ALLERGIC REACTION

Inclusion Criteria:  Patients presenting with rash, hives, shortness of breath, or other signs and symptoms, up to and including shock, apparently due to an allergic reaction. For Dystonic Reactions, please refer to #11 (below) of these guidelines.

Basic Level

  1. Assess and support ABCs. Ensure the airway is patent. Proceed with BVM ventilation and an oropharyngeal or nasopharyngeal airway, if needed.
  2. Place the patient in a position of comfort.  If there is evidence of shock, place the patient supine with the feet elevated and closely monitor the patient’s airway status.
  3. Isolate the patient from the source of the allergen, if possible.
  4. Administer oxygen, as needed, to maintain a SpO2 of at least 94%.
  5. Assess breath sounds.  If wheezing is present and paramedics are not present at the scene, EMT-Basics may administer epinephrine via the patient’s own autoinjector, if available. 
    1. During injection, hold the autoinjector against the patient’s skin for at least 10 seconds. 
    2. EMT-Basics may not administer additional autoinjector doses of epinephrine without BioTel authorization.

Advanced Level

  1. Continuously monitor ECG and ETCO2 if respiratory distress or shock is present, anticipated, or develops.
  2. Consider establishing IV access at a TKO rate or use a saline lock.
  3. Specific conditions:
If localized reaction only (hives), administer:

Adult

Diphenhydramine 25 – 50 mg IM or IV/IO

Pediatric

Diphenhydramine 1 – 2 mg/kg IM or IV/IO

If shock, severe hypoperfusion, critical airway or SBP less than 90 mmHg (70mmHg + [Age x 2] in children), administer epinephrine 1:1,000 IM (intramuscular is preferred in this setting) as soon as possible. Do not delay epinephrine administration while attempting IV/IO access.


Adult

  • Administer 1:1,000 epinephrine 0.3 mg – 0.5 mg IM. If the patient is responding but needs an additional dose, repeat single dose every 20 minutes up to a maximum total three doses (count autoinjector doses as part of the three).
  • 20 mL/kg mL Normal Saline fluid boluses IV/IO, as needed (up to 1,000 mL), to maintain a systolic blood pressure of 90 mmHg.
  • Diphenhydramine 25 – 50 mg IV/IO.
  • Administer methylprednisolone 125 mg IV/IO, if available (optional medication). • If no response to the IM epinephrine and fluid bolus within 10 minutes, administer 1:10,000 epinephrine 0.1 – 0.2 mg IV or IO (1 – 2 mL) VERY SLOWLY (over 1 minute).


Pediatric

  • Administer 1:1,000 epinephrine 0.01 mg/kg IM (0.01 mL/kg) (maximum dose is 0.3 mg); AND
  • 20 mL/kg Normal Saline fluid bolus IV/IO.
    • May repeat once (do not exceed total maximum fluid volume of 1 L);

      AND

  • Administer diphenhydramine 1 – 2 mg/kg IM or IV/IO;

    AND

  • Administer methylprednisolone IV/IO, if available (optional medication) – Reconstitute 125 mg in 2 mL (as supplied), then dilute with 8 mL Normal Saline to a final volume of 10 mL (12.5 mg/mL); Administer IVP/IO :
  • Age less than 1 yr: 12.5 mg (1 mL)
  • Age 1 to 3 yr: 25 mg (2 mL)
  • Age 3 to 5 yr: 37.5 mg (3 mL)
  • Age 5 to 9 yr: 50 mg (4 mL)
  • Age 9 to 13 yr: 62.5 mg (5 mL)
  • If no response to IM epinephrine and fluid bolus within 10 minutes, administer 1:10,000 epinephrine 0.01 mg/kg IV or IO (0.1 mL/kg) VERY SLOWLY (over 1 minute).
For bronchospasm unresponsive after 5 minutes to epinephrine IM and diphenhydramine, administer albuterol 2.5 mg via nebulizer. May repeat up to a cumulative total of three (3) doses.
  1. Monitor vital signs and transport.
  2. For additional patient care considerations not covered under standing orders, consult BioTel.
  3. Acute dystonic reaction may occur in patients using neuroleptic drugs, particularly antipsychotic medications (e.g. haloperidol, risperidone). Patients treated for dystonic reaction must be assessed by a qualified medical provider in a medical facility.
For Acute Dystonic Reaction caused by an anti-psychotic medication, administer:


Adult

Diphenhydramine 25 – 50 mg IM or IV/IO.


Pediatric

Diphenhydramine 1 – 2 mg/kg IM or IV/IO.