While recently experiencing eight incredible weeks of Emergency Medicine rotations, I was reviewing my approach to anaphylaxis. Coincidentally, there was a real case a few days later, and I found the following mnemonic useful. If you’re having trouble remembering the different components of management for adult cases of anaphylaxis in the emergency department, think of SAFE-BBOP!
This is not the exact order in which anaphylaxis should be approached, but it may facilitate memorizing commonly-used treatment modalities while learning and reviewing the general approach. The ABC algorithm should be applied first (see: https://iem-student.org/abc-approach-critically-ill/). Following the diagnosis of anaphylaxis, epinephrine should be administered promptly, as delayed administration has been associated with increased mortality (1-4).
S - Steroids
Prednisone 50mg PO or methylprednisolone 125mg IV. Glucocorticoids are theoretically used to prevent a possible biphasic reaction; however, there is limited evidence for this.
A - Antihistamines (H1 and H2)
Ranitidine 150mg PO/50mg IV, Diphenhydramine 25-50mg PO/IV. Their use is based on studies of urticaria and should only be used as an adjunct therapy.
F - Fluids
Normal saline or Ringer’s lactate 1-2 L IV.
B - Beta-blocked
If a patient is on a beta-blocker and is refractory to the administered epinephrine, consider glucagon 1-5mg slow IV bolus over 5mins, followed by an infusion at 5-15mcg/min, titrated to effect.
B - Bronchodilators
For persistent bronchospasm despite epinephrine, an inhaled bronchodilator can be considered, such as salbutamol 2.5-5mg nebulized or 4-8 puffs by MDI with spacer q20 mins x 3. This is based on studies of acute asthma exacerbation and should only be used as an adjunct therapy.
O - Oxygen
Every patient, who is critically ill, requires supportive oxygen treatment.
P - Positioning
Recumbent position with lower extremity elevation (consider left lateral decubitus position for pregnant patients to prevent inferior vena cava compression).
As for disposition considerations, the SAFE system below was introduced by Lieberman et al. (2007) to recognize the four basic actions to address with patients prior to discharge from the emergency department (5).
- Seek support
- Allergen identification and avoidance
- Follow-up for specialty care
- Epinephrine for emergencies
- Prince, B.T., Mikhail, I., & Stukus, D.R. (2018). Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. J Asthma Allergy, 11, 143-151.
- Sheikh, A., Shehata, Y., Brown, S.G., & Simons, F.E. (2009). Adrenaline for the treatment of anaphylaxis: Cochrane systematic review. Allergy, 64(2), 204.
- Simons, F.E. (2008). Emergency treatment of anaphylaxis. BMJ, 336(7654), 1141.
- McLean-Tooke, A.P., Bethune, C.A., Fay, A.C., & Spickett, G.P. (2003). Adrenaline in the treatment of anaphylaxis: what is the evidence? BMJ, 327, 1332.
- Lieberman, P.,Decker, W., Camargo, C.A. Jr., Oconnor, R., Oppenheimer, J., & Simons, F.E. (2007). SAFE: a multidisciplinary approach to anaphylaxis education in the emergency department. Ann Allergy Asthma Immunol 98(6), 519-23.
- Rosen’s Emergency Medicine: Concepts and Clinical Practice – 8th ed, 2014; Chapter 109. The World Allergy Organization Journal 2011, 4(2), 13-37.
- Campbell, R.L., & Kelso, J.M. (2019). Anaphylaxis: Emergency treatment. In A. M. Feldweg, UpToDate. Retrieved November 21, 2019, from https://www.uptodate.com/contents/anaphylaxis-emergency-treatment.
- Fanta, C.H. (2019). Acute exacerbations of asthma in adults: Emergency department and inpatient management. In H. Hollingsworth, Retrieved November 21, 2019, from