ALLERGIC REACTIONS(ANAPHYLAXIS)

This protocol is to be used for patients who may be experiencing an allergic reaction. The reaction can be

triggered by contact with an object, substance, something ingested or something injected beneath the skin (sting, bite,

IM, IV or SubQ medication or chemical, etc). The reaction can range from a mild irritation and/or twitching (with or

without a rash) of a localized area of the skin/body, to a full blown anaphylactic reaction with respiratory and

cardiovascular collapse.

SIGNS AND SYMPTOMS

• Skin – flushing, itching, hives, swelling, cyanosis.• Respiratory – dyspnea, sneezing, coughing, wheezing, stridor, laryngeal

edema, laryngospasm, bronchospasm.• Cardiovascular – vasodilation, increased heart rate, decreased blood

pressure.• Gastrointestinal – nausea/vomiting, abdominal cramping, diarrhea.• CNS – dizziness, headache, convulsions, tearing.

MILD REACTIONS

BASIC LEVEL: EMT and PARAMEDICInitial Patient Assessment Protocol 2.1.1.Airway Assessment /Management Protocol (O2 PRN) 2.1.2.Attach cardiac monitor and pulse oximeter.Transport to designated hospital.

ALS LEVEL 1: PARAMEDIC ONLYInitiate IV of Lactated Ringers or Normal Saline at TKO.Diphenhydramine HCL (Benadryl) 25mg IV or 50mg IM (Peds; 1-2mg/kg IV or IM.Ranitidine (Zantac) 150mg PO if able to swallow.

ALS LEVEL 2: MEDICAL CONTROLCall Medical Control or Medical Director for any concerns or help.

MODERATE ALLERGIC REACTIONS(edema, hives, dyspnea, wheezing, “lump in throat” feeling, difficulty swallowing, facial swelling and stable vital signs with a systolic BP> 90mmHg).

BASIC LEVEL: EMT and PARAMEDICInitial Patient Assessment Protocol 2.1.1.Airway Assessment/Management Protocol 2.1.2.Attach cardiac monitor and pulse oximeter.Transport to designated hospital.

MODERATE ALLERGIC REACTIONS cont.

ALS LEVEL 1: PARAMEDIC ONLYInitiate IV Lactated Ringers or Normal Saline at 70cc/hr.` Diphenhydramine HCL (Benadryl) 25mg IV or 50mg IM (Peds; 1-2mg/kg IV or IM.Ranitidine (Zantac) 150mg PO (Peds; 2mg/kg PO).Methylprednisolone Sodium Succinate (Solu-Medrol) 125mg IV/IO/IM.Epinephrine (1:1000) 0.4mg IM Adult (Peds 0.01mg/kg). Caution should be used with administration of Epinephrine when the patient has a history of hypertension or heart disease. Call Medical Control if you have any concerns.IF patient is on a Beta Blocker medication, administer Glucagon 2mg IV over 2-5 minutes. If you are not sure which drugs are Beta Blockers, contact Medical Control to discuss.If a patient shows signs of respiratory distress, administer;Albuterol (Ventolin) 2.5mg mixed with 2.5ml of Normal Saline nebulizer treatment. May repeat twice PRN.Add Atrovent (Ipratropium Bromide) 0.5mg to the first Albuterol nebulizer treatment only.

ALS LEVEL 2: MEDICAL CONTROLCall Medical Control or Medical Director for any concerns or help.

SEVERE ALLERGIC REACTIONS/ANAPHYLAXIS(edema, hives, severe dyspnea and wheezing, unstable vital signs with systolic

BP < 90mm Hg, possible cyanosis and/or laryngeal edema).

BASIC LEVEL: EMT and PARAMEDICInitial Patient Assessment Protocol 2.1.1.Airway Assessment/Management Protocol 2.1.2.Attach cardiac monitor and pulse oximeter.Transport to designated hospital.

SEVERE ALLERGIC REACTIONS/ANAPHYLAXIS cont.

ALS LEVEL 1: PARAMEDIC ONLYInitiate IV of Lactated Ringers or Normal Saline bolus with 250cc PRN up to 1 liter (reassess vitals and respiratory status between each bolus), then rate of 125cc/hr.(Bolus Peds with 20ml/kg then 40cc/hr).Diphenhydramine HCL (Benadryl) 25mg IV or 50mg IM (Peds; 1-2mg/kg IV or IM).Ranitidine (Zantac) 150mg PO (Peds; 2mg/kg PO).Methylprednisolone Sodium Succinate (Solu-Medrol) 125mg IV/IO/IM.Epinephrine (1:1000) 0.4mg IM Adult (Peds; 0.01mg/kg). Caution should be used with administration of Epinephrine when the patient has a history of hypertension or heart disease. Call Medical Control if you have any concerns.IF patient is on a Beta Blocker medication, give Glucagon 2mg IV over 2-5 minutes. If you are not sure which drugs are Beta Blockers, contact Medical Control to discuss.If patient shows signs of respiratory distress, administer; Albuterol (Ventolin) 2.5mg mixed with 2.5ml Normal Saline nebulizer treatment. May repeat twice PRN.Add Atrovent (Ipratropium Bromide) 0.5mg to the first Albuterol nebulizer treatment only.If the nebulized treatments do not significantly resolve the respiratory distress, consider the need for intubation.

SEVERE ALLERGIC REACTIONS/ANAPHYLAXIS

ALS LEVEL 2: MEDICAL CONTROLEpinephrine (1:10,000) 0.3mg SLOW IV in 0.1mg increments over 2 minutes. Caution should be used with administration of Epinephrine if patient has historyof hypertension or heart disease.

Diphenhydramine (Benadryl)

Benadryl products work because they contain an ingredient called diphenhydramine hydrochloride, which is an antihistamine.Here’s what happens during an allergic reaction:• The body releases a substance called histamine into the bloodstream.• Histamine travels to various parts of the body such as the eyes, nose, or skin.• Histamine causes blood vessels to widen and expand.• This causes redness, swelling, and inflammation.• Symptoms of itching, sneezing, runny eyes or nose, or hives arise.• The antihistamine in Benadryl blocks the action of histamine in the body and

helps to quickly relieve the symptoms.

Methylprednisolone Sodium Succinate (Solu-Medrol)

• Actions: Anti-inflammatory, suppresses immune response (especially in allergic reactions).

• Indications: Moderate and Severe allergic reaction, anaphylaxis, asthma/COPD.

• Precautions: Must be reconstituted and used promptly. Onset of action may be 2-6 hours and thus should not be expected to be of use in the critical first hour following an anaphylactic reaction.

RANITIDINE (Zantac)

Zantac is a antihistamine primarily effective for the histamine receptors in your stomach. They're called h-2 receptors. The histamine receptors in your blood vessels & nerve endings are primarily h-1 receptors with some h-2 receptors. When h-1 active antihistamines like Benadryl or Allegra are not sufficient to control hives, ZANTAC can be added for a little extra control. Alone, it's not very good.

Beta Blockers

Beta blockers, also known as beta-adrenergic blocking agents, are medications that reduce your blood pressure. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. When you take beta blockers, the heart beats more slowly and with less force, thereby reducing blood pressure. Beta blockers also help blood vessels open up to improve blood flow.

Common Beta Blockers

Atenolol (Tenormin)

Metoprolol (Lopressor, Toprol-XL)

Propranolol (Inderal LA, InnoPran XL)

Glucagon

Glucagon bypasses the receptors obstructed by the beta-blockers. These patients often respond poorly to epinephrine. In case of epinephrine failure, consider the use of glucagon in these patients. Class: Hormone (anti-hypoglycemic agent).Actions: Causes breakdown of glycogen to glucose.Inhibits glycogen synthesis.Elevates blood glucose level.Increases cardiac contractile force.Increases heart rate

Epinephrine 1:1,000

Epinephrine is a chemical that narrows blood vessels and opens airways in the lungs. These effects can reverse wheezing, severe skin itching, hypotension, hives and other severe allergic reaction symptoms.