a. Introduction. Anaphylaxis may occur immediately or up to 30 minutes or more after the patient is exposed to the foreign substance. In general, the sooner this reaction occurs following exposure, the more severe the signs and symptoms of the reaction. All patients receiving medication should be observed for at least 15 minutes following administration to identify developing reactions. The steps below should be followed if your patient develops an anaphylactic reaction.

b. Survey the Casualty. Before you can do anything for the patient, you must determine what type of reaction he is having. Follow the basic procedures for surveying the casualty--check the airway and pulse first.

c. Identify Signs and Symptoms of Anaphylactic Shock. The medical specialist should identify the following signs and symptoms of anaphylactic shock in the casualty.

(1) Difficulty in respiration, wheezing, coughing, and a sense of suffocation or anxiety.

(2) Weak, rapid, or imperceptible pulse.

(3) Decreased blood pressure.

(4) Cyanosis (blueness) around the lips. In persons with dark skin, the inside of the lips will appear gray, indicating a lack of oxygen.

(5) Flushing, burning, or itching sensation of the skin. Hives or red patches may be present. The redness of the skin is caused by a congestion of capillaries. Itching will often be present on the palms of the hands, between the fingers, or in the ear canals.

(6) Dizziness. Dizziness is caused by a lack of oxygen caused by difficulty in breathing.

(7) Vomiting, convulsions, and abdominal cramps. These signs are caused by the response of the victim's muscular and neurological systems.

d. Treat Anaphylactic Shock. The medical specialist will immediately treat anaphylactic shock as follows:

(1) Maintain the airway as necessary.

(2) Assist in ventilation, if proper equipment is available.

(3) Administer oxygen, if available.

(4) Monitor blood pressure every five to 15 minutes. Leave the blood pressure cuff on the patient. Continue to monitor the blood pressure until it is up--stable and patient is free of respiratory distress.

(5) Start an IV, preferably using Ringer's lactate or 0.9 percent NaCl (normal saline) solution.

(6) Perform cardiopulmonary resuscitation (CPR) if necessary for cardiac or respiratory arrest.

e. Transport. Unless contradictory to local policy, start supportive treatment and transport as soon as possible.

(1) Administer epinephrine, if available, only under the supervision of the physician, physician assistant, nurse practitioner, or by local protocol. A 1:1,000 solution is given intramuscularly or subcutaneously; the usual dosage for an adult is 0.4--0.5 ml. Pediatric doseage is determined by weight and should be ordered by a physician, physician assistant, or nurse practitioner.

(2) If signs and symptoms worsen or recur, the administration of up to four additional injections of epinephrine may be necessary. These injections may be administered every 15 minutes.

(3) Epinephrine is the drug of choice to relieve the symptoms of acute hypersensitivity reaction to drugs and of other acute allergic reactions; but, in patients suffering from shock from other causes, epinephrine may accentuate the underlying disorder. Therefore, care must be taken to perform an accurate assessment of the patient before administering epinephrine.

f. Record Treatment. Record treatment in the health record. If you can determine what drug or food caused the anaphylactic shock, enter that into the record and flag the record appropriately.

g. Evacuate Casualty. If you did not evacuate the patient earlier to a comprehensive medical treatment facility (MTF), do so at this time. As symptoms will return in about 20 per cent of patients experiencing an anaphylactic reaction, the doctor may require admission for observation and further treatment.