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Lesson

Refractory Anaphylaxis

12 min Medical Skip to quiz

Objective: If anaphylaxis is not improving, repeat intramuscular epinephrine per protocol and protect the airway. Do not push the intramuscular concentration into a vein. Glucagon does not replace epinephrine, even if the patient takes a beta blocker.

Why this matters

The first intramuscular epinephrine dose does not end every anaphylaxis. Some patients need another intramuscular dose, an airway, and treatment for shock. Do not escalate by pushing the intramuscular concentration into a vein. Do not switch to diphenhydramine and a steroid while the blood pressure is still gone.

Repeat intramuscular epinephrine is the next step most protocols already own. An infusion or glucagon is an extra, and only when your protocol says so. Glucagon does not replace epinephrine, even if the patient takes a beta blocker.

Key points
  • Persistent airway swelling, bronchospasm, or shock: repeat intramuscular epinephrine in the mid-anterolateral thigh, on the interval your protocol writes.
  • Do not give that intramuscular concentration as an intravenous push.
  • Lay a hypotensive patient flat if breathing allows. Glucagon does not replace epinephrine in a patient who takes a beta blocker.
Verbalize
  • This is still anaphylaxis. I am giving a second intramuscular epinephrine dose in the thigh, per protocol.
  • This syringe does not go in the vein.
  • The airway is changing. I am getting the airway kit now, not after the antihistamine.

Clinical sequence

  1. Confirm this is still anaphylaxis: airway swelling, bronchospasm, hypotension, or a rapidly worsening rash with either of those. Use anaphylaxis recognition if the first dose has not been given. Epinephrine is first, not an antihistamine.
  2. If life-threatening features continue, give another intramuscular dose in the mid-anterolateral thigh. Use the other leg if you are unsure the first injection landed in muscle. Use the repeat interval in your protocol. This page does not give a minute count.
  3. Oxygen, and an airway plan if the voice is changing or the tongue is swelling. Bronchodilators may help wheezing after epinephrine. They do not replace it.
  4. If the blood pressure is low, lay the patient flat when breathing allows. Fluids for shock follow your volume protocol. Sitting a hypotensive patient up can drop the blood pressure.
  5. An intravenous epinephrine infusion exists in some systems for shock that will not respond. It is a labeled drip, not the intramuscular vial pushed through a saline lock. Glucagon is an optional protocol add-on for patients on beta blockers. Give the epinephrine anyway. Glucagon does not replace it.

Teaching points

  • World Allergy Organization and AAAAI anaphylaxis guidance keep intramuscular epinephrine in the thigh as the first and repeated treatment. Antihistamines and steroids do not treat the shock.
  • Read the concentration out loud. The epinephrine concentration lesson is the safety check.
  • Remove a stinger or stop the infusion that triggered this, if you can do it without delay. Do not spend the minute before the repeat dose looking for the cause.

Common errors

  • Do not push the intramuscular epinephrine concentration into a vein.
  • Do not wait on diphenhydramine while the blood pressure stays low.
  • Do not withhold epinephrine because the patient takes a beta blocker.

Practice

One-minute check

Ten minutes after intramuscular epinephrine, the patient is still hypotensive and the tongue is larger. Say the route of the next epinephrine, the position, and the one route you will not use.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

  • World Allergy Organization anaphylaxis guidance: intramuscular epinephrine in the mid-anterolateral thigh is first-line and is repeated for persistent anaphylaxis. Antihistamines do not treat airway swelling or shock.
  • Epinephrine concentrations — the intramuscular anaphylaxis concentration and the arrest concentration are not interchangeable
  • NASEMSO National Model EMS Clinical Guidelines (2022) — repeat interval, fluids, and any infusion stay on the local card

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. Anaphylaxis that is still shocking or swelling after the first intramuscular epinephrine needs:
2. The intramuscular epinephrine concentration must not be:
3. A patient on a beta blocker who has anaphylaxis:
4. Position for a hypotensive anaphylaxis patient who is still breathing is:
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