2017 Sep-Oct;5(5):1194-1205. doi: 10.1016/j.jaip.2017.05.022. Replace epinephrine before its expiration date, or it might not work properly. peel police collective agreement 2020 peel police collective agreement 2020 2022 May 28;10(6):1260. doi: 10.3390/biomedicines10061260. Sensitive persons may have similar reactions to NSAIDs antigenically unrelated to aspirin and must take only acetaminophen for mild pain or fever. Administer epinephrine 1:1,000 (weight-based) (adults: 0.01 mL per kg, up to a maximum of 0.2 to 0.5 mL every 10 to 15 minutes as needed; children: 0.01 mL per kg, up to a maximum dose of 0.2 to 0.5 mL) by SC or IM route and, if necessary, repeat every 15 minutes, up to two doses). FOIA The site may be gently massaged to facilitate absorption. The result is symptoms such as vomiting or swelling. IV glucocorticosteroids should be administered every 6 hours at a dosage equivalent to 1 to 2 mg/kg/day. J Allergy Clin Immunol Pract. These protocols include materials for educating teachers, office workers, and kitchen staff in the prevention and treatment of anaphylaxis. Immediate Hypersensitivity Reactions Induced by COVID-19 Vaccines: Current Trends, Potential Mechanisms and Prevention Strategies. In our previous version we searched the literature until September 2009. Treat hypotension with IV fluids or colloid replacement, and consider use of a vasopressor such as dopamine (Intropin). The use of normal IV saline also is recommended. A patient with a history of anaphylaxis should be instructed on how to initiate treatment for future episodes using pre-loaded epinephrine syringes. Look for pale, cool and clammy skin; a weak, rapid pulse; trouble breathing; confusion; and loss of consciousness. 17, Antihistamines (H1 and H2 antagonists) are often used as adjunctive therapy for anaphylaxis. Symptom onset varies widely but generally occurs within seconds or minutes of exposure. Lee SE. Self-Injectable Epinephrine for First-Aid Management of Anaphylaxis. Try to stay away from your allergy triggers. Your provider might ask you questions about previous allergic reactions, including whether you've reacted to: Many conditions have signs and symptoms similar to those of anaphylaxis. More PubMed results on management of anaphylaxis. Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may result in death. Optimal management of anaphylaxis is avoidance of known triggers, but if a reaction occurs, being prepared is crucial to successful treatment and preventing. Latex allergy has become a significant problem since the widespread adoption of universal precautions against infection. Patients with a history of allergies should avoid known allergens and be reminded to always read the labels of medications and food products. Some people have allergic reactions without any known exposure to common allergens. Written instructions should be given. Bethesda, MD 20894, Web Policies The best way to manage asthma is to avoid triggers, take medications to prevent symptoms, and prepare to treat asthma episodes if they occur. Accessed Nov. 20, 2016. The reaction typically occurs without warning and can be a frightening experience both for those at risk and their families and friends. Clin Pediatr(Phila). Consider vasopressor infusion for hypotension refractory to volume replacement and epinephrine injections. 2013 May;52(5):451-61. https://www.uptodate.com/contents/search. Epub 2015 Mar 25. eCollection 2022. The Sakine IA * k1, Sule SOUND zmen Caglayan1, Suna Asilsoy2 Nevin Uzuner2 and zkan Karaman2 1Department of Pediatric Allergy and . Mehr S, Liew WK, Tey D, Tang ML. Expert: Infusion Pharmacy Technicians Can Reduce Workload in Oncology Pharmacy, Clinical Forum Recap Data Show Melanoma Site to Be Independent High-Risk Factor for Recurrence, Poor Outcomes, E-Pedigree: An Inevitability for the Industry, CCPA Speaks Out: Obama's Health Care Reform Offers Opportunities for Pharmacy. https://www.aaaai.org/Conditions-Treatments/allergies/anaphylaxis Accessed June 27, 2021. Penicillin skin testing includes major and minor determinants; the minor determinants are more predictive of future anaphylactic events. Clipboard, Search History, and several other advanced features are temporarily unavailable. Atropine may be given for bradycardia (0.3 to 0.5 mg intramuscularly or subcutaneously every 10 minutes to a maximum of 2 mg). eCollection 2015. It is commonly triggered by a food, insect sting, medication, or natural rubber latex. Their benefit is not realized for six to 12 hours after administration, so their primary role may be in prevention of recurrent or protracted anaphylaxis. 1. Anaphylaxis must be treated right away to provide the best chance for improvement and prevent serious, potentially life-threatening complications. Epub 2021 Dec 31. It is commonly triggered by a food, insect sting, medication, or natural rubber latex. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) may produce a range of reactions, including asthma, urticaria, angioedema, and anaphylactoid reactions. sneezing and stuffy or runny nose. Pingback: Previous entries relevant to 02/23/18 MR | Pediatric Focus. glucocorticosteroid vs albuterol for anaphylaxis. It is caused by a rapid immunoglobulin Emediated immune release of mediators from tissue mast cells and peripheral blood basophils, characterized by cardiovascular collapse, respiratory compromise, and cutaneous and gastrointestinal (GI) symptoms.1-4, A severe allergic reaction that is the result of exposure to a food, insect sting, medication, or physical factor, anaphylaxis was first recognized in 1902 and is considered to be both a serious and bewildering condition. Although isoproterenol may be able to overcome depression of myocardial contractility caused by beta blockers, it also may aggravate hypotension by inducing peripheral vasodilation and may induce cardiac arrhythmias and myocardial necrosis. From the Publisher: Economic Impact on Pharmacy Patients, www.epipen.com/anaphylaxis_whatis.aspx#stats, www.mdconsult.com/das/book/body/119041677-2/0/1621/383.html, http://emedicine.medscape.com/article/756150-overview, www.mdconsult.com/das/book/body/118764067-3/799184944/1365/534.html#4-u1.0-B0-323-02845-4..50172-4--cesec63_8572, www.twinject.com/downloads/twinject_Prescribing_Information.pdf, http://emedicine.medscape.com/article/135065-overview. For patients with a history of idiopathic anaphylaxis or asthma, and patients who experience severe or prolonged anaphylaxis, consider the use of systemic glucocorticosteroids. Do corticosteroids prevent biphasic anaphylaxis? It is important to note that because these agents have a much slower onset of action than epinephrine, they should never be administered alone as a treatment for anaphylaxis.15,16, Diphenhydramine is approved by the FDA for treatment of anaphylaxis, and IV administration provides faster onset of action.15 It blocks the effects of released histamine at the H1 receptor, therefore treating flushing, urticarial lesions, vasodilatation, and smooth muscle contraction in the bronchial tree and GI tract. The practice of using corticosteroids to treat anaphylaxis appears to have derived from management of acute asthma and croup. Do Corticosteroids Prevent Biphasic Anaphylaxis? In this version we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (Ovid) (1956 to September 2011), EMBASE (Ovid) (1982 to September 2011), CINAHL (EBSCOhost) (to September 2011). Campbell RL, et al. Systematic reviews of these prophylactic approaches undertaken in patients being investigated with iodinated contrast media and treated with snake anti-venom therapy have found routine prophylaxis to be of questionable value. Disclaimer. Steroids (glucocorticoids) are often recommended for use in the management of people experiencing anaphylaxis. Approximately 2% of patients with anaphylaxis potentially benefitted from a 24-hour period of observation after symptoms had resolved.. Emergency department visits for food allergy in Taiwan: a retrospective study. Desensitization carries a risk of anaphylaxis and should be performed by experienced persons in a well-equipped location. Because of their clinical similarities, the term anaphylaxis will be used to refer to both conditions. We use cookies to improve your experience on our site. These products only should be injected into the anterolateral aspect of the thigh.12,13 The epinephrine autoinjectors should not be injected into the buttock or injected intravenously.12,13 Patient education is crucial to preventing the incidence of anaphylaxis, and patients need to be aware of proper administration, storage, and handling. Continuous hemodynamic monitoring is important. redness, hives, or rash. You must seek medical care. American Academy of Pediatrics Web site. In: RS Porter, TV Jones, eds. Having a potentially life-threatening reaction is frightening, whether it happens to you, others close to you or your child. lightheadedness. We found an overall incidence of biphasic reactions of 6%, and an incidence of significant biphasic reactions of 3%, among pediatric patients admitted with anaphylaxis. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses. Choo KJ, Simons FE, Sheikh A. Glucocorticoids for the treatment ofanaphylaxis. Clin Exp Emerg Med. It should be released every five minutes for at least three minutes, and the total duration of tourniquet application should not exceed 30 minutes. If anaphylaxis is caused by an injection, administer aqueous . Patients should be observed for delayed or protracted anaphylaxis and instructed on how to initiate urgent treatment for future episodes. Epub 2013 Nov 20. 2014;113:599-608. Our community is here for you 24/7. An allergy occurs when the bodys immune system sees something as harmful and reacts. We were unable to find any randomized controlled trials on this subject through our searches. DOI: 10.1002/14651858.CD007596.pub3, Copyright 2023 The Cochrane Collaboration. If severe hypotension is present, epinephrine may be given as a continuous intravenous infusion. National Library of Medicine A single copy of these materials may be reprinted for noncommercial personal use only. Clinical predictors for biphasic reactions inchildren presenting with anaphylaxis. result from sudden release of multiple mediators, with broad classification of anaphylaxis being subdivided into immunological causes (i.e. Epinephrine is the drug of choice for acute reactions and the only medication shown to be lifesaving when administered promptly, but it is underutilized. Management of anaphylaxis: a systematic review. Epinephrine is the most effective treatment for anaphylaxis. Albuterol may cause serious allergic reactions, including anaphylaxis, which can be life-threatening and require immediate medical attention. Change), You are commenting using your Twitter account. Ann Allergy Asthma Immunol. Unable to load your collection due to an error, Unable to load your delegates due to an error. The rationale is to reduce the risk of recurring or protracted anaphylaxis. Therefore, we can neither support nor refute the use of these drugs for this purpose.. Epub 2019 Apr 26. Indeed, as you point out, the use of corticosteroids in anaphylaxis has been called into question. Created 7/31/13; reviewed 5/5/14 (no changes); updated 08/04/15. Glucocorticosteroids are often used in the management of anaphylaxis in an attempt to reduce the severity of the acute reaction and decrease the risk of biphasic/protracted reactions. Anaphylaxis. and transmitted securely. Adults should be given approximately 50 percent of this dose initially. Developing an anaphylaxis emergency action plan can help put your mind at ease. Routine premedication with glucocorticosteroids in patients receiving iodinated contrast media, snake anti-venom therapy or allergen immunotherapy is unlikely to confer clinical benefit. The most common triggers of anaphylaxis areallergens. Vega-Rioja A, Chacn P, Fernndez-Delgado L, Doukkali B, Del Valle Rodrguez A, Perkins JR, Ranea JAG, Dominguez-Cereijo L, Prez-Machuca BM, Palacios R, Rodrguez D, Monteseirn J, Ribas-Prez D. Front Immunol. 2019 Sep-Oct;7(7):2232-2238.e3. 3,11 Cutaneous symptoms, such as urticaria and angioedema, are the most common. airway) Look for cardiac causes (JVD, pedal edema, ascites) Tachycardia, anxiety . Pharmacists also should supply patients with written instructions to reinforce proper use. Individuals who are at risk for anaphylaxis or have a history of reactions are typically prescribed an epinephrine autoinjector for IM injection such as EpiPen, EpiPen Jr (Dey L.P.), or Twinject (Sciele Pharma Inc) for the emergency treatment of anaphylaxis.12,13 Patients should be encouraged to carry these autoinjectors with them at all times in case of a reaction. Use an epinephrine autoinjector, if available, by pressing it into the person's thigh. National Library of Medicine Patients receiving intravenous epinephrine require cardiac monitoring because of potential arrhythmias and ischemia. Consultation with an allergist can help (1) confirm the diagnosis of anaphylaxis; (2) identify the anaphylactic trigger through history, skin testing, and RAST; (3) educate the patient in the prevention and initial treatment of future episodes; and (4) aid in desensitization and pretreatment when indicated. Dosing for the pediatric population is 5 mg/kg/day in divided doses 3 to 4 times a day, not to exceed 300 mg/day.15, H2RAs, such as ranitidine and cimetidine, block the effects of released histamine at H2 receptors, therefore treating vasodilatation and possibly some cardiac effects, as well as glandular hypersecretion.15, Some research suggests that H2 blockers with H1 blockers have additive benefit over H1 blockers alone in treating anaphylaxis.6,15,16 Ranitidine is probably preferred over cimetidine in anaphylaxis, because of the risk for hypotension with rapidly infused cimetidine and the multiple, complex drug interactions associated with the drug.15 Cimetidine should not be administered to children with anaphylaxis, because dosages have not been established.15,16. According to the practice parameter update and another recent review, the evidence that corticosteroids reduce or prevent biphasic reactions is weak. Oral administration of glucocorticosteroids (eg, prednisone, 0.5 mg/kg) might be sufficient for less critical anaphylactic reactions. daisy yellow color flower; nfl players on steroids before and after; trailers for rent in globe, az New Service; 2017; doi:10.1016/j.otc.2017.08.013. In general, diphenhydramine is given at a dose of 10 to 50 mg IV/IM every 4 hours as needed.15 The IV rate should not exceed 25 mg/min, and should not exceed 400 mg/day.15 For milder cases, oral dosing for adults is recommended at 25 to 50 mg every 6 to 8 hours, not to exceed 400 mg/day. Your immune system tries to remove or isolate the trigger. Practical Management of Patients with a History of Immediate Hypersensitivity to Common non-Beta-Lactam Drugs. Accessed June 27, 2021. The dosage of glucagon is 1 to 5 mg (20-30 mcg/kg [maximum dose of 1 mg] in children) administered intravenously over 5 minutes and followed by an infusion (5-15 mcg/ min) titrated to clinical response. After reviewing the published evidence, the authors state that the use of corticosteroids has no role in the acute management of anaphylaxis. (LogOut/ [ corrected] The following regimen is reasonable: 1:10,000 (100 mcg per mL) epinephrine at 1 mcg per minute, increased to 10 mcg per minute as needed. Otolaryngology Clinics of North America. Identifying and. Medical offices in which the occurrence of anaphylaxis is likely should consider periodic anaphylaxis drills. Indeed, as you point out, the use of corticosteroids in anaphylaxis has been called into question. Anaphylaxis is a life-threatening reaction with respiratory, cardiovascular, cutaneous, or gastrointestinal manifestations resulting from exposure to an offending agent, usually a food, insect sting, medication, or physical factor. An official website of the United States government. They also reviewed 22 studies that specifically addressed the association of corticosteroids with biphasic anaphylaxis and only 1 study suggested a beneficial effect. Emergency department diagnosis and treatment of anaphylaxis. The physician's primary tool is a detailed history of recent exposures to foods, medications, latex, and insects known to cause anaphylaxis. Anaphylaxis: Acute diagnosis. MeSH AAFA is dedicated to improving the quality of life for people with asthma and allergic diseases. Anaphylaxis: Emergency treatment. Consider desensitization if available. However, the evidence base in support of the use of steroids is unclear. By continuing to browse this site, you are agreeing to our use of cookies. A Clinical Practice Guideline for the Emergency Management of Anaphylaxis (2020). There was no consensus on whether corticosteroids reduce biphasic anaphylactic reactions. sounds (upper vs lower. Anaphylaxis. People with asthma often have allergies as well. government site. Avoid administering cross-reactive agents. Patients should have ready access to 2 doses of an epinephrine autoinjector, with thorough training regarding correct use of a given device and an emergency action plan. Protocols for use in schools to manage children at risk of anaphylaxis are available through the Food Allergy Network. All Rights Reserved. Objectives: We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis. Anaphylaxis is a potentially fatal, systemic immediate hypersensitivity reaction involving multiorgan systems. We therefore conducted a systematic review of the literature, searching key databases for high quality published and unpublished material on the use of steroids for the emergency treatment of anaphylaxis. The report notes that the time to onset of corticosteroid effect is too slow to prevent severe outcomes, such as cardiorespiratory arrest or death, which tend to occur within 5-30 minutes for allergens such as medications, insect stings and foods. (LogOut/ Epinephrine Epinephrine is the first and most important treatment for anaphylaxis, and it should be administered as soon as anaphylaxis is recognized to prevent the progression to life-threatening symptoms as described in the rapid overviews of the emergency management of anaphylaxis in adults ( table 1) and children ( table 2 ). An allergy occurs when the bodys immune system sees a substance as harmful and overreacts to it. Anaphylaxis: Confirming the diagnosis and determining the cause(s). Jeste tutaj: tears from a star tupac san juan hills football live kankakee daily journal homes for rent glucocorticosteroid vs albuterol for anaphylaxis. Your doctor may tell you to see an allergist An allergist can help you identify your allergies and learn to manage your risk of severe reactions, Ask your doctor for an anaphylaxis action plan. The patient must be told to seek immediate professional help regardless of initial response to self-treatment. Glucocorticosteroid vs albuterol for anaphylaxis. In 2007, the American Academy of Pediatrics released guidelines on the treatment of anaphylaxis which stated that on the basis of limited data, children who are healthy and weigh 22 to 55 lb (10-25 kg) can be given 0.15 mg of epinephrine, and those who weigh .55 lb can receive 0.30 mg. Peavy RD, Metcalfe DD. Mol Biomed. During an anaphylactic attack, you can give yourself the drug using an autoinjector. At discharge, the patient should be told to return for any recurrent symptoms. All patients with anaphylaxis should be monitored for the possibility of recurrent symptoms after initial resolution.5,6 An observation period of two to six hours after mild episodes, and 24 hours after more severe episodes, seems prudent. Patients with a history of anaphylactic reactions should be encouraged to wear Medic Alert bracelets indicating known allergies. Gastrointestinal manifestations (e.g., nausea, vomiting, diarrhea, abdominal pain) and cardiovascular manifestations (e.g., dizziness, syncope, hypotension) affect about one third of patients. Osteoporosis due to a suppression of the body's ability to absorb calcium. We teach the general public about asthma and allergic diseases. Some persons may react just by handling the culprit food. Biphasic anaphylactic reactions in pediatrics. In this procedure, the patient is exposed to gradually increasing amounts of antigen, usually via intradermal, then subcutaneous, then intravenous routes. Oxygen administration is especially important in patients who have a history of cardiac or respiratory disease, inhaled b2-agonist use, and who have required multiple doses of epinephrine. Glucocorticoids for the treatment of anaphylaxis Anaphylaxis is a serious allergic reaction that is rapid in onset and may result in death. : CD007596. Anaphylaxis: Emergency treatment. swelling of your face, lips, or throat. HHS Vulnerability Disclosure, Help Why not use albuterol for anaphylaxis. Also, make sure the people closest to you know how to use it. Alternatively, serum tryptase levels peak 60 to 90 minutes after onset of anaphylaxis and remain elevated for up to five hours. Anaphylaxis [anna-fih-LACK-sis] is a serious allergic reaction that is rapid in onset and may cause death. FOIA Clipboard, Search History, and several other advanced features are temporarily unavailable. Art. This site complies with the HONcode standard for trustworthy health information: verify here. These patients may have resistant severe hypotension, bradycardia, and a prolonged course. Anaphylaxis guidelines recommend glucocorticoids for the treatment of people experiencing anaphylaxis. Copyright 2003 by the American Academy of Family Physicians. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. eCollection 2018. Treat bronchospasm, preferably with a beta II agonist given intermittently or continuously; consider the use of aminophylline, 5.6 mg per kg, as an IV loading dose, given over 20 minutes, or to maintain a blood level of 8 to 15 mcg per mL. It is commonly triggered by a food, insect sting, medication, or natural rubber latex. If you react to insect stings or exercise, talk to your doctor about how to avoid these reactions. RAST checks in vitro for the presence of IgE to antigen and carries no risk of anaphylaxis. The primary action of glucocorticoids is down-regulation of the late-phase eosinophilic inflammatory response, as opposed to the early-phase response. An official website of the United States government. Laboratory testing may help if the diagnosis of anaphylaxis is uncertain. Conn's Current Therapy 2008. Prevention of future episodes is vital (Table 6). The initial management of anaphylaxis includes a focused examination, procurement of a stable airway and intravenous access, and administration of epinephrine.2,10 [Evidence level C, consensus and expert opinion] Vital signs and level of consciousness should be documented. Epinephrine is the most effective treatment for anaphylaxis. Albuterol inhaler. Symptoms usually involve more than one organ system (part of the body), such as the skin or mouth, the lungs, the heart, and the gut. Krause RS. Kelso JM. Persistent respiratory distress or wheezing requires additional measures. You might be given a blood test to measure the amount of a certain enzyme (tryptase) that can be elevated up to three hours after anaphylaxis, You might be tested for allergies with skin tests or blood tests to help determine your trigger. As anaphylaxis is a medical emergency, there are no randomized controlled clinical trials on its emergency management. Refer to allergist if causative agent or diagnosis is unclear, if in-depth patient education is needed, or if reactions are recurrent. Although glucocorticosteroids typically are not helpful acutely because they may have no effect for 4 to 6 hours (even when administered intravenously), their use may prevent recurrent or protracted anaphylaxis. Should steroids be used for anaphylaxis after the COVID-19 vaccine? In addition, we contacted experts in this health area and the relevant pharmaceutical companies. We also searched the UK National Research Register and websites listing ongoing trials, and contacted international experts in anaphylaxis in an attempt to locate unpublished material. Glucocorticosteroids are often used in the management of anaphylaxis in an attempt to reduce the severity of the acute reaction and decrease the risk of biphasic/protracted reactions. Use your epinephrine auto-injector first (it treats both anaphylaxis and asthma), Then use your asthma quick-relief inhaler (such as albuterol), Call 911 and go to the hospital by ambulance. If an intravenous line cannot be established, the intramuscular dose can be injected into the posterior one third of the sublingual area, or the intravenous dose may be injected into an endotracheal tube. Recent findings: Additional measures then may be individualized.2,10 [Evidence level C, consensus and expert opinion] To slow absorption of injected antigens (e.g., insect stings), a tourniquet may be placed proximal to the injection site. Your provider might want to rule out other conditions. Two strengths are available: 0.3 mL of 1:1,000 epinephrine for adults, and 0.3 mL of 1:2,000 for children. We found no studies that satisfied the inclusion criteria. 2013 Jun;13(3):263-7. Like antihistamines, there is concern regarding inappropriate use as first-line therapy instead of epinephrine.. Eight to 17 percent of health care workers experience some form of allergic reaction to latex, although not all of these reactions are anaphylaxis.12 Recognizing latex allergy is critical because physicians may inadvertently expose the patient to more latex during treatment. Currently, anaphylaxis has no universally accepted definition, and consensus, diagnostic criteria, and a clear understanding of its underlying pathophysiology are lacking.4,5, Because anaphylaxis is a medical emergency that requires immediate recognition and intervention, health care professionals need to be aware of preventive measures and able to recognize its signs to ensure that the patient is treated both promptly and appropriately. We planned to include randomized and quasi-randomized controlled trials comparing glucocorticoids with any control (either placebo, adrenaline (epinephrine), an antihistamine, or any combination of these). Shaker MS, Wallace DV, Golden DBK, Oppenheimer J, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Greenhawt M, Khan DA, Lang DM, Lang ES, Lieberman JA, Portnoy J, Rank MA, Stukus DR, Wang J; Collaborators; Riblet N, Bobrownicki AMP, Bontrager T, Dusin J, Foley J, Frederick B, Fregene E, Hellerstedt S, Hassan F, Hess K, Horner C, Huntington K, Kasireddy P, Keeler D, Kim B, Lieberman P, Lindhorst E, McEnany F, Milbank J, Murphy H, Pando O, Patel AK, Ratliff N, Rhodes R, Robertson K, Scott H, Snell A, Sullivan R, Trivedi V, Wickham A; Chief Editors; Shaker MS, Wallace DV; Workgroup Contributors; Shaker MS, Wallace DV, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Golden DBK, Greenhawt M, Lieberman JA, Rank MA, Stukus DR, Wang J; Joint Task Force on Practice Parameters Reviewers; Shaker MS, Wallace DV, Golden DBK, Bernstein JA, Dinakar C, Ellis A, Greenhawt M, Horner C, Khan DA, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wang J. J Allergy Clin Immunol.
glucocorticosteroid vs albuterol for anaphylaxis
