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Anaphylaxis treatment: An evidence-based guideline for EMS

The only effective treatment for anaphylaxis is epinephrine, which should be given early and repeated as needed


The King County EMS epinephrine injection kit. (Photo by Greg Friese)

LAS VEGAS — Anaphylaxis is a life-threatening emergency that requires immediate prehospital care, but to date all treatment guidelines have been based on an in-hospital treatment. At EMS World Expo Peter Taillac, MD, detailed the process of an expert panel to research and publish an evidence-based guideline (EBG) for the recognition and treatment of anaphylaxis.

The expert panel attempted to answer a series of questions about anaphylaxis assessment and treatment through literature research and review. The guideline is intended to serve as the scientific basis for future EMS anaphylaxis protocols.

Memorable quotes on anaphylaxis treatment

“There is no downside to giving epi (for anaphylaxis).”

“Antihistamines do not treat anaphylaxis. There is no proven benefit of antihistamines for hypotension, respiratory distress or airway compromise. The only effective for treatment of anaphylaxis is epinephrine.”

Peter Taillac, MD, FACEP

Key takeaways: anaphylaxis treatment

The process for EBG development starts by proposing the important clinical questions. Some of the questions proposed by the expert panel about anaphylaxis treatment and answered in the process were:

  • What is the difference between anaphylaxis and a simple allergic reaction?
  • What are the common triggers of an allergic reaction?
  • What are the risk factors for an allergic reaction?
  • What signs and symptoms are associated with allergic reaction vs. anaphylaxis?
  • Is cardiac monitoring required when treating allergic reactions or anaphylaxis?

After posing the questions the research is conducted. Here are the key takeaways from this presentation on the development of an EBG for EMS treatment of anaphylaxis.

  • Treat anaphylaxis – hypotension, facial or oral swelling, or respiratory compromise – with epinephrine.
  • Intramuscular is the best route for epinephrine administration. Repeat dosing every five to 10 minutes until the patient improves.
  • Prehospital providers only need to know two epinephrine doses, an adult and a pediatric dose, for anaphylaxis that is always best administered into the lateral aspect of the thigh.
  • An auto-injector, when used properly, is better because it safely and simply delivers a higher level of epinephrine to the blood.
  • Cardiac monitoring is not required for a patient that receives a single dose of epinephrine. But cardiac monitoring may be useful for patients with other underlying medical problems, such as cardiac disease.
  • Histamines, like diphenhydramine (H1 blocker) and ranitidine (H2 blocker), are helpful for the treatment of symptoms, like alleviation of itching.
  • IV steroids, administered prehospital, are not recommended based on the available evidence and delayed onset of effect.
  • Administration of intravenous fluids is part of the standard treatment for hypotension (shock).
  • Any patient that has anaphylaxis and receives epinephrine should be transported.

Taillac concluded the presentation by suggesting an alternative to auto-injectors. He has authorized EMTs to whom he provides medical direction to draw up and administer epinephrine from 1 mL vials or ampoules. King County EMS has developed a similar program and distributes an epinephrine check and inject kit.

Greg Friese, MS, NRP, is the Lexipol Editorial Director, leading the efforts of the editorial team on Police1, FireRescue1, Corrections1 and EMS1. Greg served as the EMS1 editor-in-chief for five years. He has a bachelor’s degree from the University of Wisconsin-Madison and a master’s degree from the University of Idaho. He is an educator, author, national registry paramedic since 2005, and a long-distance runner. Greg was a 2010 recipient of the EMS 10 Award for innovation. He is also a three-time Jesse H. Neal award winner, the most prestigious award in specialized journalism, and the 2018 and 2020 Eddie Award winner for best Column/Blog. Connect with Greg on LinkedIn.