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Difficulty: MediumInitial Stabilization and Triage

A 35-year-old woman is brought to the emergency department by her husband due to a sudden onset of severe shortness of breath, facial swelling, and a diffuse rash. The symptoms began abruptly while they were eating at a seafood restaurant 20 minutes ago. On arrival, the patient is lethargic, extremely restless, and gasping for air. Blood pressure is 70/40 mmHg, heart rate is 138/min, and respiratory rate is 32/min. Oxygen saturation is 86% on room air. Physical examination reveals marked angioedema of the lips and tongue, prominent inspiratory stridor, and diffuse bilateral wheezing. Her skin is warm and erythematous with widespread urticaria. Which of the following are the most appropriate immediate steps in the stabilization of this patient? (Select all that apply)

  1. Endotracheal intubationAnswer
  2. Intramuscular administration of epinephrineAnswer
  3. C
    Intravenous administration of diphenhydramine
  4. D
    Obtaining a standard 12-lead electrocardiogram
  5. E
    Application of non-invasive positive pressure ventilation

Answer

The correct answers are endotracheal intubation and intramuscular administration of epinephrine.
This patient is experiencing severe, decompensated anaphylactic shock characterized by distributive shock (hypotension, tachycardia) and impending airway obstruction (stridor, massive angioedema, lethargy). In the initial stabilization of such a patient, the primary survey dictates immediate, simultaneous life-saving interventions. The severe angioedema and altered mental status mandate immediate definitive airway management with endotracheal intubation before the swelling progresses to completely obliterate the airway, which would require a surgical airway. Concurrently, intramuscular epinephrine must be administered immediately. Epinephrine acts on alpha-1 receptors to reverse peripheral vasodilation (raising blood pressure) and on beta-2 receptors to cause bronchodilation and decrease mediator release. These two steps are paramount and must occur simultaneously.

Step-by-Step Solution

1
Assess the patient's airway and breathing status.
The patient exhibits stridor, marked angioedema of the tongue and lips, severe hypoxia, and lethargy.
These findings indicate impending complete upper airway obstruction, which requires definitive airway management via endotracheal intubation before the airway is completely lost.
2
Assess the patient's hemodynamic status and identify the underlying etiology.
The patient is in decompensated distributive shock (severe hypotension, tachycardia) caused by a fulminant allergic reaction (anaphylaxis) to seafood.
Recognizing anaphylactic shock is critical because it mandates the immediate administration of intramuscular epinephrine to reverse vasodilation and bronchoconstriction.
3
Prioritize simultaneous stabilization interventions.
Both endotracheal intubation and intramuscular epinephrine must be executed concurrently.
In rapidly progressing anaphylaxis with shock and severe airway compromise, delaying either the airway security or the administration of epinephrine can lead to asphyxiation or cardiovascular collapse.

Key Concept

In severe anaphylaxis presenting with impending airway compromise (stridor, severe angioedema) and decompensated shock, immediate simultaneous stabilization requires definitive airway management (endotracheal intubation) and intramuscular epinephrine. Adjunctive medications and diagnostic testing must not delay these life-saving interventions.
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Topics

Initial Stabilization and Triage

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