Year: 2026
Type: review
Abstract: Health care providers across settings must be trained to manage anaphylaxis by (1) removing the offending allergen if still present; (2) positioning the patient with legs elevated, and if respiratory distress is present, allow the patient to sit upright with legs extended and elevated; (3) immediately administering epinephrine (adrenaline) intramuscularly (IM) or intranasally (IN) every 5 to 15 minutes for persistent anaphylaxis; and (4) optimizing airway, breathing, and cardiovascular (ABC) resuscitation. This may include supplemental oxygen, noninvasive or invasive positive-pressure ventilation, and intravenous fluid resuscitation. For life-threatening or refractory presentations, (5) IM/IN epinephrine should be administered every 5 minutes while addressing ABC derangements; this includes aggressive intravenous fluid resuscitation for patients in anaphylactic shock. Providers may continue IM or IN epinephrine or switch to the other, as both routes are considered equally efficacious based on pharmacokinetic data. An intravenous epinephrine infusion should be prepared for patients with persistent anaphylaxis after 2 doses of IM/IN epinephrine and initiated after the third dose, or earlier at the provider's discretion. In settings without epinephrine infusions, repeat IM/IN epinephrine should be administered every 5 minutes, along with other ABC interventions, and the patient should be transferred quickly to a setting equipped to provide advanced resuscitative care.
Authors: Timothy E. Dribin, Brad Sobolewski, Ronna L. Campbell, Paul J. Turner, Lene H. Garvey, Jasmeet Soar, Julie Wang, Marcus S. Shaker, Adam T. Fox, Sarayna S. McGuire, Kenneth A. Michelson, David Schnadower, Graham Roberts, Waleed Alqurashi, Moshe Ben-Shoshan, David C. Brousseau, Dianne E. Campbell, Andrew T. Clark, Antoine Deschildre, Katie Frith, Mattia Giovannini, Gideon Lack, Antonella Muraro, Mark I. Neuman, Nandinee Patel, Guillaume Pouessel, Kristina Rueter, Nicholas Sargant, Peter Smith, Susan Waserman, Gary Wing-Kin Wong, Margitta Worm, Hugh A. Sampson
Institutions: Cincinnati Children's Hospital Medical Center, University of Cincinnati, Mayo Clinic, Imperial College London, University of Copenhagen, Copenhagen University Hospital, Gentofte Hospital, Southmead Hospital, Icahn School of Medicine at Mount Sinai, Dartmouth–Hitchcock Medical Center, King's College London, Evelina London Children's Healthcare, Lurie Children's Hospital, University Hospital Southampton NHS Foundation Trust, NIHR Southampton Biomedical Research Centre, University of Southampton, University of Ottawa, Children's Hospital of Eastern Ontario, Montreal Children's Hospital, McGill University, Thomas Jefferson University, The University of Sydney, Cambridge University Hospitals NHS Foundation Trust, Université de Lille, Centre Hospitalier Universitaire de Lille, Hôpital Jeanne de Flandre, UNSW Sydney, Sydney Children's Hospital, Meyer Children's Hospital, University of Florence, St Thomas' Hospital, Azienda Ospedale - Università Padova, Boston Children's Hospital, Centre Hospitalier de Roubaix, Evaluation des technologies de santé et des pratiques médicales, The University of Western Australia, Princess Margaret Hospital for Children, Perth Children's Hospital, Bristol Royal Hospital for Children, Griffith University, St. Joseph’s Healthcare Hamilton, Hamilton Health Sciences, McMaster University, Chinese University of Hong Kong, Charité – Universitätsmedizin Berlin
Language: English
Subfield: Immunology and Allergy
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,000
Funders: AstraZeneca, Sanofi, Food Allergy Research and Education, European Respiratory Society, Aimmune Therapeutics, Celltrion, National Institute for Health and Care Research, European Commission, Novo Nordisk, National Institutes of Health, Health Resources and Services Administration, Canadian Institutes of Health Research, Medical Research Council, National Health and Medical Research Council, NIHR Imperial Biomedical Research Centre, National Institute on Aging
OpenAlex ID: W7168290989