This clinical care pathway outlines a stepwise protocol for anaphylaxis management across healthcare settings, incorporating intranasal (IN) epinephrine as an equivalent alternative to intramuscular (IM) epinephrine, based on pharmacokinetic data.
IM and IN epinephrine are considered equally efficacious based on pharmacokinetic data. For persistent anaphylaxis after two IM/IN doses, an IV epinephrine infusion should be prepared and initiated after the third dose (or earlier at provider discretion). In settings without IV infusion capability, repeat IM/IN epinephrine every 5 minutes with urgent transfer.
Equivalence of IM and IN epinephrine is based on pharmacokinetic data only — no head-to-head clinical outcome trials are cited. The pathway does not specify dosing amounts or concentrations for IN epinephrine, which may limit real-world implementation.
Clinicians can now use IN epinephrine interchangeably with IM epinephrine for anaphylaxis — switching between routes mid-resuscitation is acceptable. If anaphylaxis persists after two IM/IN doses, prepare an IV epinephrine infusion and initiate it by the third dose or sooner.
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