Dana V. Wallace, MD
Assistant Clinical Professor
Nova Southeastern University
Davie, Florida
drdanawallace@gmail.com
ANAPHYLAXIS IN THE OFFICE
ALLERGIST and Staff BE PREPARED
Templates and Forms
ARE IMPORTANT!
Templates & Forms for SIT
 Cox, L., H. Nelson, et al. "Allergen
immunotherapy: a practice parameter third
update." J Allergy Clin Immunol 127(1 Suppl):
S1-55.
– http://www.jacionline.org/article/PIIS009167491001
5034/addons [jacionline]
 www.acaai.org
– (ACAAI > Members > Practice Resources > Skin
Testing & Immunotherapy)
 Kalier, M., Lockey, R., eds. Clinical Allergy and
Immunology Series, 4th Edition
 www.drdanawallace.com
Discussing SCIT Treatment Option
www.drdanawallace.com
SLIT Patient Info (Part 1)
SLIT Patient Info (Part 2)
SLIT Patient Info (Part 3)
SLIT Side Effects
Allergy Immunotherapy
Consent process should discuss:
 Treatment and alternatives
 Potential benefit
 Potential risks, giving frequency of adverse
events, including death
 Cost associated and coverage options
 Anticipated duration of Tx
 Office policies that affect Tx, e.g. waiting
time, missed AIs
Based on 2011 Immunotherapy PP
www.acaai.org
Consent to Allergen
Immunotherapy
CONSENT FORMS TO CONSIDER
www.drdanawallace.com





Allergy testing & immunotherapy
Permission to treat a minor
Consent to take allergy vaccine out of
office to another MD for administration
Consent from remote MD agreeing to
administer AI
Privacy form to authorize info to specific
people- e.g. child custody
Consent to take Allergen Extract
Sets to another office
www.acaai.org
Cross-reacting Allergens
jacionline
Recommended Documentation SCIT
Prescription (Rx) Forms
jacionline
 Purpose:
– To define the contents of the allergen immunotherapy
extract in enough detail that it could be precisely
duplicated
 Patient information:
– Name, chart number (if applicable), birth date,
telephone number (home/mobile), email, & picture
 Preparation information:
– Name of person (& signature) preparing the allergen
immunotherapy extract & date prepared
– Vial name, by allergens included (e.g., Trees, Grass or
abbreviations (e.g., T, G, with legend)
Recommended Documentation SCIT
Prescription (Rx) Forms jacionline
 Allergen immunotherapy extract content information
for each allergen:
– Common name or genus and species
– Concentration of available manufacturer’s extract
– Volume of manufacturer’s extract to add to achieve the
projected effective concentration
• Calculate by dividing the projected effective concentration
by the concentration of available manufacturer’s extract
times the total volume
– Extract manufacturer & lot number, expiration date
– Same detail for all mixes
 Vial expiration date should not exceed of any of the
individual components
SCIT Prescription Form
jacionline
SCIT Prescription Form-completed
jacionline
Name: Jane Doe
DOB:
Chart #: 3341
Bottle #:
Maintenance Concentrate Content Rx
Total Vials
Allergen, Concentration Available, Manufacturer,
Lot # , Expiration date
IMMUNOTHERAPY
RX FORM
MODIFIED BY
DANA WALLACE,MD
Bottle Name:
8/29/1948
Projected
Effective
Australian
Pine 1:10
1C00061
8/19/03 8/19/03
Australian
PineC1:10
C 1C00061
1/1001/100
2
Bald Cypress
1:10 C 2D00061
Bald Cypress
1:10 C1/8/04
2D00061 1/8/04
1/1001/100
3
BayberryBayberry
1:10 C 1J00041
1/8/04
1:10 C
1J00041 1/8/04
1/1001/100
1/10
1/10
0.50
4
Mulberry,
Red 1:10
1J44691
3/24/03 3/24/03
Mulberry,
Red C1:10
C 1J44691
1/1001/100
1/10
1/10
0.50
5
Baccharia
1:20 G 1:20
225-40-2A19
10/2/03
Baccharia
G 225-40-2A19
10/2/03
1/1001/100
1/10
1/10
0.50
6
Dog Fennel
1:10 C 1L3291
Dog Fennel
1:10 C7/14/03
1L3291 7/14/03
1/1001/100
1/10
1/10
0.50
7
Pigweed,
Spiny Spiny
1:10 C 1:10
0M00081
8/4/03
Pigweed,
C 0M00081
8/4/03
1/1001/100
1/10
1/10
0.50
8
Ragweed,
Short Short
1:10 C 1L00191
2/4/03
Ragweed,
1:10 C 1L00191
2/4/03
1/1001/100
1/10
1/10
0.50
9
SheepSheep
Sorrel 1:10
C 1G00191
Sorrel
1:10 C 5/1/03
1G00191 5/1/03
1/1001/100
1/10
1/10
0.50
10
Yellow
Yellow
Dock 1:10
DockC 0M00431
1:10 C 0M00431
7/14/03
7/14/03
1/1001/100
1/10
1/10
0.50
11
None
None
0
1/10
1/10
0.00
12
None
None
5 5
Anitgen
Mite Pteronysinus
Mites Farinae
Cat
Other Animals
Standardized Grassed
Pollens
Molds
Projected Effective
0.5 injected
1200 AU/ml
4000 AU/ml
5000 BAU/ml
1:100/ml
8000 BAU/ml
1:100/ml
1:50/ml
High Protease:Dust Mites, Molds, Cockroach
4
Concentration Volume in ml Remake if
extract to add same Lot
available
1/10
1/10
0.50
1/10
1/10
0.50
1
Factor is volume to be injected X 10
A
177
0
1/10
1/10
0.00
A=ALK
Total Extract
5.00
C=Center
Diluent
0.00
G+Greer
Total Volume
55
HS=Hollister Steer
Concetration
1ml injected
600AU/ml
2000 AU/ml
Date and Signature
2500 BAU/ml
1:200/ml
4000 BAU/ml
1:200/ml
1:100/ml
Low Protease: Pollens. Cat, Dog
Do not mix high with low protease allergens May mix low with low, high with high
Ragweed may be mixed in either group. Keep venomous insects separate
Remakes
Date, initals & Date, initals & Date, initals & Date, initals &
Bottle Color/Vial Dilutions Volume:Volume
www.acaai.org
(ACAAI > Members >
Practice Resources >
Skin Testing &
Immunotherapy)
Brown
1:10,000,000
4 wks
Peach
Pink
Silver
Green
1:1,000,000
1:100,000
1:10,000
1:1,1000
4wks
4wks
4wks
6wks
Blue
1/100
Expiration
Expiration
Expiration
Expiration
6mths
Yellow
1/10
6mths
Red
Full Strength Earliest expiring constituent
Jane Doe
Vial A
Dana V. Wallace MD 2699 Stirling Road Suite B305 Ft. Lauderdale,FL 33312 954-963-5363 fax 963-7099
Revised 9/02
Labels for allergen
immunotherapy extracts
jacionline
 Each vial must have appropriate patient
identifiers, e.g., name, number, DOB, picture
 Contents, e.g, T, G, M, Df, D, etc.
 The dilution from the maintenance concentrate
(vol/vol) using color, numbers, letters
 Expiration date of individual vial
Allergy Extract Vial Dilution & Labeling
www.acaai.org
Allergy Extract Vial Dilution & Labeling
www.acaai.org
Vial Labels
www.acaai.org
Weekly Build-up Therapy
jacionline
Cluster SCIT Schedule
jacionline
SCIT Rush Immunotherapy Schedule
www.acaai.org
SLIT Proposed Schedules
SCIT Administration Record
 List info in separate columns
–
–
–
–
jacionline
Date of injection
Arm administered
Delivered volume in mm
Currently on antihistamine (desirable)
 Projected build-up schedule
 Description of any reaction (details may
appear on separate sheet
 Peak flow- pre and post SCIT may be
included
Best Baseline Peak Flow: ___________________
Date
ALLERGY
INJECTION
ADMIN. FORM
Time Health screen Anti-histamine
abnormal1
taken?2
Vaccine A: vaccine contents*
Peak
Arm
Flow
Vial
Number
or
Dilution
Delivered
Vaccine B: _______________
Reaction 3
Arm
Volume
Vial
Number
or
Dilution
Delivered
Reaction Injector
Volume
Initials
1.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
2.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
3.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
4.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
5.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
6.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
7.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
8.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
9.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
10.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
11.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
12.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
13.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
14.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
15.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
16.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
17.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
18.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
19.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
________
________
_________ _______
20.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
_______
________
_________ _______
21.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
_______
________
_________ _______
22.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
_______
________
_________ _______
23.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
_______
________
_________ _______
24.
___/____/____ _______
Y
N
Y N
___________
R
L
________
________
____________
R
L
_______
________
_________ _______
1.
Health screen refers to either a written or verbal interview of the patient prior to the administration of the allergy injection regarding: the
presence of increased allergy or asthma symptoms or symptoms of respiratory tract infection, beta-blocker use, change in health status
(including pregnancy) or adverse reaction to previous injection. A yes answer to this health screen may require further evaluation (see health
screen record on back page).
2. Antihistamine use: to improve consistency in interpretation of reactions it should be noted if the patient has taken an antihistamine on
injection days. Physician may also request that an antihistamines be taken consistently on injection days: recommended: Y N
3. Reaction: refers to either immediate or delayed systemic or local reactions. Local reactions (noted as LR) can be reported in millimeters as
the longest diameter of wheal and erythema.. The details of the symptoms and treatment of a systemic reaction (noted as SR) would be
recorded elsewhere in the medical record. Guidelines for dose reduction after a systemic reaction on a separate instruction sheet.
Injector
signature
Initials
Date to reorder: __/__/__
www.acaai.org
(ACAAI > Members >
Practice Resources >
Skin Testing &
Immunotherapy)
Vial 5
Vial 4
SCHEDULE
Vial 3
Vial 2
Vial 1
SCIT Administration
Record
www.acaai.org
Health Screen Form (Pre SCIT)
jacionline
 Patient identifiers, date, baseline peak flow &
BP, if advised to use antihistamines with SCIT
 Records status of:
– Asthma control, consider standardized instrument
and Peak Flow pre and post
– Beta-blocker use
– Pregnancy or other recent health care status,
including recent infection or allergy/asthma flare
– Previous adverse reaction to SCIT
– Consider BP measurement
Health Screen Form
jacionline
Immunotherapy Pre-Injection Questionnaire
PRE-INJECTION
HEALTH
SCREEN
Patient Name:____________________________________ Date:____________________
This questionnaire is designed to optimize safety precautions already in place for your allergen
immunotherapy injections (allergy shots). Please review and answer the following questions. The
nursing staff will review your responses and notify your physician if they have any questions or
concerns whether you should receive your injection(s) today. If you are pregnant or have been
diagnosed with a new medical condition, please notify the staff. (Please circle the appropriate
answer.)
1. Have you had increased asthma symptoms (chest tightness, increased cough, wheezing, or
felt short of breath) in the past week?
Yes
No
2. Have you had increased allergy symptoms (itching eyes or nose, sneezing, runny nose,
post-nasal drip, or throat-clearing) in the past week? Yes
No
3. Have you had a cold, respiratory tract infection, or flu-like symptoms
in the past two weeks?
Yes
No
4. Did you have any problems (such as increased allergy or asthma symptoms, hives, or
generalized itching or redness) within 12 hours of receiving your last injection?
Yes
No
5. Are you on any new medications? Any new eyedrops? Please specify.___________________
Staff intervention/office visit:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
www.acaai.org
Staff Signature:_________________________________________________________________
Preparing your office staff for
ANAPHYLAXIS
ANAPHYLAXIS CART
Supplies and Equipment for
Anaphylaxis Treatment in office





“NECESSARY”
Stethoscope and
sphygmomanometer
*Epinephrine 1:1000
Oxygen
IV Fluids
Tourniquets, syringes,
hypodermic needles,
large-bore needles
* Required 2011 JTF Anaphylaxis PP
“CONSIDER HAVING”
 One-way valve facemask
 Diphenhydramine inj.
 Corticosteroids inj.
“MAYBE”
 Vasopressor (Dopamine)
 Glucagon
 Automatic defibrillator
 Oral airway
ANAPHYLAXIS CART
Algorithm for Tx
Twin Jet Nebulizer
Treatment Recording Sheet
Ambu Bag- Child (450 ml) (2)
Adult (1500ml) (2)
(Disposable, latex-free)
Defibrillator with heart monitor (Optional)
ANAPHPYLAXIS CART
INVENTORY AND
UPDATE LIST
IV ADMINISTRATION
IV Pole
1000cc .9 Normal Saline (4 bags)
Hydroxyethyl starch (Hespan) 500 ml bag (2)
3-Way Stopcock (2)
Micro drip IV set (2) 60 gtt/ml
Stethoscope
Laryngoscopes
Adult and Pediatric
(optional)
DRUGS
Epinephrine 1:1000 1cc ampules (10)
Epinephrine 1:10,000 10cc pre-mixed syringes (2)
(Optional)
Epinephrine 1:1000 30 cc multidose vials (1)
Benadryl (diphenhydramine) IV 1 ml ampule, 50 mg/ml
(2)
Benadryl liquid 12.5 mg/ml (4 oz) & 25 mg tablets (10)
Zyrtec (Cetirizine) 5mg/ml (4 oz), 5 mg (5) & 10 mg (5)
tablets
Zantac(ranitidine HCL) IV 2 ml vial, 25 mg/ml (2)
Zantac(ranitidine HCL) PO 1 oz, 15 mg/ml & 150 mg
tablets
Albuterol 2.5 mg unit dose (3) or Xopenex 1.25 mg (3)
and .63 mg (3) inhalant solution
Atrovent Inhalant solution .083% unit doses (2)
Aminophylline IV, 500 mg vial , 50 mg/cc(1)
Prednisolone Syrup 15 mg/tsp 4 oz
Solu-Medrol 1 ml vial, 40 mg/ml (3)
Medrol 4 mg tablets # 20
Macro drip IV (2) 10-15 gtt/ml
Extension tubing (2)
T-Connector (2)
Catheters #22, 20, 18 (2 each)
Butterfly Needles #21, #19 (3 each)
www.acaai.org
Pulse Oximeter
Sphygmomanometer &
cuffs: child, Adult
regular, and oversized
Syringes 1cc, 5cc, 10cc, 20cc, 50cc (5 each)
Needles # 16, #18, #20, #22 (5 each)
Tourniquet (2)
Cushioned IV Boards (2)
4x4 cotton sponges (10)
1” tape Synthetic (Transpore)
Alcohol Swabs (10)
Latex Free Gloves- 1 box M, L
Saline 30 cc, 10 cc (5 each)
D5W 250 ml (4), 500 ml (1), 30 ml (2)
Atropine (ipratropium bromide) 4 ml vial, 0.5 mg/ml (2)
Dopamine 10cc vial, 40 mg/ml (2)
Glucagon 1 mg vial (3 vials)
NaHCO3 50 mEq/50 ml (Optional) (2)
Calcijex IV calcium 1 mg/ampule (Optional)
Valium IV 10 ml vial (Optional)
AIRWAY
Face mask-infant, toddler, child, adult
Oral Airways-6 cm, 7cm, 8cm, 9 cm, 10cm
Endotracheal tubes 3.5, 5,6,7, 8, 9, 10
(optional)
Scalpel, disposable (2)
OXYGEN DELIVERY
O2 E-Tank with wheeled carrier
Gas regulator
Tank wrench
Pediatric oxygen mask
Adult oxygen mask
Nasal canula
Extension tubing
Note (#) number of units to order
Check and restock monthly and after each use:
2005
Year_______
Month
Jan.
Feb.
March
Initial
Month
April
May
June
Initial
Month
July
Aug.
Sept.
Practice Name
Practice Address
Practice Phone Number
Initial
Month
Oct.
Nov.
Dec.
Initial
ANAPHYLAXIS
TREATMENT
www.drdanawallace.com
TABLE OF ANAPHYLAXIS DRUGS
Patient Name_______________________
www.drdanawallace.com
Drug
Start Strength
1:1000
1ml=1mg=
1000mcg
Auto Injector (Epi-Pen or 1:1000
TwinJect)
1ml=1mg
Epi Infusion 1st choice
1:1000
after IM
1ml=1mg
Add
Final dilution or max
Method of Delivery
A=adult, C=child
1:1000
IM
lateral thigh
Max .3 mg C
1:1000
IM
lateral thigh
1:250,000=4.0μg/ml
Epinephrine Aqueous
(Epi)
250 ml D5W
I
V
i
n
f
u
s
i
o
n
Epi IV (or IO) after
1:1000
9-27 ml Saline 1:10,000
IV #1 slow push
1-3ml=1-3mg
Over 3 minutes
cardiac arrest, if not
Flush T with 10 ml
responding to infusion
or Tracheal (T)
1:1000
None
1:1000, .3 max C
saline A, 5ml C
Epi IV after cardiac
1:1000
27-45 ml
1:10,000
IV #2
Over 3 minutes
Saline
arrest, if not responding 3-5ml=3-5 mg
to above
Epi IV high dose infusion 1:1000
250 ml D5W 1:250,000=4.0μg/ml
after cardiac arrest, if not 1mg= 1 ml
responding to above
50 mg/ml IV/IM Or 25 mg PO Max 24 hr A=400 mg IM/IV
(Benadryl) IV/IM/PO
12.5 mg/5ml PO tablet/capsule C=300 mg
PO
Cetirizine (Zyrtec) PO
5 mg/5ml or 5 mg,
PO
10 mg tablet
Ranitidine HCl (Zantac) 25 mg/ml IV/IM 20 ml D5W for
IV over 5 minutes
IV/IM/PO
75 mg/5 ml or 150 IV
mg tablet PO
PO
Albuterol
2.5 mg in 3 ml
.083%
Nebulized
Levalbuterol (Xopenex) .63-1.25 mg in 3
Nebulized
ml
Ipratropium bromide
.02% in 2.5 ml vial May add to
Nebulized
(Atrovent)
Albuterol or
Xopenex
Aminophylline
500 mg/10 ml
Add to 100 ml
IV over 30 minutes
(optional)
Saline, micro
drip
Normal Saline
1000 ml bags
1-2 L needed
IV infusion over first 60
in adult
minutes
I
M
D
i
p
h
e
n
h
y
d
r
a
m
i
n
a
x
1
μ
0
g
/
m
i
n
A
,
V
i
n
f
u
s
i
o
n
500 ml
40 mg/ml
Max 2 mg/kg/24 hr
5 mg/5 ml
4 mg
0.5 mg/ml
Glucagon (Side effects= 1 mg/ml =
N and V)
1000 μg
/
m
Max 2 mg A
Max 1 mg C
I
l
D
f
I
5
n
W
f
u
s
o
i
r
o
n
S
u
a
l
i
s
n
e
e
M
a
x
1
m
g
C
Child < 12 (C)
Dose/kg ***
0.01mg (ml) /kg
max 0 .3 mg
X wt in KG = Dose
Q ≤ 5 min
Adult
(A)
0.2-0.5 mg (ml)
X _____
=___
mg (ml)
Q ≤5 min
SR, .3 mg
JR , 0.15 mg
<15 kg
.15
mg
c
1
X
_
o
n
t
i
n
u
a
l
-
μ
4
m
l
/
m
i
c
g
m
/
i
r
o
m
n
i
(
d
r
1
o
n
=
5
-
p
s
.
6
/
2
5
m
i
rapid
3-5 minutes
T: .3-.5ml of
1:1000
10-30 ml
c
4
-
2
.
n
t
i
n
u
a
l
m
i
μ
0
m
c
l
r
o
g
/
/
m
d
m
i
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o
i
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n
p
(
s
/
.
0
0
.
μ
1
g
/
k
g
/
m
i
n
_
_
_
_
_
n
u
t
e
1
.
0
-
6
0
-
1
5
i
n
u
t
_
g
_
=
_
.
2
μ
_
5
m
l
g
m
/
i
n
0
.
u
p
μ
1
t
g
o
/
k
1
g
/
m
μ
0
i
g
/
n
a
m
i
n
↑
d
X_____
=______
ml
X_____
X______
X_______
=______
=______
=______
ml
ml
ml
X
_
_
_
_
_
_
_
_
n
_
_
μ
1
_
g
_
=
_
.
2
μ
_
5
m
l
m
g
/
i
n
)
X______
X______
=______
=_____
10 mg PO-A
mg
mg
mg
Q 6 hr
50 mg IV/IM
1 mg/kg IV/IM
X______
=______
mg
150 mg PO
2.5 mg
1.25 mg
2 mg/kg PO
1.25-2.5 mg
0.63-1.25 mg
X______
Q 20 min
Q 20 min
=______
1.25-2.5
0.63-1.25
mg
mg
mg
500 mcg=
1 vial
250-500 mcg =
½-1 vial
250-500 =
½-1 vial
mcg
5 mg/kg
5 mg/kg
X______
=______
mg
20-30 ml/kg 25%
first 10 minutes
30 ml/kg
X______
=______
ml
IV infusion over first 60
minutes
IV push
Q 6 hours
500 ml
30 ml/kg
X______
=______
ml
1 mg/kg
1 mg/kg
X______
=______
mg
PO
PO
Subcut.
25-50 mg
20-40 mg
.3-.5 mg
0.5 mg/kg
0.4 mg/kg
0.02 mg
X______
X______
X______
=______
=______
=______
mg
mg
mg
1
2
X
=
m
V
o
v
e
r
25-50 mg
0
e
_
μ
)
.1ml/kg
(0.01 mg/ kg )
max 0.3 mg=3ml
T: .05-.1 ml/kg
1ml/kg (0.1 mg/kg)
max 30 ml
=
m
_
1 mg /kg or
2 mg /kg
2.5-10 mg PO-C
I
repeat
1x PRN then q 6 hr
1
5
1
1
10-30 ml
o
-
0
3-5 minutes
C
e
Hydroxyethyl starch
Hespan (2nd choice)
Methylprednisolone
(Solu-Medrol)
Prednisolone (Pediapred)
Methylprednisolone
Atropine
Frequency
Q 6 hr
Continue, but reduce
after BP stable
? repeat X1 in 6 hrs
? repeat X1 in 6 hrs
Q 10 min.
5
m
i
n
F
o
5
-
l
1
l
5
o
w
μ
w
g
/
i
m
t
h
i
n
I
u
n
t
f
e
u
s
i
o
n
-
5
m
g
m
0
-
a
3
x
0
)
μ
g
/
k
g
(
1
m
g
_
_
_
_
_
_
_
_
_
_
_
g
Anaphylaxis Simple TX Plan
Treatment of Anaphylaxis in the Physicians Office
Assess airway breathing, circulation, and orientation
Inject epinephrine, 0.3 mg intramuscularly, in the vastus lateralis (lateral thigh)
Activate emergency medical services (call 911 or local rescue squad)[Might delay,
depending upon severity of reaction. DW]
Place patient in recumbent position and elevate the lower extremities, as tolerated
Establish and maintain airway Administer oxygen
Establish an intravenous line for venous access and fluid
replacement; keep open with normal saline [Might delay, depending upon severity of
reaction. DW]
Consider administration of nebulized albuterol, 2.5-5 mg in 3 mL of saline; repeat as
necessary
Consider administration of ancillary medications, such as H1, [H2]antihistamine, [and] or a
systemic corticosteroid
Modified from Cox, et. al. AAAAI/ACAAI JTF Report on omalizumab-associated anaphylaxis. J Allergy Clin
Immunol. 2007 Dec;120(6):1373-7.
POST AN ANAPHYLAXIS PROTOCOL
AND/OR ALGORITHM (in visible location )
Allergen Immunotherapy Systemic Reation/Anaphylaxis Treatment Record
Name:________________________ Date________________________________
Date of Birth__________________ Prescribing Physician__________________
Allergens: Tree-Grass-Weed-Mites-Cockroach-Animal Dander-Mold-Hymenoptera
Prior systemic rxn:__________ Hx of asthma?_____________
Date/time of injection:_________________ Date/time of rxn:____________________
Dilution (Vial #): ________________ New? Yes No
History of the systemic reaction (SR):
Immediate measures:
__Assess airway, breathing, circulation, and orientation
__Epinephrine IM into thigh
__Activate EMS (call 911 or local rescue squad) Y/N Time called:______AM/PM
__Management algorithm reviewed (as needed)
ANAPHYLAXIS
TX RECORD
Signs & Symptoms:
Respiratory:
Skin :
Eye/Nasal:
Shortness of breath
Hives
Runny nose
Wheezing
Angioedema
Red eyes
Cough
Generalized itch Congestion
Stridor
Flushing
Sneezing
Time
Resp. rate/ PEFR
Pulse/
O2 Saturation
Vascular
Other:
Hypotension
Difficulty swallowing
Chest discomfort Abdominal pain, nausea, diarrhea
Dizziness
Diaphoresis
Headache
BP
Intervention, Medications, Exam Comments
Time (AM/PM)/ Condition upon release:_____________________________________________________
Patient instructions:______________________________________________________________________
Follow-up call to patient: Time________ Comments:___________________________________________
Clinical impression: True SR
Questionable SR
No SR
Comments:_________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
www.acaai.org
Dosage adjustment?: ____________________________________________________________________
Signatures_______________________________ RN ___________________________________MD/DO
WAO Grading System for SCIT Systemic
Reactions: GRADE 1- one organ system

Cutaneous
– Urticaria, generalized pruritus, flushing, or sensation of heat or warmth
or
– Angioedema (not laryngeal, tongue, or uvula)
OR
 Respiratory
– Rhinitis symptoms (e.g., sneezing, rhinorrhea, nasal pruritus and/or nasal congestion
or
– Throat clearing (itchy throat)
or
– Cough perceived to originate in the upper airway mot eh lung, larynx, or trachea
Or
– Conjunctival: erythema, tearing, or pruritus
– Other: nausea, metallic taste, or headache
42
WAO Grading System for SCIT Systemic
Reactions: GRADE 2
 Symptoms/signs of more than one organ system
present
or
 Lower respiratory
 Asthma: cough, wheezing, SOB (e.g. < than 40% PEF
or FEV1 , responding to inhaled bronchodilator)
or
 Gastrointestinal
 Abdominal cramps, vomiting, or diarrhea
Or
Other: uterine cramps
Might include any of the symptoms listed in grade 1
Patients may describe a feeling of doom
WAO Grading System for SCIT Systemic
Reactions: GRADE 3
 Lower respiratory
 Asthma (e.g. 40% PEF or FEV1 )
or
 Upper respiratory
 Laryngeal, uvula, or tongue edema with or
without stridor
Note:
Might include any of the symptoms listed in grade 1 and 2
Patients may describe a feeling of doom
WAO Grading System for SCIT Systemic
Reactions: GRADE 4
 Lower or upper respiratory
– Respiratory failure with or without loss of
consciousness
or
 Cardiovascular
– Hypotension with or without loss of
consciousness
Note:
Might include any of the symptoms listed in grade 1, 2, and 3
Adults may describe a feeling of doom
WAO Grading System for SCIT Systemic
Reactions: GRADE 5
Death
[We
Must
Prevent]
Thank You
DANA WALLACE, MD
drdanawallace@gmail.com
www.drdanawallace.com
MEDICALPROFESSIONAL (USER NAME)
Allergy (PASSWORD)