| Hives (uticaria) |
- Discontinue injection if not completed
- No treatment needed in most cases - reassure the patient
- Consider diphenhydramine (Benadryl®) PO/IM/IV 25-50 mg
- If severe/widely disseminated: Epinephrine SC (1:1,000) 0.1-0.3 ml (=0.1-0.3 mg) (if no cardiac contraindications)
|
| Facial or Laryngeal Edema |
- 0.1-0.3 ml epinephrine SC or IM (1:1,000) (=0.1-0.3 mg) or, if hypotensive, 1 ml epinephrine IV (1:10,000) slowly (=0.1 mg). Repeat as needed up to 1 mg.
- Give oxygen 6-10 L/min (via mask)
- If not responsive to therapy or if there is obvious acute laryngeal edema, seek appropriate assistance (e.g., cardiopulmonary arrest response team).
|
| Bronchospasm |
- Give oxygen 6-10 L/min (via mask)
- Monitor: ECG, O2 saturation (pulse oximeter), and BP
- Give beta-agonist inhalers, such as metaproterenol (Alupent®), terbutaline (Brethaire®), or albuterol (Proventil®)(Ventolin®) 2-3 puffs; repeat as needed
- If unresponsive, epinephrine SC or IM (1:1,000) 0.1-0.3 ml (=0.1-0.3 mg) or, if hypotensive, epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg) - Repeat up to 1 mg
- Alternatively, give aminophylline 6 mg/kg IV in D5W over 10-20 minutes (loading dose), then 0.4-1 mg/kg/hr, as needed (caution: hypotension)
- Call for assistance for severe bronchospasm or if O2 saturation < 88% persists
|
| Hypotension with Tachycardia |
- Legs elevated 60° or more (preferred) or Trendelenburg position
- Monitor: ECG, O2 saturation (pulse oximeter), and BP
- Give oxygen 6-10 L/min (via mask)
- Rapid large volumes of IV isotonic Ringer’s lactate or normal saline
- If poorly responsive: Epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg) (if no cardiac contraindications). Repeat as needed up to a maximum of 1 mg
- If still poorly responsive seek appropriate assistance (e.g., arrest team).
|
| Hypotension with Bradycardia (Vagal Reaction) |
- Monitor: ECG, O2 saturation (pulse oximeter), and BP
- Legs elevated 60° or more (preferred) or Trendelenburg position
- Secure airway and give oxygen 6-10 L/min (via mask)
- Rapid large volumes of IV isotonic Ringer’s lactate or normal saline
- If unresponsive, atropine 0.6-1 mg IV slowly - repeat up to 2-3 mg in adult
- Ensure complete resolution of hypotension and bradycardia prior to discharge.
|
| Severe Hypertension |
- Give oxygen 6-10 L/min (via mask)
- Monitor: ECG, O2 saturation (pulse oximeter), and BP
- Give nitroglycerine 0.4-mg tablet, sublingual (may repeat x 3)
- Transfer to intensive care unit or emergency department
- For pheochromocytoma—phentolamine 5 mg IV
|
| Seizures or Convulsions |
- May be consequence of hypotension, primary treatment should be as indicated
- Lateral decubitus position, give oxygen, 6-10 L/min by mask
- Consider diazepam (Valium®) 5 mg or more or midazolam (Versed®) 0.5-1 mg IV
- If longer effect needed, obtain consultation; consider phenytoin (Dilantin®) infusion – 15-18 mg/kg at 50 mg/min.
- Careful monitoring of vital signs, particularly of pO2 (respiratory depression)
- Consider using cardiopulmonary arrest response team for intubation
|
| Pulmonary Edema |
- Elevate torso; rotating tourniquets (venous compression)
- Give O2 6-10 liters/min (via mask)
- Give diuretics – furosemide (Lasix®) 20-40 mg IV, slow push
- Consider giving morphine (1-3 mg IV)
- Transfer to intensive care unit or emergency department
- Corticosteroids optional
|
| Unconscious, Unresponsive, Pulseless, or Collapsed Patient |
- CALL CODE
- Institute Basic Life Support
- Establish airway, head tilt, chin lift
- Initiate ventilation and external chest compression
- Continue uninterrupted until help arrives
|