Which of the following is NOT an indication for pediatric epinephrine standing orders?

• A. Acute onset of skin or mucosal involvement with respiratory compromise
• B. Two or more of these after exposure to a likely antigen: Skin or mucosal involvement; Respiratory compromise; Decreased SBP; Persistent GI symptoms
• C. Decreased BP after exposure to a known allergen for that patient
• D. Fever and generalized malaise

Answer: (D)

Recognizing when pediatric epinephrine standing orders apply hinges on identifying signs of anaphylaxis. Epinephrine is indicated when there is sudden skin or mucosal involvement with respiratory compromise, or when two or more systemic criteria occur after exposure to a likely antigen—such as skin or mucosal involvement plus respiratory symptoms, or decreased blood pressure (low SBP) or persistent GI symptoms. In contrast, fever with generalized malaise is not anaphylaxis and does not indicate the need for epinephrine under standing orders. Fever typically points to infection or a benign illness, not a life-threatening allergic reaction, so it should not trigger epinephrine administration.