Allergic Reaction - REACTION Format

This policy applies to: Patients whose chief complaint is itching, rash or allergic reaction.

Exclusion Criteria: None

Recognize

• Itching, hives, flushing, angioedema
• Coughing, wheezing, stridor, or respiratory distress
• Chest or throat constriction
• Difficulty swallowing
• Difficulty phonating
• Nausea / vomiting
• Altered Mental Status
• Hypotension or shock
• Edema

Evaluate

• Onset and trajectory of symptoms
• Anatomic and situational location of exposure
• Insect sting or bite
• Known allergies: food, environmental, medication, other
• Known or suspected exposure: past occurrences and current event
• Known history of sensitivity or allergic reaction
• Past medical and medication history
• New clothing, soap, or detergent
• New medications

Administer Treatment

• Remove allergy trigger if known and present
• Prioritize interventions based on clinical presentation and severity of reaction
• Supplemental oxygen PRN for goal SpO2
• Attentive and prompt airway assessment and management
• Airway Management if indicated per Airway Management PCG (P1)
• If patient has suspected or known exposure and exhibits signs of any: respiratory distress, airway
  restriction, altered mental status or shock, treat accordingly
  • • Epinephrine Auto-Injector 0.3 mg IM if available
    • Vascular access per Vascular Access PCG
    • Consider crystalloid fluid bolus 500 mL IV/IO to support hemodynamics, repeat PRN
    • Diphenhydramine (Benadryl) 50 mg IM/IV/IO
    • Epinephrine (1mg/1mL) 0.3 mg IM or Epinephrine (1mg/10mL) 0.1 mg IV/IO q 3 min PRN for
      MORE SEVERE REACTION
      • • Consider Epinephrine infusion 0.01 mcg/kg/min IV/IO, titrate to max 0.1 mcg/kg/min
          as an alternative to repeat IM or IV/IO doses
        • Monitor ECG rhythm closely, Epinephrine may potentiate arrhythmias, especially in
          patients over the age of 40
    • Methylprednisolone (Solu-Medrol) 125 mg IV/IO
    • Albuterol (2.5 mg/3 mL) nebulized for wheezing or shortness of breath

Consider Differentials

• Urticaria (rash only)
• Anaphylaxis (severe systemic effect)
• Shock (severe vascular effect)
• Angioedema (drug induced or infection)
• Aspiration / airway obstruction
• Vasovagal event
• Asthma or COPD
• Infection (ex: retropharyngeal abscess, bacterial tracheitis, croup, epiglottitis, strep)
• Pulmonary edema or CHF
• Metabolic disorders

Transport Considerations

• During transport, maintain astute airway, breathing, circulation and mental status assessment with
  prompt intervention as needed. Stability can quickly change to instability in these patients.
• Consider early airway management, reference Airway Management PCG (P1)

Information

• Typically, the shorter the interval from exposure to symptoms, the more severe the reaction
• Hemodynamic instability may recur up to 24 hours after initial stabilization

Other Populations

•  Neonatal/ Pediatric drug dosing:
  • • Pediatric Epinephrine Auto-Injector JR dose is 0.15 mg for patients 15-30 Kg
    • Diphenhydramine (Benadryl) 1 mg/Kg IM/IV/IO over 5 min max dose 50 mg
    • Epinephrine (1mg/1mL) 0.01 mg/Kg IM/IV/IO q3 min until stable or infusion started
      • • Max 0.5 mg per dose (Intentionally larger than adult dosing)
        • Epinephrine infusion 0.01 mcg/Kg/min IV/IO, titrate to max 1 mcg/kg/min
    • Methylprednisolone (Solu-Medrol) 2 mg/Kg IV/IO max dose 125mg
    • Albuterol for 15 Kg or more, use adult dose
    • Albuterol for less than 15 Kg (1.25mg/ 3ml) nebulized with O2 at 6 lpm

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References

Campbell, Ronna. “Anaphylaxis: Emergency Treatment.” UpToDate, January 2022.
Sicherer, Scott. “Prescribing Epinephrine for Anaphylaxis Self-Treatment.” UpToDate, January 2022.
“U.S. Army Medevac Critical Care Flight Paramedic Standard Medical Operating Guidelines.” Jan. 2020.