CME Review Article

Management of Anaphylaxis in Children

Danica B. Liberman, MD and Stephen J. Teach, MD, MPH

1. Define anaphylaxis according to current consensus guide-

Abstract: Anaphylaxis is a severe, life-threatening immunoglobulin
lines and enumerate the criteria for its diagnosis.
E (IgE)-mediated hypersensitivity reaction. The key to successful 2. Explain the emergency management of anaphylaxis, both
management of anaphylaxis involves rapid diagnosis, assessment, prehospital and hospital-based.
and early initiation of therapy. Epinephrine is the undisputed initial 3. List strategies for the prevention of anaphylaxis.
therapy for anaphylaxis, and its administration should never be de-
layed. In most cases, additional interventions such as oxygen therapy,
fluid resuscitation, "-agonists, antihistamines, and corticosteroids
should be strongly considered. Although hospital course must be
individualized to meet each patient’s needs, a minimum of 4 to 6
A 7-year-old boy is brought to your hospital by emergency
medical services with presumed anaphylaxis. He has a
history of peanut allergy, and while celebrating a classmate’s
hours of observation period after complete symptom resolution may
birthday, he may have inadvertently ingested peanut butter
be reasonable to monitor for recurrence of symptoms and biphasic
reaction. Before discharge, every patient should receive patient contained in the cookies that his classmate brought in to share
education about anaphylaxis, a prescription for self-injectable epi- with the class. Emergency medical services report that on
nephrine, and instructions for follow-up care. their arrival to the school, the child had hives on his face and
abdomen and complained of itchiness in his mouth and
Key Words: anaphylaxis, anaphylactic, allergic reaction, abdominal cramping. He received a dose of intramuscular
allergy, epinephrine
(IM) epinephrine and a dose of nebulized albuterol in route.
TARGET AUDIENCE Now, in your emergency department, on physical examina-
This continuing medical education activity is intended tion, you find a child with diffuse urticaria and facial
for anyone who may encounter pediatric anaphylaxis or who flushing, mild respiratory distress, scattered wheezes, and
provides anaphylaxis prevention education to those at risk. vague abdominal tenderness. He is tachycardic, tachypneic,
Pediatric health specialists including pediatricians, emergency and normotensive, and his oxygen saturation on room air is
physicians, pediatric emergency physicians, and critical care 95%. The rest of his physical examination results are normal,
physicians may find this especially useful. However, other including his mental status.
health care providers, from prehospital emergency personnel Together, this child’s history and physical examination
and school nurses to postdischarge follow-up primary care results support the presumptive diagnosis of anaphylaxis. What
physicians and allergist/immunologists, will find it informative. are the diagnostic criteria for anaphylaxis? Was his prehospital
management appropriate? What additional medical manage-
LEARNING OBJECTIVES ment strategies should you initiate upon his arrival to the
emergency department? When can he be safely discharged
After completion of this article, the reader should be
home, and what special discharge instructions, if any, will he
able to answer the questions at the end of the vignette and:
need? What are the key elements in his follow-up care?

Fellow (Liberman), Associate Chief (Teach), Division of Emergency Medi-

cine, Children’s National Medical Center, Washington, DC.
Both authors have disclosed that epinephrine, diphenhydramine, and pre-
BACKGROUND AND EPIDEMIOLOGY
dinisone are all FDA approved for anaphylaxis while ranitidine, albu- The first historical account of anaphylaxis traces back
terol, glucagon, and vasopressors were not approved. thousands of years to 2641 BC when Pharaoh Menes reportedly
Dr Liberman has disclosed that she has no significant relationship with or died of an anaphylactic reaction after the sting of a wasp. At
financial interests in any commercial companies that pertain to this edu-
cational activity. present, the incidence of anaphylaxis is estimated to be ap-
Dr Teach has disclosed that he is/was at speakers bureau of AstraZeneca proximately 30 cases per 100,000 person-years. The cause of
Corporation. anaphylaxis remains unidentified in roughly one third of the
All staff in a position to control the content of this CME activity have cases. Of those cases in which a cause is identified, food is the
disclosed that they have no financial relationships with, or financial
interests in, any commercial companies pertaining to this educational
most commonly associated exposure, accounting for one third
activity. of the cases, followed by hymenoptera stings, pharmacother-
Lippincott CME Institute, Inc. has identified and resolved all faculty and apeutic agents, and finally latex. The foods most frequently
staff conflicts of interest regarding this educational activity. responsible include peanuts, treenuts, fish, shellfish, milk, and
Address correspondence and reprint requests to Danica B. Liberman, MD, egg.1 Recently, clinicians and researchers have noticed what
Children’s National Medical Center, 111 Michigan Ave, Northwest,
Washington, DC 20010. E-mail: dliberma@cnmc.org. appears to be an increase in the incidence of food allergy,
Copyright * 2008 by Lippincott Williams & Wilkins with a concomitant and anticipated increase in the incidence
ISSN: 0749-5161/08/2412-0861 of allergic reactions and anaphylaxis.2

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Liberman and Teach Pediatric Emergency Care  Volume 24, Number 12, December 2008

DEFINITION AND DIAGNOSTIC CRITERIA dition caused by an IgE-mediated reaction,[ which is Boften
OF ANAPHYLAXIS life-threatening and almost always unanticipated.[ 4
Despite anaphylaxis being not a new phenomenon, it In addition to articulating a definition of anaphylaxis,
was not until 1902 when the term anaphylaxis, meaning the Second Symposium on the Definition and Management
Bagainst protection,[ was introduced by Portier and Richet.1 of Anaphylaxis proposed revised diagnostic criteria to
They used it to describe the fatal reaction that a dog had to identify individuals experiencing an anaphylactic reaction.
his second exposure to an extract of jellyfish tentacles. A These criteria3 are outlined in Table 1. The group had 2
hundred years later, although we regularly use the term primary goals when creating their diagnostic criteria: first, to
anaphylaxis and treat its associated symptoms, there remains provide medical personnel with a clear, quick method to
a lack of universal agreement on its definition and criteria for clinically diagnose anaphylaxis and, second, to capture most
its diagnosis. Without a clear definition and diagnostic of those with anaphylaxis or at risk for it. They sought to
criteria, further research of anaphylaxis is difficult. To maximize the sensitivity of the criteria.
address these problems, a diverse group of experts convened In anaphylaxis, the IgE mediated sudden release of
in April 2004 for the Second Symposium on the Definition biologically active mediators from mast cells and basophils
and Management of Anaphylaxis. They defined anaphylaxis results in a multiorgan reaction. The most commonly af-
broadly as Ba serious allergic reaction that is rapid in onset fected organs are those with the most mast cells, including
and may cause death.[3 In 2006, the Joint Task Force on the skin, eye, nose, respiratory tract, cardiovascular system,
Practice Parameters, representing the American Academy of and gastrointestinal tract. Approximately 80% of anaphy-
Allergy, Asthma and Immunology; the American College lactic reactions include skin manifestations, such as pruritis,
of Allergy, Asthma and Immunology; and the Joint Council flushing, and generalized hives.5Y7 Therefore, criterion 1
of Allergy, Asthma and Immunology, developed an updated would successfully identify approximately 80% of patients.
practice parameter for the diagnosis and management of The remaining 20% should be identifiable by using criteria 2
anaphylaxis. The task force defined anaphylaxis as Ba con- and 3. These criteria have yet to be validated in a multicenter
prospective clinical survey, however.

TABLE 1. Clinical Criteria for Diagnosing Anaphylaxis MANAGEMENT OF ANAPHYLAXIS

Anaphylaxis Is Highly Likely When Any 1 of the Following
The keys to the management of anaphylaxis are rapid
3 Criteria Are Fulfilled:
diagnosis and the immediate initiation of medical manage-
ment. In general, the sooner an accurate diagnosis is made
1. Acute onset of an illness (minutes to several hours) with and an appropriate therapy is initiated, the better the patient’s
involvement of the skin, mucosal tissue, or both (eg, generalized outcome. Figure 1 provides an algorithm for the immediate
hives, pruritus or flushing, swollen lips-tongue-uvula) management of anaphylaxis.4 Each step is elaborated later.
And at least one of the following: Table 2 provides a list of the recommended pharmacological
a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, interventions and their appropriate dosages.
stridor, reduced PEF, hypoxemia)
b. Reduced BP or associated symptoms of end-organ dysfunction
(eg, hypotonia [collapse], syncope, incontinence) Management in the Field: Epinephrine IM,
2. Two or more of the following that occur rapidly after exposure to Bronchodilators, Intravenous Access and Fluids,
a likely allergen for that patient (minutes to several hours): Oxygen, and Antihistamines (H1 Antagonists)
a. Involvement of the skin-mucosal tissue (eg, generalized hives, In a matter of minutes, someone with an anaphylactic
itch-flush, swollen lips-tongue-uvula) reaction can become critically ill. The faster the symptom
b. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, onset after exposure to an allergen, the higher the likelihood
stridor, reduced PEF, hypoxemia) for a severe and potentially life-threatening reaction.2 As with
c. Reduced BP or associated symptoms (eg, hypotonia [collapse], any critically ill patient, the first step in management is
syncope, incontinence) addressing the airway, breathing, and circulation. Then, with
d. Persistent gastrointestinal symptoms (eg, crampy abdominal limited delay, if the patient meets any of the criteria for
pain, vomiting) anaphylaxis, the next step is to administer epinephrine.
3. Reduced BP after exposure to known allergen for that patient Although some debate exists on the medical management of
(minutes to several hours): anaphylaxis, there is universal agreement that epinephrine is
a. Infants and children: low systolic BP (age-specific) or 930% the first-line treatment. Epinephrine has both !-adrenergic
decrease in systolic BP* and $-adrenergic properties. As an !-adrenergic agonist,
b. Adults: systolic BP G90 mm Hg or 930% decrease from that epinephrine promotes vasoconstriction, which increases
person’s baseline blood pressure and decreases capillary leakage. Its $-
Adapted with permission from Sampson et al.3 adrenergic properties serve to relax bronchial smooth muscle,
*Low systolic blood pressure for children is defined as lower than increase heart rate and cardiac contractility, and inhibit sub-
70 mm Hg from 1 month to 1 year, lower than (70 mm Hg + [2  age]) sequent mediator release. Failure to inject epinephrine
from 1 to 10 years, and lower than 90 mm Hg from 11 to 17 years.
BP indicates blood pressure; PEF, peak expiratory flow.
promptly has been identified as the most important fac-
tor contributing to death in patients experiencing anaphylaxis.8

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Pediatric Emergency Care  Volume 24, Number 12, December 2008 Management of Anaphylaxis in Children

FIGURE 1. Algorithm for the treatment of acute anaphylaxis. ACLS indicates advanced cardiac life support; CPR, cardiopulmonary
resuscitation; ICU, intensive care unit. Reprinted with permission from Lieberman et al.4

There are no contraindications to giving epinephrine to tient’s commercially available preloaded epinephrine syringe
someone with an anaphylactic reaction. In fact, it is prudent (eg, EpiPen, Anapen, and Twinject) is available, it should be
to administer epinephrine in uncertain situations when some- administered without delay, preferably before emergency
one may not yet meet the diagnostic criteria. For instance, a medical personnel arrive on the scene. A 0.01-mg/kg or a
person with a history of seafood allergy and anaphylaxis who single preloaded epinephrine dose can be administered every
has just inadvertently ingested shrimp and is beginning to 5 to 15 minutes based on the patient’s status. The 5-minute
experience facial flushing should receive epinephrine. interval can be abbreviated to provide more frequent
Aqueous epinephrine at 1:1000 should be administered injections according to the discretion of the emergency
IM into the anterior-lateral thigh as soon as possible at a dose medical personnel. Recently, IM administration of epineph-
of 0.01 mg/kg (maximum dose, 0.3 mg). Of note, if the pa- rine, instead of subcutaneous, has become the preferred

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Liberman and Teach Pediatric Emergency Care  Volume 24, Number 12, December 2008

harmed from this intervention. Epinephrine typically helps re-

TABLE 2. Pharmacologic Management of Anaphylaxis
verse the bronchospasm from anaphylaxis; however, an inhaled
In the field "2-agonist such as albuterol may also benefit the patient in
Epinephrine (1:1000), 0.01 mg/kg per dose; maximum dose, respiratory distress. In severe or refractory reactions, supple-
0.3 mg per dose IM in the anterior-lateral thigh mental oxygen may not be sufficient, and it may be necessary
Alternatively, if preloaded epinephrine is available: to intubate and mechanically ventilate the patient. Intubation
10Y25 kg of 0.15-mg epinephrine IM in the anterior-lateral may also be indicated for evolving airway obstruction.
thigh Patients with poor circulatory status with hypotension
925 kg of 0.3-mg epinephrine IM in the anterior-lateral thigh or anaphylactic shock despite epinephrine administration
Albuterol ("2-agonist) metered-dose inhaler or nebulized solution should receive aggressive fluid resuscitation. The increased
every 20 min or continuously as needed vascular permeability that occurs with anaphylaxis allows a
Diphenhydramine (H1 antagonist), 1Y2 mg/kg per dose; maximum transfer of as much as 50% of the intravascular fluid into the
dose, 50 mg IV or PO (oral liquid most readily absorbed) extravascular space within 10 minutes.3,4 Patients may
Hospital-based require large volumes of intravenous (IV) fluid to maintain
adequate perfusion and blood pressure. Normal saline is an
Epinephrine as above, consider intermittent IV epinephrine
boluses vs. continuous epinephrine infusion for persistent appropriate initial fluid, and children may require up to 30
hypotension mL/kg in the first hour of management. Positioning the
Vasopressors for refractory hypotension, titrate to effect patient in a recumbent position with the lower extremities
elevated may help improve venous return, stroke volume, and
Glucagon for refractory hypotension 5Y15 2g/min, titrate to effect
thus cardiac output.
Albuterol ("2-agonist) metered-dose inhaler or nebulized solution
The final step in prehospital management is admin-
every 20 min or continuous as needed
istration of an H1 antagonist. Antihistamines are considered
Diphenhydramine (H1 antagonist), 1Y2 mg/kg per dose; maximum
a second-line treatment of anaphylaxis and should never be
dose, 50 mg PO, IV, and IM (if not already given)
administered alone. The primary effect of antihistamines is
Ranitidine (H2 antagonist), 1Y2 mg/kg per dose; maximum dose,
to relieve symptoms of pruritis, urticaria, and angioedema.
75Y150 mg PO and IV
They work synergistically with epinephrine therapy. Diphen-
Corticosteroids: prednisone at 1 mg/kg with a maximum dose of
hydramine, the most commonly used H1 antagonist, admin-
60Y80 mg PO or methylprednisolone at 1 mg/kg with a
maximum dose of 60Y80 mg IV istered orally for mild symptoms and IM or IV for more
severe symptoms, can be given at a dose of 1 to 2 mg/kg with
Discharge therapy
a maximum dose of 50 mg.
Diphenhydramine (H1 antagonist) every 6 h for 48Y72 h
Ranitidine (H2 antagonist) twice daily for 48Y72 h
Prednisone (corticosteroids) twice daily for 48Y72 h
Preloaded epinephrine autoinjector prescription and instructions Hospital-Based Management: Continuation of
Education on avoidance of allergen Prehospital Management, H2 Antagonists,
Follow-up with primary care physician and Corticosteroids
Consider referral to an allergist Every patient with an anaphylactic reaction should be
PO indicates oral. evaluated in a medical facility. The extent of prehospital
management, the patient’s status upon arrival to a medical
facility, and past medical history will guide hospital man-
route. Several small studies measuring absorption and agement. Any previously untreated patient arriving to an
plasma levels of injected epinephrine have shown a more ED in anaphylaxis should immediately receive epinephrine
rapid absorption and higher plasma levels when epinephrine and, depending upon his status, fluid resuscitation, oxygen
was administered IM into the anterior-lateral thighs of chil- therapy, inhaled "2-agonist, and diphenhydramine.
dren and adults as compared with subcutaneous injections Second-line therapies also considered standard of care
into the deltoid or thigh.9,10 These results were obtained for for anaphylaxis include H2 antagonists and corticosteroids.
both aliquots of epinephrine drawn from bottles and from Of the H2 antagonists commonly used, ranitidine has been
automatic spring-loaded epinephrine devices. One limitation studied most extensively in the pediatric population. Studies
of the studies to date is that none has been performed in directly comparing the efficacy of different H2 antagonists in
patients actually experiencing anaphylaxis. the treatment of anaphylaxis have not been done. The
Although epinephrine is the most critical intervention to pediatric dose of ranitidine is 1 to 2 mg/kg IV with a
treat the symptoms of anaphylaxis, more universal therapeutic maximum dose of 75 to 150 mg. Studies have shown that
interventions should not be overlooked, and the airway, the combination of H1 and H2 antagonists are superior to
breathing, and circulation should be continuously revisited. H1 antagonist alone in treating the cutaneous manifestations
Any patient with respiratory distress or hypoxia should be of anaphylaxis.11,12
placed on supplemental oxygen and monitored with arterial Although corticosteroids have never been shown in
blood gas measurement and continuous pulse rate oximetry. placebo-controlled trials to affect the course of anaphylaxis,
Even those not experiencing acute respiratory compromise they are important in the treatment of related diseases such as
may benefit from oxygen therapy and certainly would not be asthma and allergic rhinitis, and they have been incorporated

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Pediatric Emergency Care  Volume 24, Number 12, December 2008 Management of Anaphylaxis in Children

into algorithms for the management of anaphylaxis. The of epinephrine remain elevated for approximately 1 hour
onset of action of steroids is approximately 4 to 6 hours after IM administration, and subsequent doses of epinephrine
after administration, and they should therefore not be con- or other interventions may be required while epinephrine
sidered first-line therapy for anaphylaxis. Some authors sug- levels diminish. The phenomenon of the biphasic reaction is
gest that corticosteroids may decrease the chances of having not well understood.8 With the observation data available, it
a biphasic reaction; however, this has not been substanti- seems to occur anywhere from 1% to 20% of anaphylactic
ated in well-controlled trials, and there may be evidence that reactions, and the secondary component may be anywhere
there is no effect.8,13Y15 If corticosteroids are given, more from 1 to 72 hours after the initial reaction.6,8,14,16,17 It has
severely affected patients should receive IV methylpredniso- also been noted that a biphasic reaction seems more likely to
lone at a dose of 1 mg/kg 2 times a day (maximum single occur in patients who initially present with severe symp-
dose, 60Y80 mg). For less severe reactions, oral prednisone toms.8 In 1 series, approximately 6% of hospitalized children
at a dose of 1 mg/kg 2 times a day (maximum single dose, with anaphylaxis had a biphasic reaction, and its occurrence
60Y80 mg) can be given. was associated with delayed initial epinephrine administra-
tion.17 To date, there are no validated predictive factors with
which those at highest risk of a biphasic reaction can be
Management of Refractory Anaphylaxis: identified. In general, the biphasic reaction mimics the initial
Continuation of Hospital Management, reaction in organ systems involved. Because the occurrence
Continuous and Intermittent Epinephrine of a biphasic reaction is unpredictable and because, when it
Infusions, Vasopressors, and Glucagon does occur, the time between initial presentation and onset of
the biphasic reaction is so variable, there is no universally
Patients persistently hypotensive despite IM epinephr-
ideal duration of observation after an anaphylactic reaction.
ine and fluid administration may benefit from a continuous
Most biphasic reactions occur within 4 hours of initial pre-
epinephrine infusion. The recommended dosage range for an
sentation18; therefore, a minimum of 4 to 6 hours of obser-
epinephrine drip for both children and adults is 0.1 to 1 2g/kg
vation period after anaphylaxis may be optimal, with the
per minute (maximum, 10 2g/min), titrated based on clinical
caveat that every patient’s observation period can and should
effect. Alternatively, intermittent IV epinephrine boluses
be adjusted to meet the needs of the situation.
have been suggested as an option for refractory hypotension
or cardiovascular collapse. Both options, continuous IV epi-
nenphrine infusion and intermittent epinephrine boluses, pose
a substantial risk for lethal cardiac arrhythmias and should be HOSPITAL DISCHARGE AND FOLLOW-UP
reserved for cases refractory to epinephrine injections and AFTER ANAPHYLAXIS
aggressive volume replacement. Any patient receiving re-
Using the available data and anecdotal evidence as a
peated doses or a continuous infusion of epinephrine must be
guide, each patient’s observation period and discharge criteria
on a cardiac monitor.
should be individualized to take into account initial pre-
Additional options for the management of refractory
sentation, response to therapy, availability of close observa-
hypotension include other vasopressors. Although studied
tion at home, and accessibility of a medical facility from home.
largely in other causes of shock, potent vasopressors such as
The significance of the reaction should be emphasized to
vasopressin and dopamine may aid in the treatment of
hypotension and anaphylactic shock. Regardless of the ther- each patient and family. Hundreds of people in the United
States die of anaphylaxis each year.1 Education about the
apeutic intervention, it is critical that the patient’s hemody-
prevention and prehospital management of anaphylaxis
namic status be monitored continuously.
Although most patients taking $-blockers are adults, is critical. Before hospital discharge, every patient success-
fully treated for an anaphylactic reaction should be given
the severity of anaphylaxis and the complexity of its man-
specific instructions on prevention strategies, identification
agement are negatively impacted by the concomitant use of a
of symptoms, and acute treatment. For those with an iden-
$-blocker. In these cases and when epinephrine is ineffective
tifiable trigger, strict guidelines for avoidance of the pre-
in the management of hypotension, IV glucagon should be
cipitating allergen should be emphasized. The patient and
given to attempt to reverse hypotension. The recommended
family must be given explicit instructions on when and how
dose of glucagon in children is 20 to 30 2g/kg; the maximum
to administer epinephrine.
dose is 1 mg, given over 5 minutes, and followed by an
Simply stated, if there is any doubt, it is safer to ad-
infusion of 5 to 15 2g/min, titrated to effect.3
minister epinephrine. Although there is no consensus on who
should be prescribed self-injectable epinephrine, it seems
reasonable that every patient with a history of anaphylaxis or
OBSERVATION PERIOD AFTER ACUTE at risk for anaphylaxis should have epinephrine available at
ANAPHYLACTIC REACTION all times.1,19 Self-injectable epinephrine in the form of auto-
After successful treatment of anaphylaxis, continued injectors are currently available in 2 fixed doses: 0.15 and
observation in a medical setting is recommended for every 0.3 mg. In general, autoinjectors are more preferred than
patient for 2 primary reasons: because symptoms may recur epinephrine in ampules that must be drawn up into a syringe
as the effects of epinephrine wear off and because every pa- by the caregiver in the event of an anaphylactic reaction. This
tient is at risk for a biphasic reaction. In general, serum levels being said, following the recommended pediatric dose of

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Liberman and Teach Pediatric Emergency Care  Volume 24, Number 12, December 2008

0.01 mg/kg makes finding the ideal dose a challenge for REFERENCES
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CME EXAM
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the questions correctly. Mail a photocopy of the completed answer sheet to the Lippincott CME Institute Inc., 770 Township
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Lippincott CME Institute, Inc. by February 15, 2009. Answer sheets will be graded and certificates will be mailed to each
participant within six to eight weeks after LCMEI, Inc. receipt. The answers for this examination will appear in the March
2009 issue of Pediatric Emergency Care.
Credits
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PRA category 1 Credit TM. Physicians should only claim credit commensurate with the extent of their participation in the
activity.
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CME EXAMINATION
December 2008
Please mark your answers on the ANSWER SHEET.
Management of Anaphylaxis in Children, Liberman and Teach
1. Based on current evidence, the preferred route for an a. budesonide
epinephrine injection in anaphylaxis is: b. RBC transfusion
a. deltoid, subcutaneous c. propranolol
b. deltoid, intramuscular d. glucagon
c. vastus lateralis, intramuscular e. calcium infusion
d. vastus lateralis, subcutaneous 4. A reasonable amount of time to monitor, from onset of
2. The most important factor contributing to death in patients symptoms to hospital discharge, for a biphasic reaction is
with anaphylaxis is: at least:
a. administering an H1 antagonist orally rather than a. 1 hour
intravenously b. 4Y6 hours
b. failure to inject epinephrine promptly c. 8Y10 hours
c. inability to obtain IV access d. 24 hours
d. failure to monitor patients for a biphasic reaction 5. Prior to hospital discharge, every patient presenting in
e. delay in transport to a medical facility anaphylaxis should be provided with which of the
3. A 3-year-old boy with a history of repaired congenital following:
heart disease who is on medications presents to the a. prescription for a preloaded epinephrine autoinjector
emergency department with anaphylaxis. He is persis- b. anaphylaxis action plan
tently hypotensive despite epinephrine, fluid resuscitation, c. prescriptions for diphenhydramine, ranitidine, and
and the initiation of a dopamine drip. A therapy that may prednisone
prove beneficial in this particular patient could be: d. all of the above

* 2008 Lippincott Williams & Wilkins 867

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Liberman and Teach Pediatric Emergency Care  Volume 24, Number 12, December 2008

ANSWER SHEET FOR THE PEDIATRIC EMERGENCY CARE

CME PROGRAM EXAM
December 2008
Please answer the questions on page 867 by filling in the appropriate circles on the answer sheet below. Please mark the
one best answer and fill in the circle until the letter is no longer visible. To process your exam, you must also provide the
following information:
Name (please print):
Street Address
City/State/Zip
Daytime Phone
Specialty
1.
2.

A B C D E
A B C D E
3.
4.

A B C D E
A B C D E
5.

A B C D E
Your evaluation will help us assess whether this CME activity is congruent with LCMEI’s CME mission statement and will assist us
in future planning of CME activities. Please respond to the following questions:
1. Did the content of this CME activity meet the stated learning objectives?
[ ] Yes [ ] No
2. On a scale of 1 to 5, with 5 being the highest, how do you rank the overall quality of this educational activity?
[]5 []4 []3 []2 []1
3. Was the activity’s format (ie, print, live, electronic, Internet, etc.) an appropriate educational method for conveying the activity’s content?
[ ] Yes [ ] No
4. Did this CME activity increase your knowledge/competence in the activitys topic area? If No, please explain why not.
[ ] Yes [ ] No

5. As a result of participating in this CME activity, will you be changing your practice behavior in a manner that improves your patient
care? Please explain your answer.

6. Did you perceive any evidence of bias for or against any commercial products? If yes, please explain.
[ ] Yes [ ] No

7. How long did it take you to complete this CME activity?

__________hour(s) __________minutes
8. Please state one or two topics that you would like to see addressed in future issues.

[ ] YES! I am interested in receiving future CME programs from Lippincott CME Institute! (Please place a check mark in the box)

Mail by February 15, 2009 to

Lippincott CME Institute, Inc.
770 Township Line Road, Suite 300
Yardley, PA 19067

868 * 2008 Lippincott Williams & Wilkins

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Pediatric Emergency Care  Volume 24, Number 12, December 2008 Management of Anaphylaxis in Children

CME EXAM ANSWERS

Answers for the Pediatric Emergency Care CME Program Exam

Below you will find the answers to the examination covering the review article in the September 2008 issue. All participants
whose examinations were received by November 15, 2008 and who achieved a score of 80% or greater will receive a certificate
from Lippincott CME Institute, Inc.

EXAM ANSWERS
September 2008

1. E
2. E
3. E
4. E
5. A

* 2008 Lippincott Williams & Wilkins 869

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