A no-delay pharmacology pathway for anaphylaxis: intramuscular epinephrine first, airway and fluid resuscitation in parallel, then carefully selected infusions/adjuncts for refractory shock or bronchospasm.
Give IM epinephrine promptly and repeat it when needed rather than waiting for antihistamines or steroids.
Escalate refractory shock to monitored IV epinephrine infusion and critical-care support.
Use glucagon as an adjunct in beta-blocked refractory shock—not as first-line therapy.
Use albuterol for persistent bronchospasm after epinephrine, not instead of epinephrine.
Recognize that corticosteroids and antihistamines are adjuncts and do not reliably prevent biphasic anaphylaxis.
Full diagnostic and resuscitation pathway.
Refractory shock pharmacology after initial epinephrine-centered care.
The table below is a selection framework. Open the individual monograph for exact dosing, preparation, renal/CRRT/IHD adjustment, interactions and evidence traceability.
ICU role: First-line life-saving alpha/beta agonist for anaphylaxis.
Monitor: Airway, BP, HR/rhythm, perfusion and response after each dose.
ICU role: Beta-receptor-independent cAMP agonist used as adjunct in beta-blocked refractory anaphylaxis.
Monitor: BP/HR, glucose and airway protection.
ICU role: Adjunct inhaled beta-2 bronchodilator.
Monitor: Air entry, HR, potassium/lactate with repeated high-dose therapy.
ICU role: Additional vasopressor for refractory vasodilatory shock after epinephrine-centered therapy.
Monitor: MAP, perfusion and limb/line safety.
ICU role: Non-adrenergic vasoconstrictor adjunct in refractory vasoplegia.
Monitor: MAP, perfusion, ischemia and sodium.
ICU role: Delayed anti-inflammatory adjunct in selected patients.
Monitor: Glucose and indication-specific adverse effects.
| Agent | ICU role | Why I choose it | Why I hesitate | What I monitor |
|---|---|---|---|---|
| Epinephrine Potent Alpha-1, Beta-1, and Beta-2 Adrenergic Agonist | First-line life-saving alpha/beta agonist for anaphylaxis. | ✓ Give IM immediately into the anterolateral thigh and repeat if airway/shock symptoms persist; use monitored IV infusion for refractory shock. | ✕ Do not delay for IV access, antihistamines, steroids or nebulizers. | Airway, BP, HR/rhythm, perfusion and response after each dose. |
| Glucagon Glucagon-Receptor Agonist / Emergency Antihypoglycemic | Beta-receptor-independent cAMP agonist used as adjunct in beta-blocked refractory anaphylaxis. | ✓ Consider when hypotension/bradycardia remain refractory despite appropriate epinephrine and fluids in a beta-blocked patient. | ✕ Vomiting and aspiration risk; not a replacement for epinephrine. | BP/HR, glucose and airway protection. |
| Albuterol (Salbutamol) Short-Acting Selective Beta-2 Adrenergic Agonist (SABA) | Adjunct inhaled beta-2 bronchodilator. | ✓ Persistent bronchospasm/wheeze after epinephrine and airway support. | ✕ Does not treat upper-airway edema or vasodilatory shock. | Air entry, HR, potassium/lactate with repeated high-dose therapy. |
| Norepinephrine Potent Alpha-1 & Beta-1 Inotrope / Vasopressor | Additional vasopressor for refractory vasodilatory shock after epinephrine-centered therapy. | ✓ Selected ICU anaphylactic shock with persistent vasoplegia despite epinephrine/fluid resuscitation. | ✕ Does not replace epinephrine's bronchodilator/mast-cell stabilizing effects. | MAP, perfusion and limb/line safety. |
| Vasopressin V1a & V2 Receptor Agonist / Non-Adrenergic Vasopressor | Non-adrenergic vasoconstrictor adjunct in refractory vasoplegia. | ✓ Selected catecholamine-refractory shock in an ICU setting. | ✕ Evidence is limited and it is never first-line anaphylaxis therapy. | MAP, perfusion, ischemia and sodium. |
| Hydrocortisone Short-Acting Glucocorticoid with Clinically Relevant Mineralocorticoid Activity | Delayed anti-inflammatory adjunct in selected patients. | ✓ May be considered for concomitant asthma, adrenal insufficiency or selected prolonged reactions after epinephrine-based resuscitation. | ✕ Slow onset; does not rescue acute airway edema or shock and should never delay epinephrine. | Glucose and indication-specific adverse effects. |
Why: Epinephrine is the first-line therapy for airway and cardiovascular anaphylaxis.
Why: Controlled infusion is safer and more titratable in refractory anaphylactic shock.
Why: Glucagon can increase cardiac cAMP independent of beta receptors but does not reproduce epinephrine's full anaphylaxis effect.
Why: Bronchodilation does not correct vasoplegia or upper-airway edema.
Recognition becomes selection, then organ-failure adjustment, competing physiology and senior-level prioritization.
Minutes after ceftriaxone: wheeze, urticaria, BP 78/42.
IM epinephrine immediately plus airway/oxygenation and IV fluids. Antihistamines/steroids are secondary adjuncts.
BP recovers after epinephrine but severe bronchospasm persists.
Continue anaphylaxis reassessment and add inhaled albuterol for residual bronchospasm; it is adjunctive, not a substitute for epinephrine.
Three IM epinephrine doses and 2 L crystalloid; MAP remains 52.
Escalate to monitored IV epinephrine infusion with ICU/airway support and continue evaluating for additional vasopressor need.
Carvedilol user remains hypotensive and bradycardic despite epinephrine infusion and fluids.
Consider IV glucagon as a beta-receptor-independent adjunct while continuing full anaphylaxis resuscitation.
Severe wheeze after contrast, no rash, BP falling, new vomiting and throat tightness.
Treat as anaphylaxis despite absent skin findings: IM epinephrine and shock/airway care. Skin findings are not required for severe anaphylaxis.
Potent direct alpha/beta agonist for anaphylactic shock, cardiac arrest, post-cardiac arrest shock, and refractory septic shock — powerful inotrope and bronchodilator with transient hyperlactatemia.
Raises plasma glucose through hepatic glycogenolysis and gluconeogenesis and increases cardiac cAMP independent of beta receptors. Used for severe hypoglycemia without IV access and as a specialist-guided adjunct in beta-blocker …
Rapid inhaled beta-2 agonist used as the primary bronchodilator for acute asthma/COPD bronchospasm; repeated or continuous ICU dosing can cause tachycardia, tremor, hypokalemia and lactate elevation.
Norepinephrine is the recommended first-line vasopressor for septic shock and is widely used for other vasodilatory shock states. In cardiogenic shock, vasopressor/inotrope selection depends on blood pressure, cardiac output and …
Non-adrenergic vasopressor used in vasodilatory shock and commonly added to norepinephrine in septic shock. Critical-care guidelines often use low fixed-dose infusions, whereas current U.S. Vasostrict labeling starts septic-shock…
Short-acting glucocorticoid with mineralocorticoid activity used in acute adrenal crisis and commonly used when corticosteroids are chosen for adult septic shock; current guidelines support corticosteroids in septic shock but do …
This Masterclass teaches selection and reasoning. Exact dosing, concentration, infusion preparation, renal/hepatic/RRT adjustment and monitoring must be checked in the linked medication monograph and the institution's current formulary/protocol. Local resistance patterns and regulatory drug availability can change faster than a static teaching page.