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تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Anaphylaxis in infants and children: Rapid overview of emergency management*

Anaphylaxis in infants and children: Rapid overview of emergency management*
Diagnosis is made clinically:
The most common signs and symptoms are cutaneous (eg, sudden onset of generalized urticaria, angioedema, flushing, pruritus). However, 10 to 20% of patients have no skin findings.
Danger signs – Rapid progression of symptoms, evidence of respiratory distress (eg, stridor, wheezing, dyspnea, increased work of breathing, retractions, persistent cough, cyanosis), signs of poor perfusion, abdominal pain, vomiting, dysrhythmia, hypotension, collapse.
Acute management:
The first and most important therapy in anaphylaxis is epinephrine. There are NO absolute contraindications to epinephrine in the setting of anaphylaxis.
Airway – Immediate intubation if evidence of impending airway obstruction from angioedema. Delay may lead to complete obstruction. Intubation can be difficult and should be performed by the most experienced clinician available. Cricothyrotomy may be necessary.
IM epinephrine (1 mg/mL preparation) – Epinephrine 0.01 mg/kg should be injected IM in the mid-outer thigh. For large children (>50 kg), the maximum is 0.5 mg per dose. If there is no response or the response is inadequate, the injection can be repeated in 5 to 15 minutes (or more frequently). If epinephrine is injected promptly IM, patients respond to 1, 2, or, at most, 3 injections. If signs of poor perfusion are present or symptoms are not responding to epinephrine injections, prepare IV epinephrine for infusion (refer to below).
Place patient in recumbent position, if tolerated, and elevate lower extremities.
Oxygen – Give using a nonrebreather mask at 15 liters/minute flow rate or commercial high-flow oxygen masks (providing at least 70% and up to 100% oxygen), as needed.
Normal saline rapid bolus – Treat poor perfusion with rapid infusion of 20 mL/kg. Reevaluate and repeat fluid boluses (20 mL/kg), as needed. Massive fluid shifts with severe loss of intravascular volume can occur. Monitor urine output.
Albuterol – For bronchospasm resistant to IM epinephrine, give albuterol 2.5 mg inhaled via nebulizer. Dilute in saline if using a concentrated albuterol solution (≥0.5%). Repeat, as needed.
H1 antihistamine – Consider giving diphenhydramine 1 mg/kg (maximum 50 mg IV, over 5 minutes) or cetirizine (children aged 6 months to 5 years can receive 2.5 mg IV, those 6 to 11 years of age can receive 5 or 10 mg IV, over 2 minutes).
H2 antihistamine – Consider giving famotidine 0.25 mg/kg (maximum 20 mg) IV, over at least 2 minutes.
Glucocorticoid – Consider giving methylprednisolone 1 mg/kg (maximum 125 mg) IV.
Monitoring – Continuous noninvasive hemodynamic monitoring and pulse oximetry monitoring should be performed. Urine output should be monitored in patients receiving IV fluid resuscitation for severe hypotension or shock.
Treatment of refractory symptoms:
Epinephrine infusion In patients with inadequate response to IM epinephrine and IV saline, give epinephrine continuous infusion at 0.1 to 1 microgram/kg/minute, titrated to effect.
Vasopressors Patients may require large amounts of IV crystalloid to maintain blood pressure. Some patients may require a second vasopressor (in addition to epinephrine). All vasopressors should be given by infusion pump, with the doses titrated continuously according to blood pressure and cardiac rate/function monitored continuously and oxygenation monitored by pulse oximetry.
Glucagon – Patients on beta blockers may not respond to epinephrine and can be given glucagon 20 to 30 micrograms/kg (maximum 1 mg) IV over 5 minutes. Rapid administration of glucagon can cause vomiting.

IM: intramuscular; IV: intravenous.

* A child is defined as a prepubertal patient weighing less than 40 kg.

¶ All patients receiving an infusion of epinephrine and/or another vasopressor require continuous noninvasive monitoring of blood pressure, heart rate and function, and oxygen saturation. We suggest that pediatric centers provide instructions for preparation of standard concentrations and also provide charts for established infusion rate for epinephrine and other vasopressors in infants and children.
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