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Anaphylaxis Management (GA²LEN International Consensus 2024)

Anaphylaxis Management (GA²LEN International Consensus 2024): Suspected Anaphylaxis → Anaphylaxis Criteria Met? → ⚡ EPINEPHRINE IM - FIRST LINE → Positi...

Pathway Overview

17 steps

Algorithm Steps

17 total

  1. 01Start

    Suspected Anaphylaxis

    Acute onset of multisystem involvement after exposure

  2. 02Decision

    Anaphylaxis Criteria Met?

    Clinical diagnosis - do not delay for labs

    • CRITERION 1: Skin + respiratory OR cardiovascular compromise
    • CRITERION 2: ≥2 systems after likely allergen: skin, respiratory, GI, cardiovascular
    • CRITERION 3: Hypotension after KNOWN allergen
    • Skin signs may be absent in 10-20% of cases
  3. 03Action

    ⚡ EPINEPHRINE IM - FIRST LINE

    Anterolateral thigh - DO NOT DELAY

    • Adult: 0.3-0.5 mg IM (1:1000 = 1mg/mL)
    • Child: 0.01 mg/kg IM (max 0.3mg)
    • Auto-injector: 0.3mg (>25kg) or 0.15mg (<25kg)
    • May repeat q5-15 min if needed
    • THERE IS NO CONTRAINDICATION IN ANAPHYLAXIS
  4. 04Action

    Position Patient

    Supine with legs elevated (if tolerated)

    • Trendelenburg if hypotensive
    • Sitting if respiratory distress
    • Left lateral decubitus if pregnant
    • DO NOT sit/stand up suddenly
  5. 05Decision

    Response to Epinephrine?

    Reassess within 5-15 minutes

    • Improvement in BP, breathing, symptoms
    • If no response, repeat epinephrine
    • After 2-3 doses, consider IV epinephrine
  6. 06Action

    Repeat Epinephrine IM

    May repeat q5-15 min x 2-3 doses

    • Same dose as initial
    • Different injection site preferred
    • Continue until response or IV access
  7. 07Decision

    Refractory to IM Epinephrine?

    After 2-3 IM doses, consider IV epinephrine

  8. 08Warning

    IV Epinephrine Infusion

    For refractory anaphylaxis ONLY - requires monitoring

    • Dilute: 1mg in 100mL NS (10 mcg/mL)
    • Start: 1-4 mcg/min, titrate to effect
    • Requires cardiac monitoring
    • ICU setting preferred
    • Consider glucagon if on beta-blockers
  9. 09Outcome

    ICU Admission

    Refractory or severe - ongoing monitoring

  10. 10Action

    Observation Period

    Monitor for biphasic reaction

    • Minimum 4-6 hours for mild reactions
    • 8-12 hours for moderate-severe
    • 24 hours if prior biphasic reaction
    • Biphasic occurs in 1-20% of cases
  11. 11Action

    Consider Labs

    Do NOT delay treatment for labs

    • Serum tryptase: 15min-3hr after onset
    • Repeat at 24hr and baseline (2 weeks)
    • Helps confirm diagnosis retrospectively
    • May identify mastocytosis
  12. 12Action

    Discharge Planning

    Patient education and follow-up

    • Prescribe epinephrine auto-injector (2 devices)
    • Teach auto-injector technique
    • Written anaphylaxis action plan
    • Referral to allergist
    • MedicAlert bracelet recommendation
    • Return immediately if symptoms recur
  13. 13Outcome

    Resolved

    Symptoms controlled, safe for discharge

  14. Path rejoins step 12Shared downstream outcome
  15. 14Action

    Adjunct Therapies

    AFTER epinephrine - never delay epinephrine for these

    • IV fluids: NS bolus 1-2L (adults), 20mL/kg (peds)
    • Oxygen: High-flow, maintain SpO2 >94%
    • Albuterol: For bronchospasm not responsive to epi
    • Antihistamines: H1 (diphenhydramine) + H2 (famotidine)
    • Corticosteroids: May reduce biphasic reactions (evidence limited)
  16. Path rejoins step 07Shared downstream outcome
  17. 15Action

    Call for Help

    Activate emergency response/code team

    • Call resuscitation team
    • Note time of onset
    • Identify potential trigger
    • Prepare for escalation
  18. Path rejoins step 05Shared downstream outcome
  19. 16Action

    Remove Trigger

    If identifiable and safe to do so

    • Stop IV medications/contrast
    • Remove stinger (any method)
    • DO NOT delay epinephrine to remove trigger
  20. Path rejoins step 05Shared downstream outcome
  21. 17Action

    Consider Other Diagnoses

    Vasovagal, anxiety, other causes

    • Vasovagal syncope (pallor, bradycardia)
    • Panic attack (no objective signs)
    • Vocal cord dysfunction
    • Mastocytosis/mast cell activation
    • Hereditary angioedema (no urticaria)

Guideline Source

GA²LEN/EAACI Anaphylaxis Guidelines 2024: Acute Management and Care

DOI: 10.1111/all.16321View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Epinephrine is the ONLY first-line treatment - never delay for other interventions
  • IM epinephrine is preferred in most settings over IV
  • Beta-blocker patients may have refractory anaphylaxis requiring glucagon
  • Biphasic reactions can occur up to 72 hours - discharge education critical
  • Does not cover allergen-specific immunotherapy protocols

Applicable Regions

USEUInternational

EU: Multiple auto-injector brands available with varying doses

US: Auto-injector dosing: EpiPen 0.3mg adults, 0.15mg pediatric

International: IM adrenaline 1:1000 (1mg/mL) is standard; some areas may only have IV formulations

Version 1Next review: 2027-01-01

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Frequently Asked Questions

What is the Anaphylaxis Management (GA²LEN International Consensus 2024)?

The Anaphylaxis Management (GA²LEN International Consensus 2024) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on GA²LEN/EAACI Anaphylaxis Guidelines 2024: Acute Management and Care.

What guideline is the Anaphylaxis Management (GA²LEN International Consensus 2024) based on?

This algorithm is based on GA²LEN/EAACI Anaphylaxis Guidelines 2024: Acute Management and Care (DOI: 10.1111/all.16321).

What are the limitations of the Anaphylaxis Management (GA²LEN International Consensus 2024)?

Known limitations include: Epinephrine is the ONLY first-line treatment - never delay for other interventions; IM epinephrine is preferred in most settings over IV; Beta-blocker patients may have refractory anaphylaxis requiring glucagon; Biphasic reactions can occur up to 72 hours - discharge education critical; Does not cover allergen-specific immunotherapy protocols. Individual patient factors may require deviation from these recommendations.

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