1. Stop all infusions and blood transfusions and withhold any potential drug or food allergen. Blood and blood products should be returned to the laboratory for analysis.

2. Start oxygen (FIO2 0.6-1.0). If there is evidence of persistent hypoxaemia consider urgent intubation and mechanical ventilation.

3. If there is laryngeal obstruction, bronchospasm or facial oedema give IM or nebulised epinephrine and IV hydrocortisone. If there is not rapid relief of airway obstruction, consider urgent intubation or, in extremis, emergency cricothyroidotomy or tracheostomy. Persistent bronchospasm may require an epinephrine infusion, aminophylline infusion or assisted expiration (manual chest compression).

4. Hypotension should be treated with epinephrine IV/IM and rapid colloid infusion. Large volumes of colloid may be required to replace the plasma volume deficit in severe anaphylaxis.

• Severe oedema may coexist with hypovolaemia.

• Plasma volume has not been adequately replaced if the haemoglobin is higher than normal.

• Hetastarch is the most appropriate fluid for colloid resuscitation unless the reaction is due to a hydroxyethyl starch.

5. Persistent hypotension should be treated with further epinephrine, hydrocortisone and colloid infusion guided by central venous pressure ± cardiac output monitoring. An epinephrine infusion may be required to overcome myocardial depression. The use of military antishock trousers or norepinephrine should be considered to divert blood centrally and increase peripheral resistance.

6. Urticaria requires chlorphenamine IV or PO depending on the severity of the reaction.

7. After control of the anaphylactoid reaction, advice should be sought from the immunology laboratory and appropriate samples taken for confirmation.

8. Reactions to long-acting drugs or fluids will require continued support (perhaps for many hours).

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