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March 27, 2007 — A clinical report by the American Academy of Pediatrics recommends best practices for administering self-injectable epinephrine for first-aid treatment of anaphylaxis in children in the community. The new guidelines are published in the March issue of Pediatrics. Controversies in management addressed by these guidelines include the selection of dose, indications for prescribing an autoinjector, and decisions regarding when to inject epinephrine.
"Anaphylaxis is a severe, potentially fatal systemic allergic reaction that is rapid in onset and may cause death," write Scott H. Sicherer, MD, from the Section on Allergy and Immunology of the American Academy of Pediatrics, and colleagues. "Epinephrine is the primary medical therapy, and it must be administered promptly.... Prompt injection of epinephrine is nearly always effective in the treatment of anaphylaxis, and delayed injection of epinephrine is associated with poor outcomes including fatality."
Anaphylaxis is usually mediated by an immunologic mechanism involving immunoglobulin E and resulting in sudden systemic release of mast-cell and basophil mediators including histamine and tryptase. Although there are many clinical presentations of anaphylaxis, respiratory compromise and cardiovascular collapse are of the greatest concern because they may be fatal.
Many different triggers for anaphylaxis episodes have been identified, but food and insect stings are the most frequently reported triggers in the community setting, often necessitating emergency care plans for anaphylaxis occurring outside the hospital/medical setting.
Epinephrine is the mainstay of anaphylaxis therapy. Adjunctive therapy with antihistamines and, for those with asthma, inhaled selective ß2-adrenergic agonists, such as albuterol, may be helpful but cannot replace epinephrine.
"Physicians should carefully instruct patients and families on the indications for, and the technique for using, self-injectable epinephrine," the authors write. "Prompt administration of epinephrine is clearly indicated for treatment of significant respiratory or cardiovascular symptoms of anaphylaxis, but considerable judgment is required in many actual or possible allergic reactions in which life-threatening symptoms have not yet developed but may develop. Previous guidelines have suggested that epinephrine should be administered promptly at the onset of symptoms after exposure to an allergen that had previously caused anaphylaxis and possibly even in the absence of symptoms if there was a known exposure to an allergen that previously caused anaphylaxis with cardiovascular collapse."
After epinephrine injection for first-aid treatment of anaphylaxis, advanced care should be sought urgently by calling 911 (in the United States) or the equivalent for additional care and emergency transport to a hospital emergency department.
Based primarily on anecdotal evidence, the recommended epinephrine dose for anaphylaxis in children is 0.01 mg/kg, not to exceed 0.30 mg. The preferred route of administration for first-aid treatment is intramuscular injection of epinephrine into the vastus lateralis of the lateral thigh, which allows early peak epinephrine concentration needed for effective management. Intravenous administration of epinephrine carries increased risks for dilution errors and dosing errors, which may lead to overdose and adverse effects such as cardiac dysrhythmias.
Epinephrine autoinjectors are currently available in only 2 fixed doses: 0.15 and 0.30 mg. On the basis of most recent, but somewhat limited data, the guidelines recommend using autoinjectors with 0.15 mg of epinephrine for otherwise healthy young children weighing 10 to 25 kg (22 - 55 lb) and autoinjectors with 0.30 mg of epinephrine for those weighing 25 kg (55 lb) or more. However, specific clinical circumstances also must be considered in these decisions.
"The lack of additional autoinjector doses is a serious concern," the authors write. "Nevertheless, pediatricians are advised to prescribe the optimal dose from an autoinjector for each child, even when that dose cannot possibly be precisely 0.01 mg/kg.... For children who weigh less than 10 kg (22 lb), the physician and family should weigh the risks of delay in dosing and dosing errors when an ampule/syringe/needle is used against accepting nonideal autoinjector doses, taking into consideration the specific health needs of the individual child and abilities of the caregivers."
Effective care for individuals at risk for anaphylaxis mandates comprehensive management involving families, allergic children, schools, camps, and other youth organizations.
Reducing the risk for anaphylaxis requires confirmation of the trigger, teaching the patient and family to avoid the relevant allergen, preparing an individualized written emergency anaphylaxis action plan, and educating supervising adults regarding how to recognize and treat anaphylaxis.
Epinephrine should be prescribed for children who have experienced anaphylaxis who may re-encounter the trigger in the community. In some cases, self-injectable epinephrine should be prescribed for children who have not yet experienced anaphylaxis but who are at increased risk based on their specific trigger, comorbid conditions such as asthma, and/or limited ability to recognize anaphylaxis.
"Optimally, evaluation by an allergy/immunology specialist with American Board of Allergy and Immunology or international equivalent certification should be obtained to confirm allergic triggers, to provide education on trigger avoidance, and to initiate specific preventive treatment (eg, venom-injection immunotherapy for insect-sting anaphylaxis)," the authors conclude. "Written emergency action plans and review of care plans in the child's medical home with specific responsibilities for school, child care, or camp personnel; families; and children are needed to ensure a safe environment for those at risk."
All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless they are reaffirmed, revised, or retired at that time or earlier. The report states that the recommendations provided do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations may be appropriate based on individual circumstances.
Pediatrics. 2007;119:638-646.
Clinical Context
Anaphylaxis is a potentially life-threatening illness that can be confusing to both patient and clinician. Patients may overstate or understate their symptoms following a significant allergic reaction, making the diagnosis of anaphylaxis unclear. Generally, anaphylaxis requires the acute onset of symptoms involving the skin (hives, pruritis, flushing), respiratory system (dyspnea, wheeze, stridor), or cardiovascular system (hypotonia, syncope). One set of criteria for the diagnosis of anaphylaxis also includes possible gastrointestinal symptoms, including crampy abdominal pain and vomiting.
Epinephrine is critical to rapidly improve the course of anaphylaxis. The current review examines the use of epinephrine as first-aid treatment of anaphylaxis in children outside of the healthcare setting.
Study Highlights
An intramuscular injection into the vastus lateralis muscle of the lateral thigh is the best route of administration of epinephrine. This type of injection produces peak plasma epinephrine concentrations in 8 minutes compared with 34 minutes after subcutaneous injection into the deltoid region. Intravenous epinephrine should be reserved for patients who do not improve with intramuscular epinephrine.
The standard needle length on the autoinjector is a half inch, which may not be sufficient to reach the muscle in obese adolescents.
The dose of epinephrine should be 0.01 mg/kg, up to a maximum of 0.30 mg. This presents a dilemma for clinicians in that the prefilled autoinjector kits use doses of only 0.15 and 0.30 kg, making the precise dosing of children and adolescents difficult if not impossible. While there is little direct evidence comparing one dose with another, the authors suggest the following dosing algorithm based on patient weight:
10 kg or less: Consider use of ampule of epinephrine with needle and syringe to draw correct dose (0.01 mg/kg) of epinephrine. The main difficulties with this approach are timing and accuracy. One study demonstrated that parents required 142 seconds to draw a dose of 0.09 mL of epinephrine vs 52 seconds for clinicians. Moreover, the actual dose of epinephrine drawn by parents ranged between 0.004 and 0.151 mL.
10 to 25 kg: Autoinjection with 0.15 mg of epinephrine.
25 kg or more: Autoinjection with 0.30 mg of epinephrine.
A second dose of epinephrine is required for anaphylaxis in up to 35% of cases. Epinephrine may be repeated 5 to 20 minutes after the initial dose.
Differentiating between a severe allergic reaction and anaphylaxis can be difficult, and patients should be instructed to err on the side of caution in terms of when to use their epinephrine.
All children with a history of anaphylaxis should be considered for treatment with epinephrine. In addition, children with acute generalized urticaria following an insect sting should receive epinephrine to use after future stings, as the risk for anaphylaxis with future stings is approximately 10%. Patients with a history of severe allergy and asthma also should be considered for epinephrine therapy, as should children with severe allergy who use nonselective β-blockers.
The epinephrine injection may be applied through clothing. Epinephrine should be kept away from extreme temperatures and direct sunlight to protect against drug degradation, and the solution will not necessarily appear different after degradation has occurred.
Possible transient adverse events associated with epinephrine administration include tremor, anxiety, and palpitations.
Pearls for Practice
Symptoms of anaphylaxis may include hives, pruritis, flushing, dyspnea, wheeze, stridor, syncope, crampy abdominal pain, and vomiting.
Treatment of anaphylaxis in children weighing less than 10 kg consists of a needle and syringe to draw the correct dose (0.01 mg/kg) of epinephrine. Children who weigh between 10 and 25 kg should receive autoinjection with 0.15 mg of epinephrine, and children who weigh 25 kg or more may receive autoinjection with 0.30 mg of epinephrine.
March 27, 2007 — A clinical report by the American Academy of Pediatrics recommends best practices for administering self-injectable epinephrine for first-aid treatment of anaphylaxis in children in the community. The new guidelines are published in the March issue of Pediatrics. Controversies in management addressed by these guidelines include the selection of dose, indications for prescribing an autoinjector, and decisions regarding when to inject epinephrine.
2007年3月27日美国小儿科学会发布的临床报告推荐一项最佳治疗措施-----采用能自我注射肾上腺素急救社区儿童速发型过敏反应。这一新指南发表在《儿科杂志》3月刊上。《指南》发布的疾病管理内容中有争议的部分包括剂量选择、开出自我注射剂处方的适应症、注射肾上腺素的时机。
"Anaphylaxis is a severe, potentially fatal systemic allergic reaction that is rapid in onset and may cause death," write Scott H. Sicherer, MD, from the Section on Allergy and Immunology of the American Academy of Pediatrics, and colleagues. "Epinephrine is the primary medical therapy, and it must be administered promptly.... Prompt injection of epinephrine is nearly always effective in the treatment of anaphylaxis, and delayed injection of epinephrine is associated with poor outcomes including fatality."
“速发型过敏反应是一种严重的、潜在致死性全身性过敏反应”，来自美国小儿科学会过敏与免疫分会Scott H. Sicherer博士及其同事写道，“治疗首选肾上腺素，而且必须快速注射...，快速注射肾上腺素治疗速发型过敏反应几乎常常有效，延迟注射肾上腺素与包括死亡在内的不良预后相关。”
Anaphylaxis is usually mediated by an immunologic mechanism involving immunoglobulin E and resulting in sudden systemic release of mast-cell and basophil mediators including histamine and tryptase. Although there are many clinical presentations of anaphylaxis, respiratory compromise and cardiovascular collapse are of the greatest concern because they may be fatal.
速发型过敏反应通常是由包括免疫球蛋白E（IgE）在内的免疫机制介导，导致组织突然释放肥大细胞、嗜碱性细胞分泌的介质，包括组胺、类胰蛋白酶。虽然速发型过敏反应有许多临床表现，但因为呼吸窘迫、心血管虚脱可能致死，所以最受关注。
Many different triggers for anaphylaxis episodes have been identified, but food and insect stings are the most frequently reported triggers in the community setting, often necessitating emergency care plans for anaphylaxis occurring outside the hospital/medical setting.
已经明确了许多可引起速发型过敏反应的致敏原，但食物和虫叮咬是社区最常报道的两大触发因素，其引起的在医院或临床之外发生的速发型过敏反应常常需要急救处理。
Epinephrine is the mainstay of anaphylaxis therapy. Adjunctive therapy with antihistamines and, for those with asthma, inhaled selective ß2-adrenergic agonists, such as albuterol, may be helpful but cannot replace epinephrine.
肾上腺素是治疗速发型过敏反应的主要药物，抗组胺药及吸入选择性ß2肾上腺能阻滞剂（如沙丁胺醇）治疗哮喘等辅助治疗对患者有益但不能取代肾上腺素。
"Physicians should carefully instruct patients and families on the indications for, and the technique for using, self-injectable epinephrine," the authors write. "Prompt administration of epinephrine is clearly indicated for treatment of significant respiratory or cardiovascular symptoms of anaphylaxis, but considerable judgment is required in many actual or possible allergic reactions in which life-threatening symptoms have not yet developed but may develop. Previous guidelines have suggested that epinephrine should be administered promptly at the onset of symptoms after exposure to an allergen that had previously caused anaphylaxis and possibly even in the absence of symptoms if there was a known exposure to an allergen that previously caused anaphylaxis with cardiovascular collapse."
“医师应当向患者及其家属详细介绍可自我注射肾小腺素的适应症和使用技巧，”作者写道，“快速注射肾上腺素毫无疑问是治疗速发型过敏反应的呼吸或心血管症状的，但要求对很多真正的或可能的过敏反应中哪些还没有发展到危及生命症状但可能发展到危及生命作出大量判断。以前的《指南》已经建议暴露于曾经引起过速发型过敏反应的抗原后出现症状时就立即注射肾上腺素，如果是暴露于曾经引起伴心血管虚脱的过速发型过敏反应的已知抗原，即使没有出现症状，也要快速注射肾上腺素。”
After epinephrine injection for first-aid treatment of anaphylaxis, advanced care should be sought urgently by calling 911 (in the United States) or the equivalent for additional care and emergency transport to a hospital emergency department.
速发型过敏反应急救治疗注射肾上腺素后，需通过电话联系911（在美国）紧急寻求进一步治疗，或同等机构寻求继续治疗，以及急送至医院急诊部门。
Based primarily on anecdotal evidence, the recommended epinephrine dose for anaphylaxis in children is 0.01 mg/kg, not to exceed 0.30 mg. The preferred route of administration for first-aid treatment is intramuscular injection of epinephrine into the vastus lateralis of the lateral thigh, which allows early peak epinephrine concentration needed for effective management. Intravenous administration of epinephrine carries increased risks for dilution errors and dosing errors, which may lead to overdose and adverse effects such as cardiac dysrhythmias.
主要根据经验证据，治疗儿童速发型过敏反应肾上腺素推荐剂量为0.01 mg/kg，不超过0.30 mg。紧急治疗时，首选部位是大腿外侧股外侧肌肌内注射肾上腺素，这就能及早达到有效治疗所需的肾上腺素浓度峰值。血管内注射肾上腺素增加了稀释误差与剂量误差风险，这可能导致过量及如心律失常之类的作用。
Epinephrine autoinjectors are currently available in only 2 fixed doses: 0.15 and 0.30 mg. On the basis of most recent, but somewhat limited data, the guidelines recommend using autoinjectors with 0.15 mg of epinephrine for otherwise healthy young children weighing 10 to 25 kg (22 - 55 lb) and autoinjectors with 0.30 mg of epinephrine for those weighing 25 kg (55 lb) or more. However, specific clinical circumstances also must be considered in these decisions.
目前可用的自动注射肾上腺素制剂仅有2种固定剂量：0.15 and 0.30 mg。基于最新近的、但有点局限的资料，《指南》推荐体重在10-25kg(22-55lb)的健康年幼儿童使用0.15mg的肾上腺素自动注射制剂 ，体重在 0.30 mg（55lb）或以上的使用0.3mg的肾上腺素自动注射制剂.但是，在作出这些决定时也必须考虑特殊临床情况。
"The lack of additional autoinjector doses is a serious concern," the authors write. "Nevertheless, pediatricians are advised to prescribe the optimal dose from an autoinjector for each child, even when that dose cannot possibly be precisely 0.01 mg/kg.... For children who weigh less than 10 kg (22 lb), the physician and family should weigh the risks of delay in dosing and dosing errors when an ampule/syringe/needle is used against accepting nonideal autoinjector doses, taking into consideration the specific health needs of the individual child and abilities of the caregivers."
“附加剂量的缺乏受到密切关注，”作者写道，“不过，即使不能按0.01 mg/kg精确计算剂量时，仍建议儿科医师为每个儿童开出自动注射剂最优剂量...，对于体重轻于10kg(22lb)的儿童，考虑到儿童个体特殊健康需求及家庭护理人员的能力，当使用的安瓿、针头、注射器与接受非理想自动注射剂量不配套时，医师和家长应当权衡剂量延误及剂量误差风险。”
Effective care for individuals at risk for anaphylaxis mandates comprehensive management involving families, allergic children, schools, camps, and other youth organizations.
对于速发型过敏反应高危个体的有效护理要求全面共同管理，包括家庭、过敏儿童自己、学校、训练营及其他青少年组织。
Reducing the risk for anaphylaxis requires confirmation of the trigger, teaching the patient and family to avoid the relevant allergen, preparing an individualized written emergency anaphylaxis action plan, and educating supervising adults regarding how to recognize and treat anaphylaxis.
减少速发型过敏反应发病风险要求确认致敏原、教导患者及家属避免相关的过敏原、个体发生速发型过敏反应的紧急书面预案，以及培训监护成人有关怎样辨别和治疗速发型过敏反应。
Epinephrine should be prescribed for children who have experienced anaphylaxis who may re-encounter the trigger in the community. In some cases, self-injectable epinephrine should be prescribed for children who have not yet experienced anaphylaxis but who are at increased risk based on their specific trigger, comorbid conditions such as asthma, and/or limited ability to recognize anaphylaxis.
曾经历过速发型过敏反应的儿童可能在社区再次遇到致敏原，应当为其开出肾上腺素处方。在某些情况下，未经历过速发型过敏反应的儿童，但基于特殊致敏原、伴发疾病（如哮喘）和/或辨别速发型过敏反应有限能力，也应当为其开出可自动注射的肾上腺素处方。
"Optimally, evaluation by an allergy/immunology specialist with American Board of Allergy and Immunology or international equivalent certification should be obtained to confirm allergic triggers, to provide education on trigger avoidance, and to initiate specific preventive treatment (eg, venom-injection immunotherapy for insect-sting anaphylaxis)," the authors conclude. "Written emergency action plans and review of care plans in the child's medical home with specific responsibilities for school, child care, or camp personnel; families; and children are needed to ensure a safe environment for those at risk."
作者总结道，“最理想的情况是应当获得美国过敏反应及免疫医学委员或国际同等认证机构评估：证实引起过敏反应的致敏原，提供有关避免致敏原的教育，传授详细的预防治疗方法（如毒素注射免疫治疗虫虰咬引起的速发型过敏反应），紧急措施书面计划，家中儿童医疗护理计划的回顾，学校、儿童护理或训练营管理人员、家庭的特殊职责，以及必须确保那些高危儿童处于安全环境。”
All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless they are reaffirmed, revised, or retired at that time or earlier. The report states that the recommendations provided do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations may be appropriate based on individual circumstances.
来自美国小儿科学会的所有临床报告自动有效期为发布后的5年，除非重新发布、修订、5年后或更早时间里作废。报告声明其所推荐的建议不适用于例外的治疗过程或不能成为医学治疗标准。建立个体状况基础上的治疗可能是合适的。
Pediatrics. 2007;119:638-646.
《小儿科杂志》2007;119:638-646。
Clinical Context
临床背景
Anaphylaxis is a potentially life-threatening illness that can be confusing to both patient and clinician. Patients may overstate or understate their symptoms following a significant allergic reaction, making the diagnosis of anaphylaxis unclear. Generally, anaphylaxis requires the acute onset of symptoms involving the skin (hives, pruritis, flushing), respiratory system (dyspnea, wheeze, stridor), or cardiovascular system (hypotonia, syncope). One set of criteria for the diagnosis of anaphylaxis also includes possible gastrointestinal symptoms, including crampy abdominal pain and vomiting.
速发型过敏反应是潜在危及生命的疾病，一直困扰患者及临床医师。患者可能夸大或缩小因明显过敏反应引起的症状，使速发型过敏反应诊断不明确。总之，诊断速发型过敏反应要求有急性出现症状包括皮肤（麻疹、搔痒、发红）、呼吸系统（呼吸困难、气急、喘鸣）、或心血管系统（肌张力减退、晕厥）。速发型过敏反应一套诊断标准也包括可能出现的腹部绞痛及呕吐等胃肠道症状。
Epinephrine is critical to rapidly improve the course of anaphylaxis. The current review examines the use of epinephrine as first-aid treatment of anaphylaxis in children outside of the healthcare setting.
肾上腺素能够快速紧急改善速发型过敏反应过程。目前文献确定肾上腺素是卫生保健单位外的儿童速发型过敏反应急救治疗药物。
Study Highlights
学习重点
An intramuscular injection into the vastus lateralis muscle of the lateral thigh is the best route of administration of epinephrine. This type of injection produces peak plasma epinephrine concentrations in 8 minutes compared with 34 minutes after subcutaneous injection into the deltoid region. Intravenous epinephrine should be reserved for patients who do not improve with intramuscular epinephrine.
大腿外侧股外侧肌肌内注射肾上腺素是最佳注射部位，8分钟内就可达到血浆肾上腺素浓度峰值，与之相比，三角肌区皮下注射需要34分钟才能达到。肌内注射肾上腺素后不能缓解的患者应当静脉注射肾上腺素。
The standard needle length on the autoinjector is a half inch, which may not be sufficient to reach the muscle in obese adolescents.
自动注射剂标准针头长度为半英寸，这对于肥胖青少年不足以注射到肌肉内。
The dose of epinephrine should be 0.01 mg/kg, up to a maximum of 0.30 mg. This presents a dilemma for clinicians in that the prefilled autoinjector kits use doses of only 0.15 and 0.30 kg, making the precise dosing of children and adolescents difficult if not impossible. While there is little direct evidence comparing one dose with another, the authors suggest the following dosing algorithm based on patient weight:
肾上腺素注射剂量应为 0.01 mg/kg，最大不超过0.30 mg。由于预装的自动注射装置使用剂量只有0.15和0.30 mg两种，这给医师带来两难境地，使确定儿童和青少年准确剂量是困难的，甚至是不可能的。由于几乎没有直接证据比较多种剂量，作者建议根据患者体重遵循下面的剂量换算规则：
10 kg or less: Consider use of ampule of epinephrine with needle and syringe to draw correct dose (0.01 mg/kg) of epinephrine. The main difficulties with this approach are timing and accuracy. One study demonstrated that parents required 142 seconds to draw a dose of 0.09 mL of epinephrine vs 52 seconds for clinicians. Moreover, the actual dose of epinephrine drawn by parents ranged between 0.004 and 0.151 mL.
10kg及以下：考虑使用肾上腺素安瓿，用注射器和针头抽吸肾上腺素正确剂量 (0.01 mg/kg)。这种方法的主要难点是抽吸时间及准确性。一项研究表明患者父母亲抽0.09ml剂量需142秒，而医师只要52秒。而且，父母亲抽吸的肾上腺素剂量波动范围在0.004至0.151ml之间。
10 to 25 kg: Autoinjection with 0.15 mg of epinephrine.
10至25kg：0.15mg的肾上腺素自动注射剂。
25 kg or more: Autoinjection with 0.30 mg of epinephrine.
25kg及以上：0.30mg的肾上腺素自动注射剂。
A second dose of epinephrine is required for anaphylaxis in up to 35% of cases. Epinephrine may be repeated 5 to 20 minutes after the initial dose.
35%的速发型过敏反应患者需要第二次注射肾上腺素。第一次注射后5至20分钟可重复注射肾上腺素。
Differentiating between a severe allergic reaction and anaphylaxis can be difficult, and patients should be instructed to err on the side of caution in terms of when to use their epinephrine.
很难区分严重过敏反应和速发型过敏反应，就使用肾上腺素的时机而言，应当教导患者父母亲小心驶得万年船。
All children with a history of anaphylaxis should be considered for treatment with epinephrine. In addition, children with acute generalized urticaria following an insect sting should receive epinephrine to use after future stings, as the risk for anaphylaxis with future stings is approximately 10%. Patients with a history of severe allergy and asthma also should be considered for epinephrine therapy, as should children with severe allergy who use nonselective β-blockers.
具有速发型过敏反应病史的所有儿童应当考虑用肾上腺素治疗。此外，虫虰咬后出现急性全身荨麻疹的儿童，因为将来虰咬出现速发型过敏反应的风险近10%，将来虰咬后应当使用肾上腺素。有严重过敏症和哮喘病史的父母亲，与有严重过敏症使用非选择性β受体阻滞剂的儿童一样，应当考虑肾上腺素治疗。
The epinephrine injection may be applied through clothing. Epinephrine should be kept away from extreme temperatures and direct sunlight to protect against drug degradation, and the solution will not necessarily appear different after degradation has occurred.
肾上腺素可以隔着衣服注射。肾上腺素应当保持远离极端温度和太阳直射，避免药物降解，降解发生后溶液外观并不一定显示有什么不同。
Possible transient adverse events associated with epinephrine administration include tremor, anxiety, and palpitations.
与注射肾上腺素相关的可能的短暂副作用包括震颤、焦虑和心悸。
Pearls for Practice
实践精华：
Symptoms of anaphylaxis may include hives, pruritis, flushing, dyspnea, wheeze, stridor, syncope, crampy abdominal pain, and vomiting.
速发型过敏反应可能包括麻疹、搔痒、皮肤发红、呼吸困难、气急、喘鸣、晕厥、腹部绞痛及呕吐。
Treatment of anaphylaxis in children weighing less than 10 kg consists of a needle and syringe to draw the correct dose (0.01 mg/kg) of epinephrine. Children who weigh between 10 and 25 kg should receive autoinjection with 0.15 mg of epinephrine, and children who weigh 25 kg or more may receive autoinjection with 0.30 mg of epinephrine.
儿童速发型过敏反应的治疗：体重10kg及以下的儿童使用注射器和针头抽吸肾上腺素正确剂量 (0.01 mg/kg);体重10 至25 kg的儿童使用 0.15mg的肾上腺素自动注射剂;体重25kg及以上的儿童使用0.30mg的肾上腺素自动注射剂。
编译： （共2818字）
2007年3月27日美国小儿科学会发布的临床报告推荐一项最佳治疗措施-----采用能自我注射肾上腺素急救社区儿童速发型过敏反应。这一新指南发表在《儿科杂志》3月刊上。《指南》发布的疾病管理内容中有争议的部分包括剂量选择、开出自我注射剂处方的适应症、注射肾上腺素的时机。
“速发型过敏反应是一种严重的、潜在致死性全身性过敏反应”，来自美国小儿科学会过敏与免疫分会Scott H. Sicherer博士及其同事写道，“治疗首选肾上腺素，而且必须快速注射...，快速注射肾上腺素治疗速发型过敏反应几乎常常有效，延迟注射肾上腺素与包括死亡在内的不良预后相关。”
速发型过敏反应通常是由包括免疫球蛋白E（IgE）在内的免疫机制介导，导致组织突然释放肥大细胞、嗜碱性细胞分泌的介质，包括组胺、类胰蛋白酶。虽然速发型过敏反应有许多临床表现，但因为呼吸窘迫、心血管虚脱可能致死，所以最受关注。
已经明确了许多可引起速发型过敏反应的致敏原，但食物和虫叮咬是社区最常报道的两大致敏原，在医院或临床之外，这两种致敏原引起的速发型过敏反应常常需要急救处理。
肾上腺素是治疗速发型过敏反应的主要药物，抗组胺药及吸入选择性ß2肾上腺能阻滞剂（如沙丁胺醇）治疗哮喘等辅助治疗对患者有益但不能取代肾上腺素。
“医师应当向患者及其家属详细介绍可自我注射肾小腺素的适应症和使用技巧，”作者写道，“快速注射肾上腺素毫无疑问能改善速发型过敏反应的呼吸或心血管症状，但要求对许多真正的或可能的过敏反应中哪些还没有发展到危及生命症状但可能发展到危及生命作出大量判断。以前的《指南》已经建议暴露于曾经引起过速发型过敏反应的抗原后出现症状时就立即注射肾上腺素，如果是暴露于曾经引起过伴心血管虚脱的速发型过敏反应的已知抗原，即使没有出现症状，也要快速注射肾上腺素。”
速发型过敏反应急救治疗注射肾上腺素后，需通过电话联系911（在美国）紧急寻求进一步治疗，或同等机构寻求继续治疗，以及急送至医院急诊部门。
主要根据经验证据，治疗儿童速发型过敏反应肾上腺素推荐剂量为0.01 mg/kg，不超过0.30 mg。紧急治疗时，首选部位是大腿外侧股外侧肌肌内注射肾上腺素，这就能及早达到有效治疗所需的肾上腺素浓度峰值。血管内注射肾上腺素增加了稀释误差与剂量误差风险，这可能导致药物过量及如心律失常之类的副作用。
目前可用的自动注射肾上腺素制剂仅有2种固定剂量：0.15 和 0.30 mg。基于最新近的、但有些局限的资料，《指南》推荐体重在10-25kg(22-55lb)的健康年幼儿童使用0.15mg的肾上腺素自动注射制剂 ，体重在 0.30 mg（55lb）或以上的使用0.3mg的肾上腺素自动注射制剂.但是，在作出这些决定时也必须考虑临床特殊情况。
“附加剂量的缺乏受到密切关注，”作者写道，“不过，即使不能按0.01 mg/kg精确计算剂量时，仍建议儿科医师为每个儿童开出自动注射剂最优剂量...，对于体重轻于10kg(22lb)的儿童，考虑到儿童个体特殊健康需求及家庭护理人员的能力，当使用的安瓿、针头、注射器与接受非理想自动注射剂量不配套时，医师和家长应当权衡剂量延误及剂量误差风险。”
对于速发型过敏反应高危个体的有效护理要求全面共同管理，包括家庭、过敏儿童自己、学校、训练营及其他青少年组织。
减少速发型过敏反应发病风险要求确认致敏原、教导患者及家属避免相关的过敏原、个体发生速发型过敏反应的紧急书面预案，以及培训监护成人关于辨别与治疗速发型过敏反应的方法。
曾经历过速发型过敏反应的儿童可能在社区再次遇到致敏原，应当为其开出肾上腺素处方。在某些情况下，未经历过速发型过敏反应的儿童，但基于特殊致敏原、伴发疾病（如哮喘）和/或辨别速发型过敏反应有限能力，也应当为其开出可自动注射的肾上腺素处方。
作者总结道，“最理想的情况是应当获得美国过敏反应及免疫医学委员或国际同等认证机构评估：证实引起过敏反应的致敏原，提供有关避免致敏原的教育，传授详细的预防治疗方法（如毒素注射免疫治疗虫虰咬引起的速发型过敏反应），紧急措施书面计划，家中儿童医疗护理计划的回顾，学校、儿童护理或训练营管理人员、家庭的特殊职责，以及必须确保那些高危儿童处于安全环境。”
来自美国小儿科学会的所有临床报告自动有效期为发布后的5年，除非重新发布、修订、5年后或更早时间里作废。报告声明其所推荐的建议不适用于所有的治疗过程，也不能作为医学治疗标准。患者可能适合个体化治疗。
附：《小儿科杂志》2007;119:638-646。
临床背景
速发型过敏反应是潜在危及生命的疾病，一直困扰患者及临床医师。患者可能夸大或缩小因明显过敏反应引起的症状，使速发型过敏反应诊断不明确。总之，诊断速发型过敏反应要求有急性出现症状包括皮肤（麻疹、搔痒、发红）、呼吸系统（呼吸困难、气急、喘鸣）、或心血管系统（肌张力减退、晕厥）。速发型过敏反应一套诊断标准也包括可能出现的腹部绞痛及呕吐等胃肠道症状。
肾上腺素能够快速紧急改善速发型过敏反应过程。目前文献确定肾上腺素是卫生保健单位外的儿童速发型过敏反应急救治疗药物。
学习重点
大腿外侧股外侧肌肌内注射肾上腺素是最佳注射部位，8分钟内就可达到血浆肾上腺素浓度峰值，与之相比，三角肌区皮下注射需要34分钟才能达到。肌内注射肾上腺素后不能缓解的患者应当静脉注射肾上腺素。
自动注射剂标准针头长度为半英寸，这对于肥胖青少年不足以注射到肌肉内。
肾上腺素注射剂量应为 0.01 mg/kg，最大不超过0.30 mg。由于预装的自动注射装置使用剂量只有0.15和0.30 mg两种，这使医师处于两难境地，很难确定儿童和青少年准确剂量，有时甚至是不可能的。由于几乎没有直接证据比较多种剂量，作者建议根据患者体重遵循下面的剂量换算法则：
10kg及以下：考虑使用肾上腺素安瓿，用注射器和针头抽吸肾上腺素正确剂量 (0.01 mg/kg)。这种方法的主要难点是抽吸时间及准确性。一项研究表明患者父母亲抽0.09ml剂量需142秒，而医师只要52秒。而且，父母亲抽吸的肾上腺素剂量波动范围在0.004至0.151ml之间。
10至25kg：0.15mg的肾上腺素自动注射剂。
25kg及以上：0.30mg的肾上腺素自动注射剂。
35%的速发型过敏反应患者需要第二次注射肾上腺素。第一次注射后5至20分钟可重复注射肾上腺素。
很难区分严重过敏反应和速发型过敏反应，就使用肾上腺素的时机而言，应当教导患者父母亲小心驶得万年船。
具有速发型过敏反应病史的所有儿童应当考虑用肾上腺素治疗。此外，虫虰咬后出现急性全身荨麻疹的儿童，因为将来虰咬出现速发型过敏反应的风险近10%，将来虰咬后应当使用肾上腺素。有严重过敏症和哮喘病史的父母亲，与有严重过敏症使用非选择性β受体阻滞剂的儿童一样，应当考虑肾上腺素治疗。
肾上腺素可以隔着衣服注射。肾上腺素保存应当远离极端温度和太阳直射，避免药物降解，降解发生后溶液外观并不一定显示有什么不同。
与注射肾上腺素相关的可能的短暂副作用包括震颤、焦虑和心悸。
实践精华：
速发型过敏反应可能包括麻疹、搔痒、皮肤发红、呼吸困难、气急、喘鸣、晕厥、腹部绞痛及呕吐。
儿童速发型过敏反应的治疗：体重10kg及以下的儿童使用注射器和针头抽吸肾上腺素正确剂量 (0.01 mg/kg);体重10 至25 kg的儿童使用 0.15mg的肾上腺素自动注射剂;体重25kg及以上的儿童使用0.30mg的肾上腺素自动注射剂。
Study Highlights
学习重点
研究重点是否更合适
恕我冒昧，
个人一点浅见，共同探讨一下
A clinical report by the American Academy of Pediatrics recommends best practices for administering self-injectable epinephrine for first-aid treatment of anaphylaxis in children in the community.
美国小儿科学会发布的临床报告推荐一项最佳治疗措施-----采用能自我注射肾上腺素急救社区儿童速发型过敏反应。
后半句“急救”的对象为“速发型过敏反应”，感觉似乎欠妥，是否急救的对象应为 儿童？
采用自行注射式肾上腺素治疗突发速发型过敏反应的社区儿童。
采用自行注射式肾上腺素紧急救治速发型过敏反应的社区儿童。
个人意见，仅供参考：
American Academy of Pediatrics
美国小儿科学会
美国儿科学会
recommends best practices for administering self-injectable epinephrine for first-aid treatment of anaphylaxis in children in the community.
推荐一项最佳治疗措施-----采用能自我注射肾上腺素急救社区儿童速发型过敏反应。
推荐选用可以自我注射的肾上腺素作为儿童在生活中发生过敏反应时的最佳急救措施之一。
Pediatrics
《儿科杂志》
《儿科学》杂志
Controversies in management addressed by these guidelines
《指南》发布的疾病管理内容中有争议的部分
在这些《指南》里，关于疾病治疗的内容中有争议之处
Prompt injection of epinephrine is nearly always effective in the treatment of anaphylaxis, and delayed injection of epinephrine is associated with poor outcomes including fatality."
快速注射肾上腺素治疗速发型过敏反应几乎常常有效，延迟注射肾上腺素与包括死亡在内的不良预后相关。
快速注射肾上腺素对于过敏反应几乎总是有效，而延迟注射肾上腺素则可能导致包括死亡在内的种种不良预后。
Anaphylaxis is usually mediated by an immunologic mechanism involving immunoglobulin E and resulting in sudden systemic release of mast-cell and basophil mediators including histamine and tryptase.
速发型过敏反应通常是由包括免疫球蛋白E（IgE）在内的免疫机制介导，导致组织突然释放肥大细胞、嗜碱性细胞分泌的介质，包括组胺、类胰蛋白酶。
过敏反应通常是通过包括免疫球蛋白E（IgE）在内的免疫机制引起。其结果是肥大细胞、嗜碱性粒细胞分泌的组胺、类胰蛋白酶等介质突然释放入血。
Although there are many clinical presentations of anaphylaxis, respiratory compromise and cardiovascular collapse are of the greatest concern because they may be fatal.
虽然速发型过敏反应有许多临床表现，但因为呼吸窘迫、心血管虚脱可能致死，所以最受关注。
尽管过敏反应的临床表现多种多样，然而由于可能会致命，其中最重要的还是呼吸障碍和循环系统功能衰竭。
Many different triggers for anaphylaxis episodes have been identified, but food and insect stings are the most frequently reported triggers in the community setting, often necessitating emergency care plans for anaphylaxis occurring outside the hospital/medical setting.
已经明确了许多可引起速发型过敏反应的致敏原，但食物和虫叮咬是社区最常报道的两大触发因素，其引起的在医院或临床之外发生的速发型过敏反应常常需要急救处理。
尽管目前已经明确了许多事物都可以引起过敏反应，但食物和虫叮咬仍是最常见的医院外致敏原，由其引起的在医院外发生的过敏反应常需急救处理。
Epinephrine is the mainstay of anaphylaxis therapy. Adjunctive therapy with antihistamines and, for those with asthma, inhaled selective ß2-adrenergic agonists, such as albuterol, may be helpful but cannot replace epinephrine.
肾上腺素是治疗速发型过敏反应的主要药物，抗组胺药及吸入选择性ß2肾上腺能阻滞剂（如沙丁胺醇）治疗哮喘等辅助治疗对患者有益但不能取代肾上腺素。
肾上腺素是治疗过敏反应的主要药物。抗组胺药及吸入选择性ß2肾上腺能阻滞剂（如沙丁胺醇）等辅助治疗对哮喘患者可能有益，但是不能替代肾上腺素。
Pediatrics. 2007;119:638-646.
《小儿科杂志》2007;119:638-646。
《儿科学》杂志2007年第119卷的第638-646页。
