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Management of Acute Reactions in Adults
Urticaria
1. Discontinue injection if not completed
2. No treatment needed in most cases
H1-receptor blocker: Diphenhydramine (Benadryl®) PO/IM/IV 25-50 mg If severe or widely disseminated: Alpha agonist (arteriolar and venous constriction) Epinephrine SC (1:1,000) 0.1-0.3 ml (=0.1-0.3 mg) (if no cardiac contraindications) Facial or Laryngeal Edema
1. Give alpha agonist (arteriolar and venous constriction): Epinephrine SC or IM (1:1,000) 0.1-0.3 ml
(=0.1-0.3 mg) or, if hypotension evident, Epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg). Repeat as needed up to a maximum of 1 mg. If not responsive to therapy or if there is obvious acute laryngeal edema, seek appropriate assistance (e.g., cardiopulmonary arrest response team). Bronchospasm
1. Give
Monitor: electrocardiogram, O2 saturation (pulse oximeter), and blood pressure. 2. Give beta-agonist inhalers [bronchiolar dilators, such as metaproterenol (Alupent®), terbutaline (Brethaire®), or albuterol (Proventil®)(Ventolin®) 2-3 puffs; repeat prn. If unresponsive to inhalers, use SC, IM or IV epinephrine. 3. Give epinephrine SC or IM (1:1,000) 0.1-0.3 ml (=0.1-0.3 mg) or, if hypotension evident, Epinephrine (1:10,000) slowly IV 1 ml (=0.1 mg). Repeat as needed up to a maximum of 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 (e.g., cardiopulmonary arrest response team) for severe bronchospasm or if O2 saturation < 88% persists. Hypotension with Tachycardia
1. Legs elevated 60° or more (preferred) or Trendelenburg position.
2. Monitor:
4. Rapid intravenous administration of large volumes of 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., cardiopulmonary arrest response team). Hypotension with Bradycardia (Vagal Reaction)
1. Monitor
2. Legs elevated 60° or more (preferred) or Trendelenburg position. 3. Secure airway: give O2 6-10 liters/min (via mask). 4. Secure IV access: rapid fluid replacement with Ringer’s lactate or normal saline. 5. Give atropine 0.6-1 mg IV slowly if patient does not respond quickly to steps 2 – 4. 6. Repeat atropine up to a total dose of 0.04 mg/kg (2-3 mg) in adult. 7. Ensure complete resolution of hypotension and bradycardia prior to discharge. Hypertension, Severe
1. Give
2. Monitor electrocardiogram, pulse oximeter, blood pressure. 3. Give nitroglycerine 0.4-mg tablet, sublingual (may repeat x 3); or, topical 2% ointment, apply 1 in. 4. Transfer to intensive care unit or emergency department. 5. For pheochromocytoma—phentolamine 5 mg IV. Seizures or Convulsions
1. Give
2. Consider diazepam (Valium®) 5 mg (or more, as appropriate) or midazolam (Versed®) 0.5-1 mg IV. 3. If longer effect needed, obtain consultation; consider phenytoin (Dilantin®) infusion – 15-18 mg/kg at 4. Careful monitoring of vital signs required, particularly of pO2 because of risk to respiratory depression 5. Consider using cardiopulmonary arrest response team for intubation if needed. Pulmonary Edema
1.
Elevate torso; rotating tourniquets (venous compression). Give diuretics – furosemide (Lasix®) 20-40 mg IV, slow push.
Transfer to intensive care unit or emergency department.

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