Anaphylaxis in a child

Anaphylaxis is a sudden, severe allergic reaction that involves two or more body systems, such as skin, breathing, gut and circulation. In children it often follows a food, insect sting or medicine, and it can block the airway or cause shock within minutes.

Key symptoms

• Hives, flushing, itching or swelling of the lips, tongue or face
• Cough, wheeze, hoarse voice or trouble breathing
• Vomiting, belly cramps or diarrhea
• Pale, floppy, sleepy or unusually quiet child
• A sense that something is very wrong, often soon after a known trigger

What you find on exam

• Airway: stridor, drooling, swelling of the tongue or throat
• Breathing: work of breathing, wheeze, oxygen saturation
• Circulation: heart rate, capillary refill, blood pressure for age
• Skin: hives and swelling, though the skin can be normal
• Weight or length-based estimate to dose medicines

Tests

• Diagnosis is clinical; never delay epinephrine to wait for tests
• Continuous monitoring of heart rate, oxygen saturation and blood pressure
• Serum tryptase within a few hours can support the diagnosis later
• Referral for allergy testing after recovery

Treatment basics

• Intramuscular epinephrine in the outer thigh, 0.01 mg/kg up to 0.3 mg, repeat every 5 to 15 minutes if needed
• Lay the child flat with legs raised, or sitting if breathing is hard; give high-flow oxygen
• IV or IO normal saline bolus of 20 mL/kg for low blood pressure or poor perfusion
• Add-on drugs after epinephrine: albuterol for wheeze, diphenhydramine for itching
• Observe for a biphasic reaction, prescribe two auto-injectors and teach an action plan

Practice it in Making Synapses

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Related guides

Sources: NASEMSO National Model EMS Clinical Guidelines; NREMT psychomotor skill sheets (EMT and Paramedic); NCCPA PANCE Content Blueprint. Written by Making Synapses. Making Synapses is not affiliated with these organizations.