> For the complete documentation index, see [llms.txt](https://handbook.teddwa.xyz/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://handbook.teddwa.xyz/allergies.md).

# Allergies

Assess allergic reactions, identify anaphylaxis, and provide time critical treatment.

### Assess the reaction

1. Complete the primary assessment. Address airway, breathing, or circulatory compromise first.
2. Ask about the suspected allergen, exposure time, prior reactions, asthma, and prescribed epinephrine.
3. Look for anaphylaxis after likely exposure. Key signs include throat tightness, hoarseness, stridor, wheeze, hypoxia, hypotension, syncope, or persistent vomiting.

Skin findings alone may indicate an allergic reaction. Anaphylaxis can occur without a rash or hives.

### Perform a focused skin and airway examination

Expose the patient as needed and inspect the trunk, neck, extremities, and exposure site. Preserve privacy and prevent heat loss.

Check for:

* Hives, flushing, itching, swelling, or a rapidly spreading rash.
* Lip, tongue, face, eyelid, or neck swelling.
* Pallor, cyanosis, diaphoresis, mottling, or delayed capillary refill.

Inspect the mouth and tongue. Listen for voice change, stridor, wheeze, or diminished breath sounds. Recheck mental status, pulse, blood pressure, respiratory effort, and SpO₂.

### Treat suspected anaphylaxis

Give **epinephrine promptly** for suspected anaphylaxis. Do not delay it for antihistamines, corticosteroids, IV access, or rash progression.

Follow local protocol and medical direction. Use the patient’s prescribed auto-injector when appropriate.

For anaphylaxis, give **epinephrine 1 mg/mL (1:1,000) IM** in the outer mid-thigh:

* **Adults:** 0.3–0.5 mg IM.
* **Children:** 0.01 mg/kg IM, up to 0.3 mg per dose.
* Repeat in 5–15 minutes for persistent or recurrent symptoms, under protocol.

Do not use IV epinephrine for routine anaphylaxis treatment. Do not inject into the buttock, hands, or feet.

### ALS treatment for refractory symptoms

There is **no absolute contraindication** to IM epinephrine for suspected anaphylaxis. Cardiovascular disease, pregnancy, advanced age, or beta-blocker use require caution and close monitoring. They do not replace epinephrine with an alternative medication.

Contact medical control immediately if a protocol directs withholding epinephrine. Treat airway, breathing, and circulatory compromise while awaiting direction.

ALS may use the following adjuncts under protocol:

* **Nebulized albuterol** for persistent bronchospasm or wheeze.
* **Isotonic crystalloid** for hypotension or poor perfusion.
* **Glucagon** for refractory hypotension in a patient taking a beta-blocker.
* **IV epinephrine infusion or vasopressors** for shock that persists after IM epinephrine and fluids.
* **Diphenhydramine** for hives or itching after epinephrine.
* **Dexamethasone, methylprednisolone, or prednisone** when corticosteroid treatment is indicated.

Diphenhydramine may relieve hives or itching. Corticosteroids may be considered for persistent symptoms or asthma exacerbation. These medications do not rapidly treat airway edema, bronchospasm, or shock.

### Support and transport

Keep a hypotensive patient supine with legs elevated when tolerated. Let a patient with severe respiratory distress remain in the position that best supports breathing. Do not let the patient stand or walk.

Provide oxygen for hypoxia or respiratory distress. Assist ventilations with a BVM when breathing is inadequate. Request ALS for airway swelling, respiratory distress, hypotension, altered mental status, or symptoms that persist after epinephrine.

All patients treated with epinephrine need emergency evaluation. Reassess airway, breath sounds, skin, blood pressure, pulse, mental status, and SpO₂ every 5 minutes.

{% hint style="warning" %}
Antihistamines and corticosteroids are adjuncts. They do not replace epinephrine for anaphylaxis.
{% endhint %}


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