Great article. Probably recognized by most readers already, but the typo in Weingart’s last bullet point should read “as best I can tell, the o.3 mg IM we give….” and not “0.3 mcg”

I hate to be the guy that comments a correction but want to make sure no one is left with any dosing confusion on this important topic.

Hi guys Despite this being targeted at a different location/population (OT/anaesthetists), the Australian and New Zealand Anaesthesia Allergy group has guidelines on this. They can be found at http://www.anzaag.com/Mgmt%20Resources.aspx. IV adrenaline is part of the standard of care for moderate/severe anaphylaxis in anaesthesia. Dosing is similar to some of the recommendations you have above, though I have had to use 200mcg boluses in an otherwise healthy 33 yo with severe anaphylaxis. There was no response until I gave 50 mcg (which was a brief drop in HR from ~150 to ~140 bpm with no improvement in blood pressure). One big… Read more »

Since we have to practise base on case reports and case series (because no one is ever going to do a RCT of adrenaline for anaphylaxis) my favourite paper is Brown SGA, Blackman KE, Stenlake V, et al Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation Emergency Medicine Journal 2004;21:149-154. The original study was an RCT of immunotherapy for anaphylaxis from insect stings, and to assess the efficacy of the treatment they gave all the patients (treated and placebo) a diagnostic sting challenge. Of the 68 patients in the study, 21 of the patients who… Read more »

Great article. Thank you. We see the IM dose of 0.5mg given IV in the sim lab often. It is a curious error. We teach the use of IV adrenaline for anaphylaxis after 2-3 doses IM adrenaline and persistent hypotension as per NZRC guidelines. To make as safe/easy as possible (outside specialised areas who are more familiar with IV infusions) : We Put 1mg (1ml of 1:1,000) in a 1000mls normal saline. You now have 1:1,000,000 or 1mcg/ml. Using a 20d/ml IV set Run drip 2drops/sec = 6mcg/min. Titrate to effect. 4drops/sec=12mcg/min etc.. OR Take 20mls of solution and push… Read more »

Can anyone speak to the use of glucagon in patients on beta blockers unresponsive to epi in anaphylaxis? Also Uptodate current rec is max dose 0.5 mg IM weight based as first dose. Do most of you max at 0.3 mg as first dose?

I can also attest to the success of IV Epinephrine in the (centrally and peripherally) hypo perfusing anaphylaxis pt. Very similar to the case presentation provided here. 50 yr old male postal worker stung by bee whilst at work. Found to be ashen, diaphoretic, complaining of the urge to void and extreme malaise. Extricated from vehicle, no tone. LOC barely sufficient to convey previous HX anaphylaxis from bee sting that resulted in MVA. Prior to EMS arrival pt. self administered auto injector to lateral thigh (5min prev.). Upon examination HR 45, BP 60/40, no airway involvement nor urticaria or rash,… Read more »

I can also attest to the success of IV Epinephrine in the (centrally and peripherally) hypo perfusing anaphylaxis pt. Very similar to the case presentation provided here. 50 yr old male postal worker stung by bee whilst at work. Found to be ashen, diaphoretic, complaining of the urge to void and extreme malaise. Extricated from vehicle, no tone. LOC barely sufficient to convey previous HX anaphylaxis from bee sting that resulted in MVA. Prior to EMS arrival pt. self administered auto injector to lateral thigh (5min prev.). Upon examination HR 45, BP 60/40, no airway involvement nor urticaria or rash,… Read more »