Anaphylaxis

Kevin Burns, PA-Ca,*, Bryce Campbell, MPH, PA-C

b
,
Jordan Gleason, PA-Cb

KEYWORDS
 Anaphylaxis  Epinephrine  Steroid  Allergy

KEY POINTS
 Anaphylaxis is a serious, rapidly developing allergic reaction that may result in death if
untreated.
 Anaphylaxis may affect a variety of organ systems, with mortality most associated with
compromise of the airway, breathing, or circulatory status.
 The mainstay of treatment for anaphylaxis is epinephrine. Any patient with clinical signs of
anaphylaxis should receive intramuscular epinephrine, with consideration for intravenous
epinephrine in cases of hemodynamic collapse.
 Adjunctive therapies to epinephrine in the treatment of anaphylaxis include steroids, an-
tihistamines, inhaled bronchodilators, and intravenous fluids. Although beneficial, they
do not supplant epinephrine as definitive management.
 Patients who are stable for discharge from the emergency department should receive ed-
ucation about their condition, and should be discharged with an epinephrine autoinjector
for use in future anaphylactic reactions.

INTRODUCTION

The term “anaphylaxis” was first introduced into the medical lexicon in 1902 by the
French physiologist Charles Richet.1 Richet, along with colleague Paul Portier, pre-
sented the term during a lecture to the Societé de Biologie in Paris regarding their dis-
covery of what is now known as anaphylaxis.2 Richet and Portier exposed dogs to a
small dose of sea anemone toxin in an attempt to allow the dog to develop an immu-
nity to the substance. The initial exposure caused little significant reaction; however,
after a second exposure of the same dosage several days later, the animals developed
wheezing, bloody vomitus, and died within 25 minutes. The term “anaphylaxis” was

Disclosure Statement: The authors have nothing to disclose.

a
Emergency Medicine PA Residency, Department of Emergency Medicine, Yale Emergency
Medicine, Yale New Haven Hospital, 464 Congress Avenue, Suite 260, New Haven, CT 06519,
USA; b Department of Emergency Medicine, Yale Emergency Medicine, Yale New Haven Hospi-
tal, 464 Congress Avenue, Suite 260, New Haven, CT 06519, USA
* Corresponding author.
E-mail address: [email protected]

Physician Assist Clin 2 (2017) 345–356

http://dx.doi.org/10.1016/j.cpha.2017.02.002 physicianassistant.theclinics.com
2405-7991/17/ª 2017 Elsevier Inc. All rights reserved.
346 Burns et al

coined, meaning “lack of protection.”2 For his work on the topic of anaphylaxis,
Charles Richet was awarded the 1913 Nobel Prize in Physiology or Medicine.
Anaphylaxis has been defined as a serious allergic reaction that is rapid in onset and
may cause death.3 The World Allergy Organization (WAO) has established more formal
clinical criteria for the diagnosis of anaphylaxis (Boxes 1 and 2) that describe anaphy-
laxis as being likely if a patient meets at least one of a combination of several different
clinical complaints.4 Although comprehensive, the WAO criteria involve multiple com-
ponents that may be challenging to recall at the bedside. Some emergency medicine
providers have proposed more straightforward criteria: any allergic reaction that may
compromise the airway, breathing, or circulation should be treated as an anaphylactic
reaction.5
Anaphylaxis is typically the result of an immunologic response to a foreign sub-
stance. Most commonly this is the result of an immunoglobulin E (IgE)-dependent
response, but depending on the triggering agent, may be caused by a host of other
mechanisms (Fig. 1). Initial exposure to the offending agent results in the binding of
IgE to receptors on the mast cells and basophils. After a second exposure, antigen
binds with the IgE to activate mast cells and basophils, causing the release of a variety
of chemical mediators throughout the body. Mediators such as histamine, tryptase,
leukotrienes, prostaglandins, cytokines, and platelet-activating factor flood the sys-
temic circulation.6 These chemicals induce bronchoconstriction, vasodilation, and

Box 1
World Allergy Organization clinical criteria for diagnosis of anaphylaxis

Anaphylaxis is highly likely when any 1 of the following 3 criteria is fulfilled:

1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal
tissue, or both (eg, generalized urticaria, itching or flushing, swollen lips-tongue-uvula)
AND AT LEAST 1 OF THE FOLLOWING:
a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak
expiratory flow [PEF], hypoxemia)
b. Reduced blood pressure or associated symptoms of end-organ dysfunction (eg,
hypotonia [collapse], syncope, incontinence)
OR
2. Two or more of the following that occur rapidly after exposure to a likely allergen for that
patient (minutes to several hours)
a. Involvement of the skin-mucosal tissue (eg, generalized urticaria, itch-flush, swollen lips-
tongue-uvula)
b. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF,
hypoxemia)
c. Reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope,
incontinence)
d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)
OR
3. Reduced blood pressure after exposure to known allergen for that patient (minutes to
several hours)
a. Infants and children: low systolic blood pressure (age-specific) or greater than 30%
decrease in systolic blood pressure
b. Adults: systolic blood pressure of less than 90 mm Hg or greater than 30% decrease from
that person’s baseline

Data from Simons FE, Ardusso LR, Dimov V, et al. World allergy organization anaphylaxis
guidelines for the assessment and management of anaphylaxis. J Allergy Clin Immunol
2011;127(2):593.e3.
 Anaphylaxis 347

Box 2
Key treatments

 Rapid administration of intramuscular (IM) epinephrine for hypotension, dyspnea, or

significant edema of the airway.
 Administer epinephrine with slow intravenous (IV) push if there is imminent airway loss,
profound hypotension, or worsening symptoms despite IM epinephrine.
 In addition to IV epinephrine, consider treating supraglottic and laryngeal edema with
aerosolized epinephrine while preparing to establish a definitive airway.
 Hypotension should be treated with aggressive fluid resuscitation using a crystalloid
solution.
 Corticosteroids and antihistamines (H1 and H2) should be used as a supplementary therapy in
addition to epinephrine and fluids.

increase vascular permeability, resulting in the life-threatening clinical sequelae of an

anaphylactic reaction. On rare occasions, anaphylaxis can also be triggered by non-
IgE mechanisms, such as IgG, the complement system, and nonimmunologic causes
that result in direct activation of the mast cells and basophils.
The true prevalence of anaphylaxis in the general population is unknown. Wood and
colleagues7 reported a prevalence in the United States of at least 1.6% to 7.7% across
the population surveyed. A review of a European population estimated that 0.3% of
the those in Europe experience an episode of anaphylaxis over the course of their
lives.8 There also appears to be a relationship between age and risk of anaphylaxis.
Children age 4 years and younger have been found to have rates of anaphylaxis
almost 3 times higher than that of other age groups.9

Clinical Features
The symptoms and clinical features of anaphylaxis are multisystemic and Tables 1
and 2 list the frequency of symptoms. Anaphylaxis may occur within seconds, or be
delayed more than an hour after an exposure. More rapid reactions are associated
with a higher mortality.10 Anaphylaxis is primarily a clinical diagnosis. History may
confirm exposure to a possible allergen, such as a new drug, food, or sting. However,
there is no gold standard diagnostic test, and the diagnosis of anaphylaxis should be
considered in any rapidly progressing multisystem illness.11 Early clinical features of
anaphylaxis include pruritus of the palms and soles, tingling of the mouth and tongue,
generalized warmth, tightness in the chest, and a lump in the throat. Up to 90% of pa-
tients have urticaria or angioedema. Urticaria, defined as edema of the upper dermis,
appears as raised erythematous wheals in evanescent pruritic patches. Angioedema,
which involves the deep dermis, is often described as puffy, nonpitting areas of skin or
mucous membrane. Angioedema is generally painless and nonpruritic.12
Edema of the larynx can result in upper airway obstruction and is the most common
cause of death from anaphylaxis. The onset can be sudden and mimic that of foreign
body obstruction or sudden cardiac death. Angioedema of the oropharynx, lips, and
tongue is less likely to cause airway obstruction, but should be treated promptly
and aggressively, as it may progress to laryngeal edema. Bronchospasm is a common
symptom in anaphylaxis, but tends to be less severe unless the patient has a preex-
isting history of asthma.12 Other common mucous membrane manifestations seen in
anaphylaxis include rhinitis, nasal obstruction, chemosis, and conjunctivitis.12
348 Burns et al

Fig. 1. Causes of anaphylaxis. HMW, high molecular weight; NSAIDs, non-steroidal anti-in-
flammatory drugs.a Trigger anaphylaxis by more than one mechanism. (Data from
Simons FE, Ardusso LR, Bilò MB, et al. World Allergy Organization anaphylaxis guidelines:
summary. J Allergy Clin Immunol 2011;127(2):589; with permission.)

The second most common cause of death after laryngeal edema is refractory hypo-
tension. Defined as a symptomatic drop in systolic blood pressure of 20 to 30 mm Hg,
this is typical of anaphylaxis when a patient is initially presenting with dizziness, syn-
cope, or sudden death.13
Abdominal pain and cramping are often overlooked symptoms of anaphylaxis.
These symptoms are most commonly seen in food-mediated reactions. Angioedema
of the gut lining results in nausea, vomiting, diarrhea, and rarely hematochezia.
 Anaphylaxis 349

Table 1
Clinical features of anaphylaxis

Organ System Signs and Symptoms

Cardiovascular Hypotension, tachycardia, dizziness, lightheadedness, syncope, confusion,
weak pulse, decreased urine output
Dermatologic Hives, swelling, itching, warmth, redness; angioedema, swelling of the deep
dermal layer: lips, eyes, hands, nonpruritic tingling
Gastrointestinal Abdominal pain, cramping, diarrhea, vomiting
Gynecologic/ Uterine cramping, mucosal edema and erythema, vulvovaginal itching,
Obstetric preterm labor
Neurologic Irritability, anxiety, somnolence, lethargy, feeling of “impending doom,”
headache, seizure
Respiratory Coughing, wheezing, shortness of breath, stridor, chest pain, intercostal/
accessory muscle use, hoarseness, dysphagia, throat tightness (globus),
deep dermal swelling of the lips, uvula, tongue, airway obstruction,
sudden death
Ocular/Ear Lid edema, redness, chemosis, tearing, itching, mucosal swelling, nasal
nose throat congestion/rhinorrhea, itching

Symptoms of acute coronary syndrome, Takotsubo cardiomyopathy, ventricular

tachycardia, and nonspecific ST-T wave changes are reported in anaphylaxis. These
symptoms are attributed to decreased perfusion secondary to hypotension, hypox-
emia, and iatrogenic epinephrine therapy. It is believed that histamine and cytokines
also may induce coronary vasospasm and cardiac dysrhythmias.14
A biphasic mediator release can occur in up to 20% of cases, causing recurrence of
symptoms hours to days after the initial exposure.15 This concern for recurrence of

Table 2
Frequency of anaphylaxis signs and symptoms

Signs and Symptoms Frequency in Anaphylaxis, %

Cutaneous
Urticaria and angioedema 62–90
Flushing 45–55
Pruritus without rash 2–5
Respiratory
Dyspnea, wheeze 45–50
Upper airway angioedema 50–60
Rhinitis 15–20
Hypotension, dizziness, syncope, diaphoresis 30–35
Abdominal
Nausea, vomiting, diarrhea, abdominal pain 25–30
Miscellaneous
Headache 5–8
Substernal pain 4–5
Seizure 1–2

Data from Lieberman P, Nicklas RA, Oppenheimer J. The diagnosis and management of anaphylaxis
practice parameter: 2010 update. J Allergy Clin Immunol 2010;126(3):480.e35; with permission.
350 Burns et al

symptoms may affect decisions regarding disposition of these patients (see the sec-
tion “Disposition,” later in this article).

MANAGEMENT
Epinephrine
The treatment of anaphylaxis is similar to that of all critically ill patients in the emer-
gency department. There must be a rapid assessment of the patient’s overall condi-
tion by first evaluating the patient’s airway, breathing, and circulation. When the
clinical criteria defining anaphylaxis are met, the patient should receive epinephrine
immediately.3 However, the provider’s gestalt should never be overlooked, as many
patients will present without clearly meeting all the parameters of the WAO definition
and should still be treated with epinephrine. Examples include a patient with a history
of near-death anaphylaxis to peanuts who ingested peanuts and presents within mi-
nutes experiencing urticaria and generalized flushing.3
All published guidelines clearly identify epinephrine as the first-line medication for
the treatment of anaphylaxis.16 Epinephrine has potent life-saving alpha-1 adrenergic
vasoconstriction effects on the small arterioles in most body organ systems. This
vasoconstriction decreases mucosal edema, preventing and reducing upper airway
obstruction, and increases blood pressure, preventing and reducing shock. The
beta-1 adrenergic effects lead to increased rate and force of cardiac contractions.
The beta-2 effects lead to bronchodilation and decreased release of histamine, tryp-
tase, and other mediators of inflammation from mast cells and basophils.17 The initial
dose of epinephrine for anaphylaxis is 0.3 to 0.5 mL (1:1000 dilution) administered as
an intramuscular (IM) injection. Children should receive 0.01 mg/kg up to a maximum
of 0.3 mL.18 Epinephrine is best absorbed in large muscle groups, and ideally the
vastus lateralis (lateral thigh) should be the primary site used for IM injections.19 The
dose of epinephrine can be repeated every 5 to 15 minutes based on clinical effect.3
Hypotension generally responds to IM epinephrine and intravenous fluid resuscita-
tion. However, if hypotension persists, intravenous (IV) epinephrine may be given. The
most common error in the treatment of anaphylaxis is too much epinephrine given too
quickly, precipitating cardiac dysrhythmias and chest pain.12 A push dose preparation
of epinephrine can be achieved by using 1 mL of 1:10,000 epinephrine diluted in 5 to
10 mL of normal saline and given as a slow IV push over 3 to 5 minutes. If life-
threatening symptoms continue, the dose may be repeated. Alternatively, an epineph-
rine drip can be started by using 1 mL of 1:1000 dilution of epinephrine in 250 mL of
5% dextrose in water, infused at 1 to 10 mg/min (0.014–0.14 mg/kg per minute).18 It is
believed that a continuous infusion of epinephrine may be preferred over intermittent
push doses, which have been linked to adverse outcomes. If cardiac arrest ensues
during the treatment of anaphylaxis, the aforementioned treatment regimen should
be discontinued and advanced cardiac life support algorithms should be followed.12
Although caution should be exercised with the administration of epinephrine to elderly
patients and those with established coronary artery disease, epinephrine should never
be withheld from a patient with true anaphylaxis.
Aerosolized epinephrine may be considered in the setting of severe angioedema.
Racemic epinephrine 2.25% solution, 0.5 mL in 3.5 mL saline, or epinephrine
1:1000, 5 mL can be administered via nebulizer. This may decrease supraglottic
and laryngeal edema while preparations are made for a definitive airway.12
Patients with severe allergies or prior anaphylaxis will frequently carry an epineph-
rine autoinjector (EAI). The development of commercial autoinjectors has allowed pa-
tients and families to be able to self-administer the correct dose of IM epinephrine
 Anaphylaxis 351

without the medical training needed to draw up and administer a drug using a standard
vial and syringe. Autoinjectors are generally available in both pediatric (0.15 mg) and
adult (0.3 mg) formulations. In the United States, commonly prescribed brand name
EAI’s include EpiPen/EpiPen Jr. (Mylan Inc., Canonsburg, PA) and Adrenaclick (Ame-
dra Pharmaceuticals, Horsham, PA). Although primarily used in the community, some
have advocated for the use of EAIs within the hospital to limit medication errors. Kan-
war and colleagues20 presented a case series of iatrogenic epinephrine overdoses
within their institution. One solution that was proposed was to stock crash carts
with EAIs clearly labeled “use only for anaphylaxis” to avoid the inadvertent adminis-
tration of cardiac arrest dosage epinephrine. Recent research has shown that EAIs are
underused in the emergency treatment of anaphylaxis in the community; noninvasive
sublingual epinephrine administration is being proposed as an alternative treatment.
Studies have shown sublingual administration of epinephrine 40 mg from tablet formu-
lation achieves an epinephrine plasma concentration similar to those obtained after
epinephrine 0.3 mg IM.21 Fast-disintegrating sublingual epinephrine may be a feasible
alternative to IM epinephrine that warrants further development.22
Often, patients will have received epinephrine in the prehospital setting before initial
emergency department evaluation. During the initial emergency department assess-
ment, it is imperative to fully assess the patient for alternative causes of his or her com-
plaints, as well as any adverse reactions to the previously given epinephrine, before
the administration of additional anaphylaxis treatments.12

Second-Line Medications
Aside from the use of epinephrine in the anaphylactic patient, there are other treat-
ments currently used in the emergency department for management of anaphylaxis.
It is important to note that there is limited evidence to support improvement in surviv-
ability, morbidity, and mortality with the use of second-line medications. Depending on
the patient’s symptoms, treatment modalities include antihistamines, b (beta)-2 ago-
nists, supplemental oxygen, and glucocorticoids. None of these treatments should
ever be considered curative or sufficient in the treatment of the anaphylactic patient
without concomitant use of epinephrine.
Patients in early anaphylaxis may present with cutaneous symptoms of flushing, ur-
ticaria, pruritus, or nonspecific rashes. In these patients, an H1 antihistamine medica-
tion, such as diphenhydramine at a dose 50 mg (1–2 mg/kg for pediatric patients), may
be given as a slow IV push. If IV or intraosseous access is not readily available, IM or
oral medications (of identical doses) may be given as well, with an expected slower
onset of effect.23 Lin and colleagues24 demonstrated that the addition of an H2 antihis-
tamine, such as ranitidine or cimetidine, will improve the urticaria and heart rate at
2 hours post administration when compared with diphenhydramine alone. This study
specifically used ranitidine 50 mg IV in the test group, but by theory of extrapolation
and class-effect, other H2 antihistamine may provide similar results. There was no sig-
nificant difference between the test and control groups in comparing angioedema, er-
ythema, blood pressures, and other varied symptoms.25
Patients who are experiencing wheezing or bronchospasm that are refractory to the
initial IM epinephrine dose, or are continuing to have difficulty with oxygenation, may
benefit from a more selective b-2 adrenergic medication,23 such as albuterol, levalbu-
terol, or terbutaline. Nebulized albuterol at 2.5 mg is a reasonable initial dosage.
Persistent bronchospasm may require additional doses, including the potential use
of continuous nebulized albuterol at 15 to 20 mg/h.
Glucocorticoid medications, such as hydrocortisone, methylprednisolone, and
dexamethasone, have not been proven to be effective in the acute phase of
352 Burns et al

anaphylaxis due to their delayed onset of action. This class of medications may play a
role in the “protracted” or “biphasic” immune response that sometimes occurs in
anaphylactic patients. There is no current literature to support the efficacy of a
short-term “burst” (3–5 days) of glucocorticoids in comparison with a single dose.
Therefore, it is currently recommended to give only 1 dose at the onset of symp-
toms.16,25,26 There have been no studies to date looking at the efficacy of hydrocorti-
sone compared with dexamethasone or any other combination of glucocorticoids in
anaphylaxis.26

Intravenous Fluids
Anaphylaxis, if untreated, may progress to anaphylactic shock (a subset of distributive
shock). In these instances, treatments must be aggressive and specific to the patient’s
clinical condition. Unless otherwise contraindicated, patients with anaphylaxis should
be given crystalloid boluses. This is especially important for patients with hypotension
(Table 3). Normal saline is typically the intravenous fluid of choice and tends to remain
in the intravascular space longer than dextrose-containing fluids. If the patient is fluid
responsive, then he or she may benefit from continued administration of crystalloids,
as long there is no contraindication to such (eg, depressed ejection fraction, end-stage
renal disease).23

Vasopressors
For the patients who are not fluid responsive, or who may need some restriction in
volume-expansion treatments, other vasoactive medications may be implemented
in addition to epinephrine. Dopamine, norepinephrine, and vasopressin all may be
considered as adjunctive therapies for the hypotensive patient. Methylene blue limits
vasodilation through the inhibition of nitric oxide cyclic guanosine monophosphate,
and also may be considered as an alternative for the patient with refractory
hypotension.27
In the subset of patients who are prescribed b-adrenergic antagonists, there have
been multiple case studies reporting increased bronchospasm and refractoriness to
initial doses of epinephrine. These patients may require multiple IM doses of epineph-
rine, as well as an epinephrine IV infusion. Although being on a b-blocker does not in-
crease one’s risk of developing anaphylaxis, it is important to recognize if the patient is
taking these medications, as glucagon at a dose of 1 to 5 mg may need to be admin-
istered IM. If it is not, the epinephrine may work only at the a receptors, causing a re-
flexive vagal response, ultimately worsening the hypotension.23,28–35
Patients who have failed all standard interventions and who are approaching com-
plete vascular collapse also may be considered as candidates for extracorporeal

Table 3
Hypotension definitions in anaphylaxis

Age Systolic Blood Pressure, mm Hg

Term neonates, 0–28 d <60
Infants, 1–12 mo <70
Children, >1–10 y <70 1 (2  age in y)
Beyond 10 y <90

Data from Lieberman P, Nicklas RA, Oppenheimer J. The diagnosis and management of anaphylaxis
practice parameter: 2010 update. J Allergy Clin Immunol 2010;126(3):480.e35; with permission.
 Anaphylaxis 353

membrane oxygenation, where available, to serve as a bridge until they are able to
recover from the initial episode.27

DISPOSITION

Discharging a patient who presented with anaphylaxis can occur after an observation
period and after the patient’s symptoms have resolved. During this period, the patient
should be observed for a protracted or biphasic reaction.15,36 Although these reac-
tions are seemingly rare, occurring less than 0.25% of the time, they have the potential
to be fatal.37 Unfortunately, the time frame for this reaction to occur has been docu-
mented to be anywhere from 5 minutes up to 4 days after the initial response.38
Because observation of all patients with anaphylaxis for up to 4 days is clinically
impractical, current practice guidelines suggest time frames of 4 to 8 hours, depend-
ing on the patient’s history.36 Grunau and colleagues37 demonstrated a 0.18% rate of
clinically important biphasic reactions, 2 of which were patients who failed to meet
criteria for anaphylaxis on their initial emergency department visits. Given the relative
rarity and unpredictable time frame of the biphasic reaction, and the capacity for the
patient to self-medicate at home with EAIs, there may be some support for shorter
observation periods than what are currently recommended.
Risk factors of having a protracted or biphasic response include severe asthma and
previous protracted or biphasic responses. Unfortunately, these risk factors are not a
fail-safe system either. Previous severity of reactions is not a predictor of future reac-
tions; patients who have had mild reactions in the past are not immune to having
anaphylactic responses next time with a biphasic pattern.36 Other medical comorbid-
ities, such as chronic pulmonary or cardiac disease, and higher-risk patient popula-
tions (poor outpatient follow-up or unreliable patient subsets), also should warrant a
prolonged observation period.
Before the patient leaves the department, he or she must be well educated on the
myriad of symptoms that can comprise an anaphylactic reaction, how to properly
administer an EAI, how to call an emergency medical system provider, and when to
follow up with an allergist-immunologist. He or she also must be discharged with a
prescription for at least 2 EAI devices: one to carry on his or her person at all times,
and one to have at home/school/work or any other area in which it may be needed
on a regular basis.36 Surprisingly, these recommendations are not well followed,
with large discrepancies in practice styles, ranging from no EAI pen prescriptions,
to education of how they work, or not getting proper follow-up for patients who are
able to be discharged from the department on the same day.39
Admission to the hospital should be considered with any patient who has a history of
severe anaphylaxis (requiring previous intensive care unit admission, intubation, cen-
tral venous access with vasopressor medications), has ingested a potential allergen,
has required more than 1 dose of epinephrine, has had progression of symptoms
despite treatment, or has any laryngeal edema. Other patients who may be considered
for admission are those who would likely need, and not be able to get, close follow-up
with an allergist-immunologist. These patients may have new allergens that have not
been identified, difficult to manage in the emergency department, or may have diffi-
culty adhering to an outpatient treatment regimen.36

SUMMARY

Anaphylaxis is a rapidly progressing, life-threatening disease state that requires early

recognition, appropriate treatment, and close monitoring. Because of its high degree
of variance in presentation, it is imperative to consider anaphylaxis in the differential
354 Burns et al

diagnosis of a multitude of presenting chief complaints. The mainstay of treatment for

anaphylaxis is epinephrine; this is typically given as an IM injection in the anterolateral
thigh. For patients in extremis, epinephrine also may be administered via the IV or
intraosseous route. Adjunctive therapies, such as antihistamines, IV fluids, and ste-
roids, also may be given, but should never replace epinephrine as the treatment for
anaphylaxis. All patients who are treated for anaphylaxis in the emergency department
should receive EAIs at the time of discharge to allow for self-administration of epineph-
rine in the event of future anaphylactic episodes.

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