Definitions and Scope
- •Allergen. An environmental substance that triggers an abnormal or heightened immune response in susceptible individuals. Common sources of allergens include foods, plant or animal elements, and medications.
- •Allergy. An abnormal or heightened immune response against an allergen.
- •Anaphylaxis. An acute, potentially-life threatening response to an allergen that progresses to involve multiple organ systems and is described in further detail later.
- •Asthma. Abnormal bronchial constriction and inflammation arising from exposure to an inciting allergen, infection, extremes of temperature, or physical exertion.
- •Anaphylactoid reaction. An acute inflammatory or anaphylaxis-like response without prior exposure to the inciting allergen.
- •Angioedema. Subcutaneous or submucosal swelling and inflammation arising from exposure to an allergen or deficiency of an inflammatory inhibitor.
- •Antigen. A substance or agent that incites an immune response with antibody production. An antigen may be environmental, as in allergens, bacteria, and viruses, or intrinsic to the body, as in autoimmune diseases.
- •Hypersensitivity reaction. A heightened immune response against an antigen leading to inflammatory damage to the body. A hypersensitivity reaction may be immediate or delayed and is classified according to the specific types of antibodies or immune cells involved (Table 1).6Table 1Hypersensitivity reactions
Reaction type Type I Type II Type III Type IV Name IgE-mediated hypersensitivity IgG-mediated cytotoxic hypersensitivity Immune complex–mediated hypersensitivity Cell-mediated hypersensitivity Mechanism IgE antibodies activate mast cells IgG antibodies activate T cells and complement Antigen–antibody complexes activate complement and neutrophils Antigens activate T cells and macrophages Onset Immediate (within minutes) Intermediate (minutes to hours) Intermediate (hours) Delayed (48–72 h) Clinical example Anaphylaxis Blood transfusion reaction Serum sickness Contact dermatitis, poison ivyAdapted from Punt et al.120
National Outdoor Leadership School
|Annual enrollment (mean±SD)||5093±190||41,732±2427|
|Age, y (median) [IQR] (range)||20  (6–84)||16  (10–78)|
|Anaphylaxis cases in all students, n (%)||21 (0.03%)||39 (0.01%)|
|Field time (p-d)||1,945,057||1,839,730|
|Anaphylaxis incidence (per p-d)||1/96,622||1/46,173|
|(per million p-d)||10||21|
|Age, y (median) [IQR] (range)||32  (20–72)||27  (18–77)|
|Anaphylaxis cases in all instructors, n||3||7|
|Field time (p-d)||486,534||NA|
|Anaphylaxis incidence (per p-d)||1/162,178||NA|
|(per million p-d)||6|
|Totals (students + instructors)|
|Anaphylaxis cases, n||24||46|
|Field time (p-d)||2,431,591||NA|
|Anaphylaxis incidence (per p-d)||1/101,316||NA|
|(per million p-d)||10|
|Cases per year (mean±SD) (range)||2±2 (0–10)||3±2 (0–8)|
|Allergen||Cases at NOLS n (%)||Cases at OB n (%)|
|Hymenoptera/Insect stings||8 (33)||20 (43)|
|Peanuts/Tree nuts||8 (33)||7 (15)|
|Other foods||5 (21)||4 (9)|
|Plants/Pollen/Grasses||1 (4)||1 (2)|
|Marine life/Jellyfish||0 (0)||1 (2)|
|Asthma trigger||0 (0)||4 (9)|
|Unknown||2 (8)||9 (20)|
|Total||24 (99)||46 (100)|
Outward Bound—UNITED STATES
Increase in the Field Reporting of Anaphylaxis by NOLS and OB
|NOLS injury and illness database||2005–2019||1984–2004|
|Total field time (p-d)||2,431,591||2,446,159|
|Incidence per p-d||1/101,316||1/1,223,080|
|Incidence per p-d||1/5207||1/16,417|
|Year||NOLS students with food allergy, n (%)||Nut allergy (% of total allergies)|
- Platts-Mills T.A.E.
- Commins S.P.
- Biedermann T.
- van Hage M.
- Levin M.
- Beck L.A.
- et al.
- 1.Cutaneous or mucosal signs that occur suddenly, progress within minutes to hours, and are accompanied by respiratory compromise, hypotension, or persistent gastrointestinal symptoms.
- 2.Acute onset of hypotension or respiratory compromise, including severe bronchospasm or laryngeal involvement, even in the absence of skin involvement.
General Considerations and Decontamination
Routes of Administration
- Sampson H.A.
- Muñoz-Furlong A.
- Campbell R.L.
- Adkinson Jr., N.F.
- Bock S.A.
- Branum A.
- et al.
Epinephrine Injection Devices
|Name||Mechanism; medicine container||Dose (mg)||Needle length (mm)||Safety features post-injection||Manufacturer|
|EpiPen (G)||Spring; cartridge||0.15||12.7||Automatic needle guard||Meridian Medical Technologies, United States|
|Auvi-Q (United States),|
|Compressed gas; cartridge||0.1||7.4||Automatic retractable needle||Kaléo, United States|
|Adrenaclick (G)||Spring; syringe||0.15||12.7||Carrier case for syringe + exposed needle||Meridian Medical Technologies, United States|
|Emerade||Spring; syringe||0.15||16||Automatic needle guard||Medeca Pharma, Sweden|
|Jext||Spring; cartridge||0.15||13||Automatic needle guard||ALK-Abelló, Denmark|
|Anapen||Spring; syringe||0.15||12.7||Manual sliding needle guard||Bioprojet, United Kingdom|
|Symjepi||Plunger; fixed-dose syringe||0.15||15.9||Manual sliding needle guard||Adamis Pharmaceuticals, United States|
|Epi Kit||Plunger on 1 mL syringe; 1 mg epinephrine in 1 mL vial||Variable, up to 1 mg||25.4||Manual sliding needle guard||Curaplex, United States|
Autoinjectors; Prefilled Syringes
Vials or Ampules
|Epinephrine (Adrenaline)||IM: anterior lateral thigh > deltoid |
|0.01 mg·kg-1, up to 0.3-0.5 mg per dose Q 5-15 min PRN|
Infusion: 0.1 microgram·kg-1·min-1, titrate to clinical effect
Bolus: 50–100 microgram·min-1
1B (choice of anterior lateral thigh)
|H1 antihistamines||Diphenhydramine PO, IM, IV|
Certirizine PO, IV
|25–50 mg Q 4–6 h|
Peds: 1 mg·kg-1 per dose
10 mg QD
Peds: <6 y: 2.5 mg; 6–11 y: 5–10 mg QD
|Secondary treatment; cutaneous manifestations (rash, edema, pruritis)||1C|
|H2 antihistamines||Famotidine PO, IV||20 mg BID|
Peds >3 mo: 0.25 mg·kg-1 dose BID
|Possible synergistic effect with H1 antihistamines||2B|
Metered-dose inhaler, 90 microgram·actuation-1
2 inhalations; frequency varies with severity
≥12 y: 2.5–5 mg
5–12 y: 1.25–2.5 mg;
1–5 y: 1.25 mg
|Secondary treatment; bronchospasm||1C|
Methylprednisolone PO, IM, IV
Dexamethasone PO, IM, IV
|1-2 mg·kg-1, up to 50–60 mg QD|
Peds: ÷ Q12–24 h
1–2 mg·kg-1, up to 40-60 PO/IM QD, 80-125 mg IV QD
Peds: ÷ Q12–24 h
6–9 mg QD
Peds: 0.3 mg·kg-1 QD
possible prevention of biphasic reaction
|Glucagon||IV||Initial dose: 1–5 mg|
Peds: 0.02–0.03 mg·kg-1, up to 1 mg per dose
Subsequent infusion at 5–15 microgram·min-1, titrate to clinical effect
|Refractory cases in patients on β blockers||2C|
|Desensitization therapy||SQ, PO||Protocol of sequentially increasing antigen dose.||Prior anaphylaxis to Hymenoptera venom or peanuts||1B|
|Weight kg (lb)||Minimum needle length for IM injection (mm)|
|Female or male <60 (130)||16|
|Female or male 60–70 (130–152)||25|
|Female 70–90 (152–200)||25|
|Male 70–118 (152–260)||25|
|Female >90 (200)||38|
|Male >118 (260)||38|
- Campbell R.L.
- Bellolio M.F.
- Knutson B.D.
- Bellamkonda V.R.
- Fedko M.G.
- Nestler D.M.
- et al.
Inhaled β Agonists
Post-treatment observation period
Appendix A. Supplemental Material(s)
- Supplementary Table 1.
- Appendix 1
- Appendix 2
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