Concentration safety (1 mg/mL (1:1000) for **IM** and **nebulization** · 0.1 mg/mL (1:10 000) for **IV bolus/infusion** only — fatal dosing errors occur when 1:1000 is given IV undiluted (EAACI, RCUK, PALS))
Max 0.5 mg/dose · Duration: PRN · 0.01 mg/kg (10 mcg/kg) IM — anterolateral mid-outer thigh; repeat q5–15 min PRN; max 0.5 mg/dose; may give through clothing; do NOT use buttock (EAACI, WAO, RCUK, ASCIA)
• IM anaphylaxis (first-line): **0.01 mg/kg** (10 mcg/kg) of **1:1000** IM anterolateral thigh — repeat **q5–15 min** if no improvement; **max 0.5 mg/dose**; no arbitrary limit on doses in life-threatening anaphylaxis (EAACI, WAO, RCUK, ASCIA, AAP).
• IV bolus (NOT first-line anaphylaxis): **0.01 mg/kg** of **1:10 000** (0.1 mL/kg) — max **1 mg** in cardiac arrest/PALS protocols; refractory anaphylaxis only under senior supervision after failed IM doses; risk of arrhythmias with IV bolus (RCUK, EAACI, PALS, ERC).
• IV infusion (refractory anaphylaxis / shock): **0.1–1 mcg/kg/min** of 1:10 000 solution titrated to BP and perfusion — ICU/specialist only; continuous cardiac monitoring; example: 10 kg child at 0.5 mcg/kg/min ≈ 5 mcg/min; prepare infusion per local PALS/ICU protocol — calculator shows bolus only; see **Anaphylaxis** card for full refractory pathway (RCUK, EAACI, WAO, ERC).
Duration: See linked cards · This card provides route-specific dose calculators; for full ABCDE pathways, adjuncts (salbutamol, antihistamines, fluids), observation, and discharge planning use the dedicated condition cards
• **Croup protocol** — use **Croup** card for Westley severity scoring, dexamethasone dosing (0.15 vs 0.6 mg/kg), oxygen targets, admission/ICU criteria, and observation after nebulized epinephrine (NICE NG51, AAP, CPS).
• **Auto-injector weight bands**: **<7.5 kg** → ampoule + syringe 0.01 mg/kg IM (more precise than fixed device); **7.5–<25 kg** → **0.15 mg** EpiPen Jr / Auvi-Q 0.15; **≥25 kg** → **0.3 mg** EpiPen / Auvi-Q 0.3; Auvi-Q 0.1 mg available for 7.5–25 kg where licensed (ASCIA 2024, AAP 2023).
• **IV adrenaline**: reserve for **refractory anaphylaxis** (≥2 IM doses inadequate), **cardiac arrest**, or **shock** per PALS — never substitute IV for timely IM in uncomplicated anaphylaxis; continuous monitoring mandatory (RCUK, EAACI, ERC, PALS).
• **Concentration check**: always verify **1:1000 (1 mg/mL)** for IM and nebulization vs **1:10 000 (0.1 mg/mL)** for IV — undiluted 1:1000 IV is a reported cause of fatal medication errors (EAACI, RCUK, ISMP).
Clinical notes
• IM preferred first-line for anaphylaxis: give **0.01 mg/kg** (10 mcg/kg) of **1:1000** IM into **anterolateral mid-outer thigh** without delay — antihistamines and steroids do NOT treat airway obstruction or hypotension and must never delay adrenaline (EAACI, WAO, RCUK, ASCIA, AAP).
• IV indications only when appropriate: IV bolus/infusion reserved for **refractory anaphylaxis** after failed IM doses, **cardiac arrest**, or **shock** per PALS/ERC — IV bolus risks arrhythmias; IM remains preferred at every stage until infusion established under specialist care (RCUK, EAACI, WAO, ERC).
• Dosing errors: most common fatal errors are **1:1000 given IV** (should be 1:10 000), **subcutaneous instead of IM** (slower absorption), and **delayed IM** while preparing secondary agents — double-check concentration, route, and site before administration (EAACI, RCUK, ISMP).
• Monitoring with IV adrenaline: continuous **HR, BP, pulse oximetry, and ECG**; watch for tachycardia, hypertension, arrhythmias, and myocardial ischemia — titrate infusion to perfusion; have defibrillator and advanced airway support available (RCUK, ERC, PALS).
• Never delay IM for anaphylaxis: if anaphylaxis is suspected, administer IM adrenaline immediately while continuing ABCDE assessment — repeat q5–15 min if no improvement; call for help and prepare second dose concurrently; auto-injectors are acceptable community alternative when ampoule unavailable (EAACI, WAO, ASCIA, AAP).
• EAACI Guidelines — Anaphylaxis (pediatric and adult) (2021)
• WAO — Anaphylaxis guidance update (2020)
• ERC — European Resuscitation Council Guidelines (pediatric resuscitation and drugs) (2021)
+ 4 more
• AAP Clinical Report — Anaphylaxis (2023)
• Resuscitation Council UK — Emergency treatment of anaphylaxis (2021)
• ASCIA — Acute management of anaphylaxis and adrenaline auto-injector dosing (2024)
