Grade Skin GI Tract Respiratory Tract Cardiovascular Neurological 1 Localized itching, flushing, hives, welts Oral itching, oral "tingling," mild lip swelling 2 Generalized itching, flushing, hives, welts Any of the above, nausea and/or vomiting once Nasal congestion and/or sneezing Change in activity level 3 Any of the above Any of the above plus repetitive vomiting Runny nose, marked congestion, sensation of throat itching or tightness Increased heartrate (increase >15 beats/min) Change in activity level plus anxiety 4 Any of the above Any of the above plus diarrhea Any of the above, hoarseness, "barky" cough, difficulty swallowing, difficulty breathing, wheezing, blue or purple-tinged skin Any of the above, abnormal heart rhythm and/or low blood pressure "Light headedness," feeling of "pending doom" 5 Any of the above Any of the above, loss of bowel control Any of the above, respiratory arrest Heart beating too slowly (severe) and/or low blood pressure or cardiac arrest Loss of consciousness

All symptoms are not mandatory. The severity score should be based on the organ system most affected, eg, if grade 3 respiratory symptoms are present but only grade 1 GI symptoms, then the anaphylaxis severity score would be "grade 3." Boldface symptoms are absolute indications for the use of epinephrine; use of epinephrine with other symptoms will depend on patient’s history.