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Patients DO NOT have to present with integumentary involvement to be in anaphylaxis - up to 20% of patients experiencing anaphylaxis will have absent or unrecognized skin signs.

Patients DO NOT have to exhibit hypotension to diagnose ongoing anaphylaxis.

Anaphylaxis is unpredictable in time to onset, and the severity of presenting signs and symptoms exist on a spectrum. Stay ahead of the curve and give epi early.

World Allergy Organization's Clinical Criteria for Anaphylaxis [1]:

Anaphylaxis is highly likely when any one of the following three criteria is fulfilled:

1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized urticaria, itching or flushing,
swollen lips-tongue-uvula)

AND AT LEAST ONE OF THE FOLLOWING:

1. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)
2. Reduced blood pressure or associated symptoms of end-organ dysfunction (eg. hypotonia collapse, syncope, incontinence)

2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):

1. Involvement of the skin-mucosal tissue (eg, generalized urticaria, itch-flush, swollen lips-tongue-uvula)
2. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)
3. Reduced blood pressure or associated symptoms (eg, hypotonia collapse, syncope, incontinence)
4. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)

3. Reduced blood pressure after exposure to known allergen for that patient (minutes to several hours):

1. Infants and children: low systolic blood pressure (age-specific) or greater than 30% decrease in systolic blood pressure.
2. Adults: systolic blood pressure of less than 90 mm Hg or greater than 30% decrease from that person’s baseline.

1st Line:

• IM Epi -> IV Fluids -> IV epi PRN.
• IM epi should be administered in the lateral thigh
• If the patient is know to be on beta blockers, give glucagon 1mg IVP if available

2nd Line:

• Inhaled beta agonists, antihistamines, and glucocorticoids.

Refractory anaphylaxis

• Methylene Blue
• Transport to an ECMO-capable facility