cardiovascular / hemodynamic

Refractory Anaphylaxis / Anaphylactic Shock

Airway, bronchospastic or circulatory collapse not responding to initial anaphylaxis therapy.

CLINICAL ALGORITHMMedically Verified (2026-09-16)

Anaphylaxis: epinephrine first, airway early, escalate refractory shock

Level: Controlled React algorithm

Visual bedside algorithm

Anaphylaxis: epinephrine first, airway early, escalate refractory shock

Step 1 · Emergency

Epinephrine now

Give IM epinephrine 0.3–0.5 mg in the anterolateral thigh
Repeat every 5–15 minutes if airway, breathing or circulatory compromise persists
Call for help, position supine when tolerated and give oxygen

Step 2 · Treat

Airway + circulation

Remove the trigger when feasible and obtain IV access
Give crystalloid for hypotension with repeated reassessment
Progressive upper-airway edema requires early expert airway management with rescue front-of-neck access preparation

Step 3 · Assess / decide

Reassess the phenotype

Treat bronchospasm and ongoing hypoxemia in parallel
Look for persistent vasoplegia, myocardial dysfunction or an alternative diagnosis
Antihistamines and corticosteroids are adjuncts and must never delay epinephrine

Step 4 · Escalate / reassess

Refractory anaphylaxis

Use a monitored IV epinephrine infusion when repeated IM doses fail, commonly starting within 0.05–0.5 mcg/kg/min and titrating to response/local protocol
Consider glucagon in beta-blocked patients with resistant shock
Escalate vasopressor/critical-care support and monitor for biphasic recurrence according to severity

Bedside bottom line

IM epinephrine is first-line treatment. Antihistamines and steroids are adjuncts, not substitutes, and should never delay epinephrine.

Figure: Anaphylaxis: epinephrine first, airway early, escalate refractory shock. This action-focused visual summarizes the linked Clinical Problem; the full problem text, evidence references and local policy remain the source of truth.(Action pathway — use the full evidence-linked problem and local protocol for clinical decisions)

Recognize

Recognize anaphylaxis clinically; skin findings may be absent. Do not wait for tryptase.

Act now

Give repeated IM epinephrine, oxygen and crystalloid; secure an early expert airway if edema progresses. For persistent shock, use a monitored titrated IV epinephrine infusion.

Reassess

Reassess airway edema, bronchospasm, perfusion and epinephrine response; treat biphasic-risk patients with appropriate monitored observation.

Evidence status

Review metadata not yet recorded.

Status, review dates and guideline versions appear here once editorial metadata is authored for this content.

Actionable Clinical Workflows (16)

Step-by-step ICU Processes

Difficult Ventilator Weaning & Tracheostomy Workflow

From identifying weaning failure pathophysiology to progressive conditioning, tracheostomy timing (days 7–14), and speaking valve decannulation.

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Initial Hemodynamic Resuscitation & Shock Bundling

From recognizing hypoperfusion and initial crystalloid bolus to dynamic fluid responsiveness assessment and vasopressor targets.

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Vasopressor & Inotrope Initiation & Titration

From first-line norepinephrine titration to multi-agent vasopressor escalation and inotrope selection.

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Refractory Shock Support Escalation

From multi-vasopressor failure to rescue non-adrenergic agents and mechanical circulatory support.

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Deep-Dive Topic Destinations (3)

Reference Knowledge

Anaphylaxis & Refractory Anaphylactic Shockspecial-critical-care

Immediate epinephrine-first management of airway edema, bronchospasm, vasoplegia and refractory anaphylactic shock in the ICU.

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Shock: Foundational Critical Care Frameworkcardiovascular

Cellular dysoxia, DO2/VO2 physiology, the 4 shock phenotypes, dynamic fluid responsiveness (PLR/PPV) vs fluid tolerance (VExUS), and vasoactive pharmacology.

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Airway Management & Rapid Sequence Intubationprocedures

The 7 Ps of ICU intubation, the physiologically difficult airway, BOUGIE/DEVICE video laryngoscopy trials, hemodynamic optimization, waveform capnography, and scalpel-bougie cricothyroidotomy.

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