Editing Anaphylaxis (section)

==Management==
Anaphylaxis is a [[medical emergency]] that may require [[Cardiopulmonary resuscitation|resuscitation]] measures such as [[airway management]], [[Oxygen therapy|supplemental oxygen]], large volumes of [[Intravenous therapy|intravenous fluids]], and close monitoring.<ref name=EAACI2014/> [[Passive leg raise]] may also be helpful in the emergency management.<ref name="Simons 2010 pp. S161–S181">{{cite journal | last=Simons | first=F. Estelle R. | title=Anaphylaxis | journal=The Journal of Allergy and Clinical Immunology | publisher=Elsevier BV | volume=125 | issue=2 | year=2010 | issn=0091-6749 | pmid=20176258 | doi=10.1016/j.jaci.2009.12.981 | pages=S161–S181| doi-access=free }}</ref>

Administration of intravenous fluid bolus and epinephrine is the treatment of choice with [[Histamine antagonist|antihistamines]] used as adjuncts.<ref>{{cite journal |last1=Shaker |first1=Marcus S. |last2=Wallace |first2=Dana V. |last3=Golden |first3=David B.K. |last4=Oppenheimer |first4=John |last5=Bernstein |first5=Jonathan A. |last6=Campbell |first6=Ronna L. |last7=Dinakar |first7=Chitra |last8=Ellis |first8=Anne |last9=Greenhawt |first9=Matthew |last10=Khan |first10=David A. |last11=Lang |first11=David M. |last12=Lang |first12=Eddy S. |last13=Lieberman |first13=Jay A. |last14=Portnoy |first14=Jay |last15=Rank |first15=Matthew A. |date=April 2020 |title=Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis |journal=Journal of Allergy and Clinical Immunology |language=en |volume=145 |issue=4 |pages=1082–1123 |doi=10.1016/j.jaci.2020.01.017|pmid=32001253 |s2cid=215728019 |doi-access=free }}</ref> A period of in-hospital observation for between 2 and 24 hours is recommended for people once they have returned to normal due to concerns of biphasic anaphylaxis.<ref name=CEA11/><ref name=Rosen2010/><ref name=BI05/><ref name=UK08>{{cite web |url=http://www.resus.org.uk/pages/reaction.pdf |title=Emergency treatment of anaphylactic reactions – Guidelines for healthcare providers |date=January 2008 |access-date=2008-04-22 |publisher=Resuscitation Council (UK) |url-status=live |archive-url=https://web.archive.org/web/20081202181557/http://www.resus.org.uk/pages/reaction.pdf |archive-date=2008-12-02 }}</ref>

===Epinephrine===
[[File:Epipen.jpg|thumb|upright=1.3|An old version of an EpiPen brand auto-injector]]
[[Epinephrine (medication)|Epinephrine]] (adrenaline) (1 in 1,000) is the primary treatment for anaphylaxis with no absolute [[contraindication]] to its use.<ref name=EAACI2014/> It is recommended that an epinephrine solution be given [[Intramuscular injection|intramuscularly]] into the mid anterolateral thigh as soon as the diagnosis is suspected.<!-- <ref name=EAACI2014/> --> The injection may be repeated every 5 to 15 minutes if there is insufficient response.<ref name=EAACI2014/> A second dose is needed in 16–35% of episodes with more than two doses rarely required.<ref name=EAACI2014/> The intramuscular route is preferred over [[Subcutaneous tissue|subcutaneous]] administration because the latter may have delayed absorption.<ref name=EAACI2014/><ref name=Epi10>{{cite journal|last=Simons|first=KJ|author2=Simons, FE|title=Epinephrine and its use in anaphylaxis: current issues|journal=Current Opinion in Allergy and Clinical Immunology|date=August 2010|volume=10|issue=4|pages=354–61|pmid=20543673|doi=10.1097/ACI.0b013e32833bc670|s2cid=205435146}}</ref> It is recommended that after diagnosis and treatment of anaphylaxis, the patient should be kept under observation in an appropriate clinical setting until symptoms have fully resolved.<ref name="pmid32001253">{{cite journal | vauthors = Shaker MS, Wallace DV, Golden DK, Oppenheimer J, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Greenhawt M, Khan DA, Lang DM, Lang ES, Lieberman JA, Portnoy J, Rank MA, Stukus DR, Wang J, Riblet N, Bobrownicki AP, Bontrager T, Dusin J, Foley J, Frederick B, Fregene E, Hellerstedt S, Hassan F, Hess K, Horner C, Huntington K, Kasireddy P, Keeler D, Kim B, Lieberman P, Lindhorst E, McEnany F, Milbank J, Murphy H, Pando O, Patel AK, Ratliff N, Rhodes R, Robertson K, Scott H, Snell A, Sullivan R, Trivedi V, Wickham A, Shaker MS, Wallace DV, Shaker MS, Wallace DV, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Golden DK, Greenhawt M, Lieberman JA, Rank MA, Stukus DR, Wang J, Shaker MS, Wallace DV, Golden DK, Bernstein JA, Dinakar C, Ellis A, Greenhawt M, Horner C, Khan DA, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wang J | title = Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis | journal = J Allergy Clin Immunol | volume = 145 | issue = 4 | pages = 1082–1123 | date = April 2020 | pmid = 32001253 | doi = 10.1016/j.jaci.2020.01.017 | doi-access = free }}</ref> Minor adverse effects from epinephrine include [[tremor]]s, anxiety, headaches, and [[palpitation]]s.<ref name=World11/>

People on [[Beta blocker|β-blockers]] may be resistant to the effects of epinephrine.<ref name=CEA11/> In this situation if epinephrine is not effective intravenous [[Glucagon_(medication)|glucagon]] can be administered which has a mechanism of action independent of [[Adrenergic receptor|β-receptor]]s.<ref name=CEA11/>

If necessary, it can also be given [[Intravenous therapy|intravenously]] using a dilute epinephrine solution. Intravenous epinephrine, however, has been associated both with [[Cardiac dysrhythmia|dysrhythmia]] and [[myocardial infarction]].<ref name=EAACI2014/> [[Epinephrine autoinjector]]s used for self-administration typically come in two doses, one for adults or children who weigh more than 25&nbsp;kg and one for children who weigh 10 to 25&nbsp;kg.<ref>{{cite journal|last1=Halbrich|first1=M|last2=Mack|first2=DP|last3=Carr|first3=S|last4=Watson|first4=W|last5=Kim|first5=H|title=CSACI position statement: epinephrine auto-injectors and children &lt; 15 kg.|journal=Allergy, Asthma, and Clinical Immunology|date=2015|volume=11|issue=1|pages=20|pmid=26131015|pmc=4485331|doi=10.1186/s13223-015-0086-9|doi-access=free}}</ref>

===Adjuncts===
[[Histamine antagonist|Antihistamines]] (both [[H1 antagonist|H1]] and [[H2 antagonist|H2]]), while commonly used and assumed effective based on theoretical reasoning, are poorly supported by evidence.<ref>{{cite journal|last1=Nurmatov|first1=UB|last2=Rhatigan|first2=E|last3=Simons|first3=FE|last4=Sheikh|first4=A|title=H2-antihistamines for the treatment of anaphylaxis with and without shock: a systematic review.|journal=Annals of Allergy, Asthma & Immunology|date=February 2014|volume=112|issue=2|pages=126–31|pmid=24468252|doi=10.1016/j.anai.2013.11.010}}</ref><ref name=She2007/> A 2007 [[Cochrane Collaboration|Cochrane]] review did not find any good-quality studies upon which to base recommendations<ref name=She2007>{{cite journal |vauthors=Sheikh A, Ten Broek V, Brown SG, Simons FE |title=H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review |journal=Allergy |volume=62 |issue=8 |pages=830–7 |date=August 2007 |pmid=17620060 |doi=10.1111/j.1398-9995.2007.01435.x |s2cid=27548046 |doi-access=free }}</ref> and they are not believed to have an effect on airway edema or spasm.<ref name=CEA11/> [[Corticosteroids]] are unlikely to make a difference in the current episode of anaphylaxis, but may be used in the hope of decreasing the risk of biphasic anaphylaxis. Their prophylactic effectiveness in these situations is uncertain.<ref name=BI05>{{cite journal |author=Lieberman P |title=Biphasic anaphylactic reactions |journal=Ann. Allergy Asthma Immunol. |volume=95 |issue=3 |pages=217–26; quiz 226, 258 |date=September 2005 |pmid=16200811 |doi= 10.1016/S1081-1206(10)61217-3}}</ref>  [[Nebulizer|Nebulized]] [[salbutamol]] may be effective for [[bronchospasm]] that does not resolve with epinephrine.<ref name=CEA11/> [[Methylene blue]] has been used in those not responsive to other measures due to its presumed effect of relaxing smooth muscle.<ref name=CEA11/>

===Preparedness===
People prone to anaphylaxis are advised to have an allergy action plan.<!-- <ref name=Mart08/> --> Parents are advised to inform schools of their children's allergies and what to do in case of an anaphylactic emergency.<!-- <ref name=Mart08/> --> The action plan usually includes use of [[epinephrine autoinjector]]s, the recommendation to wear a [[Medical identification tag|medical alert bracelet]], and counseling on avoidance of triggers.<ref name=Mart08>{{cite journal|last=Martelli|first=A|author2=Ghiglioni, D|author3=Sarratud, T|author4=Calcinai, E|author5=Veehof, S|author6=Terracciano, L|author7=Fiocchi, A|title=Anaphylaxis in the emergency department: a paediatric perspective|journal=Current Opinion in Allergy and Clinical Immunology|date=August 2008|volume=8|issue=4|pages=321–9|pmid=18596589|doi=10.1097/ACI.0b013e328307a067|s2cid=205434577}}</ref> [[Allergen immunotherapy|Immunotherapy]] is available for certain triggers to prevent future episodes of anaphylaxis. A multi-year course of subcutaneous [[Desensitization (medicine)|desensitization]] has been found effective against stinging insects, while oral desensitization is effective for many foods.<ref name=Review09/>