– Observation and H-1 antihistamine (diphenhydramine- 25-50mg PO/IM/IV)

1. ADD – IV fluids (normal saline, Lactated ringers)
2. Epinephrine (1:10,000)- 0.1mg – IV slowly
3. Epinephrine (1:1000) – 0.1-0.3mg – subcutaneously
4. H-2 antihistamine

• cimetidine injectable-300mg-diluted to 20 ml-IV slowly [Pediatric-5-10mg/kg-diluted to 20ml- IV slowly]
• ranitidine injectable-50mg-diluted to 20ml-IV slowly

– 10 L/min

– 2-3 deep inhalations (metaproterenol, terbutaline or abuterol) Use nebulizer if available- albuterol 0.5% solution- 0.5ml in 3ml normal saline- breathe through nebulizer tube for 8-10 minutes

(1:1000)-0.1-0.2mg- may give 0.3mg – subcutaneously [Pediatric- 0.01mg/kg up to 0.3mg maximum- subcutaneously]

(1:10,000) – 0.1mg – IV slowly [Pediatric- 0.01mg/kg – IV slowly]

==== A. Elevate patient legs

-normal saline or lactated ringers solution-Rapidly ~If hypotension unresponsive- vasopressor (epinephrine or dopamine) get appropriate assistance – Call CODE ~Epinephrine – (1:10,000)- 0.1mg- IV slowly ~IV solution – 1mg in 250ml D5W- start at 4mcgm/min (1ml/min) 4. VAGAL REACTION (HYPOTENSION AND BRADYCARDIA): A. Elevate patient legs B. Oxygen by mask (10 L/min) C. IV fluids- normal saline or lactated ringers solution- Rapidly D. Atropine – 0.6-1.0mg IV- repeat q 3-5 min (as needed)- 3mg total ~Pediatric- 0.02mg/kg IV-starting dose- 0.1-0.6mg dose- 2mg total 5. ANAPHYLACATOID REACTION (GENERALIZED SYSTEMIC REACTION): A. Suction – as needed B. Elevate patient legs – if hypotensive C. Oxygen by mask (10 L/min) D. IV fluids – normal saline or lactated ringers solution- Rapidly E. Epinephrine – (1:10,000)- 0.1mg- IV slowly – incrementally over 2-5 minutes ~Pediatric- 0.01mg/kg – IV slowly – 0.1mg total (Limit amount of Epinephrine in patients taking non-cardioselective beta-adrenergic blocking drugs) ~Alternate drug therapy for severe reaction in patients taking beta-adrenergic blocking medications- ~Isoproterenol- (1:5000)- 0.2mg/ml- IV slowly- 0.5-1.0ml diluted to 10ml with normal saline- 1ml (20 microgram) increments ~Glucagon- 1-5 mg IV bolus- followed by IV infusion of 5-15 microgram/min (may cause hypotension) F. Antihistamines- ~H-1 blocker- diphenydramine 25-50mg- IV slowly- (may exacerbate or cause hypotension-may thicken bronchial secretions) ~H-2 blocker- cimetidine injectable 300mg- diluted to 20 ml- IV slowly ~Pediatric- 5-10mg/kg- diluted- IV slowly - ranitidine injectable 50mg- diluted to 20 ml- IV slowly G. Beta-2-agonist metered dose inhaler- 2-3 deep inhalations (metaproterenol, terbutaline or abuterol)- Use nebulizer if availablealbuterol 0.5% solution- 0.5ml in 3ml normal saline- breathe through nebulizer tube for 8-10 minutes H. Corticosteroids- Hydrocortisone 200mg IV slowly - Methylprednisolone 80mg IV slowly 6. ANGINA: A. Oxygen by mask – 10 L/min B. IV fluids – very slowly C. Nitroglycerin – 0.4mg-sublingually- may repeat q 15 minutes D. Morphine – 2 mg IV slowly 7. HYPERTENSION: A. Oxygen by mask – 10 L/min B. IV fluids – very slowly- primarily to maintain IV access C. Nitroglycerin – 0.4mg-sublingually or 2% ointment topically-1-2 inch strip D. If secondary to autonomic dysreflexia- ~nifedipine 10mg capsule- punctured or chewed and swallowed (nifedipine sublingually- is no longer recommended as the first line drug for treatment of all hypertensive crises- due to very poor sublingual absorption and reported serious adverse effects) D. If secondary to pheochromocytoma- phentolamine- 5mg- IV slowly 8. SEIZURES: A. Protect patient B. Airway- suction as needed- monitor airway for tongue obstruction C. Oxygen by mask – 10 L/min D. If caused by hypotension +/- bradycardia- treat per protocols E. Uncontrolled- consider diazepam- 5mg IV slowly 9. HYPOGLYCEMIA: A. Oxygen by mask – 10 L/min B. IV fluids – D5W C. IV glucose – Dextrose 50% solution- IV push D. Oral glucose – glass of orange juice plus sugar or glass of milk

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