First 5 minutes for critical patient
›Immediate stabilization workflow
›Monitoring
›Cardiac monitor
›Pulse oximetry
›Access
›Two IV lines for hypotension or anaphylaxis
›Intraosseous access if no IV access in shock
›Oxygen
›Supplemental oxygen for oxygen saturation less than 92 percent
›Early airway planning for stridor or voice change
›Epinephrine for anaphylaxis
›Adult epinephrine IM 0.3 mg to 0.5 mg of 1 mg per mL into lateral thigh
›Repeat every 5 to 15 minutes if persistent symptoms
Pharmacologic ladder for isolated urticaria
›Symptom control
›Second generation H1 antihistamine first line
›Cetirizine 10 mg PO daily
›Fexofenadine 180 mg PO daily
›Up dosing for persistent symptoms off label
›Cetirizine 20 mg PO twice daily maximum 40 mg per day
›Fexofenadine 180 mg PO twice daily maximum 360 mg per day
›Sedating H1 antihistamine adjunct
›Diphenhydramine 25 mg to 50 mg PO or IV every 6 hours as needed
›Hydroxyzine 25 mg PO every 6 hours as needed
›H2 blocker adjunct
›Famotidine 20 mg PO or IV twice daily
›Limited incremental benefit over H1 alone
›Glucocorticoid short course selected cases
›Prednisone 40 mg PO daily for 3 to 5 days
›Avoid for uncomplicated mild cases
Anaphylaxis treatment bundle
›Time critical therapy
›Epinephrine first line
›Adult epinephrine IM 0.3 mg to 0.5 mg of 1 mg per mL into lateral thigh
›Pediatric epinephrine IM 0.01 mg per kg of 1 mg per mL maximum 0.3 mg
›IV fluids for hypotension
›Normal saline 1 L bolus adult
›Repeat bolus based on perfusion and blood pressure
›Bronchospasm
›Albuterol nebulized 2.5 mg to 5 mg
›Repeat based on response
›Adjunct antihistamine
›Diphenhydramine 25 mg to 50 mg IV or PO
›Not a substitute for epinephrine
›Adjunct steroid
›Methylprednisolone 125 mg IV selected cases
›Does not prevent early airway compromise
Angioedema phenotype specific management
›Histaminergic angioedema likely
›Similar treatment to urticaria
›Epinephrine if anaphylaxis features present
›Bradykinin mediated angioedema suspected
›ACE inhibitor discontinuation
›Avoid future ACE inhibitor exposure
›Document as drug reaction
›Airway priority
›Early anesthesia or ENT support for tongue or laryngeal symptoms
›Lower threshold for intubation if progression
›Targeted therapies local protocol dependent
›C1 inhibitor concentrate 20 units per kg IV for hereditary angioedema
›Icatibant 30 mg subcutaneous single dose for hereditary angioedema
›Response monitoring and repeat exams
›Recheck vitals every 15 minutes until stable after epinephrine
›Repeat airway exam after each intervention
›Symptom recurrence watch for biphasic reaction