2-11 ACUTE ALLERGIC REACTION

A condition in which the patient has been exposed to an allergen such as bee stings, certain foods or medicines and exhibits any or all of the following symptoms: itching, hives, respiratory distress, airway swelling, and hypotension

EMR - Emergency Medical Responder

1. Initial assessment.
   1. It is useful, but not necessary to identify source of reaction.
   2. Assess for latex allergy and utilize latex-free equipment as needed.
   3. Time from onset.  Severe reactions usually occur within 30 minutes.
   4. History of anaphylaxis, epinephrine use or intubation.
2. Oxygen as indicated, if not already administered.
3. Patients with a systolic blood pressure of <90 mm Hg, difficulty breathing or swelling of the face, mouth and throat should be treated as anaphylactic shock. If the patient has not already used an EpiPen, administer an EpiPen if trained to do so and Call for ALS Intervention.
   1. Note: An EpiPen should only be used once - unless specifically ordered differently by Medical Control.

EMT - Emergency Medical Technician  Perform/Confirm All Above Interventions

1. If the patient has a mild reaction (isolated rash or subjective complaints with no physical findings and normal vital signs):
   1. Reassure and begin transport under observation.
   2. If the patient has wheezing, administer albuterol (Ventolin) 2.5 mg with or without ipratropium (Atrovent) 500 mcg via nebulizer; may repeat once if no relief
2. If the patient has a severe reaction (SBP < 90, swelling of face, mouth or throat or stridor):
   1. Assure ALS Response is in route and initiate transport as early as possible.
   2. Place patient in trendelenberg if SBP <90 provided the position is tolerated by respiratory effort.
   3. Administer EpiPen, if not already administered and there are no contraindications
      1. As an alternative to an EpiPen, providers that have been specifically trained to do so, may consider administering Epinephrine 1:1,000 dose 0.3 mg IM if no contraindications.
   4. Apply cardiac monitor if trained to do so.
3. Report any changes to medical control as soon as patient care safely allows.

AEMT – Advanced Emergency Medicine Tech   Perform/Confirm All Above Interventions

1. If the patient has a moderate reaction with more than one system (rash and wheezing, mouth swelling and wheezing, respiratory distress and rash, GI symptoms and rash):
   1. Administer an albuterol (Ventolin) 2.5 mg with or without ipratropium (Atrovent) 500 mcg via nebulizer; may repeat once if no relief
   2. Consider administration of an EpiPen, if no already utilized by the patient. Establish IV NS at TKO, do not delay further care
2. If the patient has a severe reaction (SBP < 90, swelling of face, mouth or throat or stridor):
   1. Place the patient in Trendelenburg position if tolerated by respiratory effort
   2. Establish IV NS wide-open and give a bolus 500 ml.  Recheck vital signs and if SBP still less than 90 mm hg, consult Medical Control for further fluid orders
   3. Administer EpiPen, if not already administered and there are no contraindications
      1. As an alternative to an EpiPen, providers that have been specifically trained to do so, may consider administering Epinephrine 1:1,000 dose 0.3 mg IM if no contraindications.
   4. Administer an albuterol (Ventolin) 2.5 mg with or without ipratropium (Atrovent) 500 mcg via nebulizer; may repeat once if no relief
3. Assure ALS Response for any severe reaction and consider for any moderate reaction.

Intermediate - Perform/Confirm All Above Interventions

1. If the patient has a mild reaction (isolated rash or subjective complaints with no physical findings and normal vital signs):
   1. Epinephrine is not used for itching and hives
2. If the patient has wheezing, administer albuterol (Ventolin) 2.5 mg with or without ipratropium (Atrovent) 500 mcg via nebulizer; may repeat once if no relief If the patient has a moderate reaction with more than one system (rash and wheezing, mouth swelling and wheezing, respiratory distress and rash, GI symptoms and rash)
   1. Administer an albuterol nebulizer if not already given. This may be repeated once after 5 minutes if wheezing persists.
   2. Consider administration of Epinephrine 1:1000 with a dose of 0.3 mg IM if no contraindications.
3. If the patient has a severe reaction (SBP < 90, swelling of face, mouth or throat or stridor):
   1. Administer Epinephrine 1:1,000 dose 0.3 mg IM if no contraindications
   2. Administer a fluid bolus of 500 ml of NS if SBP <90
   3. Consult Medical Control.
      1. Consider administration of Epinephrine 0.1 ml of 1:1,000 solution or 1 ml of 1:10,000 solution IV/IO for refractory anaphylactic shock.
         1. Dilute with 9-10 ml NS or administer with IV/IO running wide open
         2. Cardiac Monitoring required due to risk of cardiac dysrhythmias
      2. Consider administration of 1 mg Glucagon IV/IO if patient on a Beta Blocker and in refractory shock
4. Perform appropriate airway management based on patient’s condition.

Paramedic - Perform/Confirm All Above Interventions

1. Ensure all above interventions.
2. If the patient has a mild reaction (isolated rash or subjective complaints with no physical findings and normal vital signs):
   1. Epinephrine is not used for itching and hives
   2. If the patient has wheezing, administer albuterol (Ventolin) 2.5 mg with or without ipratropium (Atrovent) 500 mcg via nebulizer; may repeat once if no relief
   3. Consider administration of Benadryl  25 mg IV/IO or 50 mg IM
3. If the patient has a moderate reaction with more than one system (rash and wheezing, mouth swelling and wheezing, respiratory distress and rash, GI symptoms and rash)
   1. Administer albuterol (Ventolin) 2.5 mg with or without ipratropium (Atrovent) 500 mcg via nebulizer; may repeat once if no relief Consider administration of Epinephrine 1:1,000 with a dose of  0.3 mg IM if no contraindications.
4. If the patient has a severe reaction (SBP < 90, swelling of face, mouth or throat or stridor):
   1. Administer Epinephrine (1:1000) 0.3 mg IM.
   2. Administer Benadryl  25 mg IV/IO or 50 mg IM
   3. Administer a fluid bolus of 500 ml of NS if SBP <90
   4. Consult Medical Control.
      1. Consider administration of Epinephrine 0.1 ml of 1:1,000 solution or 1 ml of 1:10,000 solution IV/IO for refractory anaphylactic shock.
      2. Dilute with 9-10 ml NS or administer with IV running wide open
      3. Cardiac Monitoring required due to risk of cardiac dysrhythmias
      4. Consider administration of 1 mg Glucagon IV/IO if patient on a Beta Blocker and in refractory shock
5. Perform appropriate airway management based on patient’s condition.