscitation for severe hypotension or shock.

▪︎Amp epinephrine (1/1000 or 1mg/1ml), give 0.3-0.5mg IM in the mid-outer thigh, repeated every 5-15 minutes(or more frequently) as needed(rapid injection).
▫️If epinephrine is injected promptly IM, most patients respond to 1, 2, or at most, 3 doses. If symptoms are not responding to epinephrine injections, prepare IV epinephrine for infusion.
▫️The first and most important treatment in anaphylaxis is epinephrine. There are NO absolute contraindications to epinephrine in the setting of anaphylaxis.

▪︎Neb Albuterol (salbutamol)  2.5 to 5 mg in 3 mL saline via nebulizer, or 2 to 3 puffs by metered dose inhaler. Repeat, as needed.
* For bronchospasm resistant to IM epinephrine.

▪︎Monitoring – Continuous noninvasive hemodynamic monitoring and pulse oximetry monitoring should be performed.

▪︎Consider intubation if indicated Immediate intubation if evidence of impending airway obstruction from angioedema. Delay may lead to complete obstruction.

▪️Adjunctive therapies:
*these medication shouldn’t be used as initial or sole treatment .

▫️H1 antihistamine – Consider giving cetirizine 10 mg IV (given over 2 minutes) or diphenhydramine 25 to 50 mg IV (given over 5 minutes) – for relief of urticaria and itching only.

▫️H2 antihistamine – Consider giving famotidine 20 mg IV (given over 2 minutes).

▫️Amp methylprednisolone 125 mg IV
OR
Amp hydrocortisone 200mg IV

🔹️Treatment of refractory symptoms

▪︎Amp epinephrine 0.1 mcg/kg/min continuous infusion by infusion pump, Titrate the dose continuously according to blood pressure, cardiac rate and function, and oxygenation.
▫️For patients with inadequate response to IM epinephrine and IV saline, give epinephrine continuous infusion
▫️For dilution and making epinephrine drip, adding 1 mg (1 mL of 1:1000 concentration) to 1000 mL of normal saline or 5% dextrose in water, Final concentration is 1mcg/ml. The infusion should be started at a rate of 1 mcg/min and can be titrated up to a maximum of 10 mcg/min based on the patient's hemodynamic response.

▪︎consider second vasopressors (in addition to epinephrine).
*All vasopressors should be given by infusion pump, with the doses titrated continuously according to blood pressure and cardiac rate/function and oxygenation monitored by pulse oximetry.

▪︎Amp  Glucagon 1 to 5 mg IV over 5 minutes, followed by infusion of 5 to 15 micrograms/minute.
*Patients on beta blockers may not respond to epinephrine.
*Rapid administration of glucagon can cause vomiting.



▪︎Appendix:

▪︎ما دو نوع آمپول اپی‌نفرین (1000/1 و سایز کوچکتر و حجمش 1ml) و (1/10000 وسایز بزرگ و حجمش 10ml) داریم. که کوچیکتره غلظتش بیشتره و یعنی 1mg/1ml و بزرگتره میشه 1mg/10ml. پس وقتی میگیم 0.5mg  تزریق بشه یعنی یا از آمپول کوچک 0.5ml(نصف آمپول) بکشیم یا از آمپول بزرگ 5ml(نصف آمپول)❗️وقتی بخوایم IV بدیم(مثلا در cpr) از اونی که رقیق‌ شده استفاده میکنیم(1mg/10ml) و برای IM(مثلا در آنافیلاکسی) از اونی که کوچیکتره(1mg/1ml).

📝 فهرست مطالب کانال
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