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Question

Difficulty: MediumInitial Stabilization and Triage

A 22-year-old woman is brought to the emergency department by ambulance due to the rapid onset of severe breathing difficulty and lightheadedness. She was at a seafood restaurant when her symptoms began approximately 15 minutes ago. On arrival, the patient is lethargic and gasping for air. She exhibits prominent facial and lip swelling, and a diffuse, raised erythematous rash is visible on her trunk and extremities. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 72/40 mm Hg, pulse of 145/min, respirations of 32/min, and oxygen saturation of 84% on room air. Examination reveals profound oropharyngeal edema and audible stridor. Intravenous access is rapidly established. Which of the following are the most appropriate simultaneous initial steps in stabilizing this patient? (Select all that apply)

  1. Intramuscular administration of epinephrineAnswer
  2. Endotracheal intubationAnswer
  3. C
    Intravenous administration of methylprednisolone
  4. D
    Intravenous administration of diphenhydramine
  5. E
    Plain radiography of the soft tissues of the neck

Answer

The most appropriate simultaneous initial steps are the intramuscular administration of epinephrine and endotracheal intubation.
This patient is in anaphylactic shock with impending airway occlusion, evidenced by hypotension, hypoxia, stridor, oropharyngeal edema, and altered mental status. The most critical immediate steps in stabilization (following the Airway, Breathing, Circulation paradigm) include securing the airway with endotracheal intubation before the edema completely obliterates the airway, and simultaneously administering intramuscular epinephrine. Epinephrine is the primary life-saving treatment for anaphylaxis, acting via alpha-1, beta-1, and beta-2 receptors to reverse peripheral vasodilation, reduce airway edema, and induce bronchodilation. These two interventions must be performed concurrently and without delay.

Step-by-Step Solution

1
Identify the clinical syndrome
The patient is experiencing anaphylactic shock with impending airway loss.
Exposure to a potential allergen (seafood) is followed rapidly by distributive shock (hypotension, tachycardia), cutaneous signs (rash, swelling), and severe respiratory compromise (stridor, hypoxia).
2
Determine the required stabilization priorities (ABCs)
The patient requires immediate airway control and circulatory support.
Lethargy, hypoxia, and stridor indicate an unprotected and failing airway. Hypotension indicates decompensated shock.
3
Select the appropriate interventions for these priorities
Endotracheal intubation and intramuscular epinephrine must be administered simultaneously.
Epinephrine is the universal first-line treatment for anaphylaxis, while intubation secures the airway before profound edema makes it impossible to do so.

Key Concept

In patients presenting with severe anaphylaxis characterized by impending airway obstruction and decompensated shock, immediate simultaneous stabilization with intramuscular epinephrine and advanced airway management (endotracheal intubation) is prioritized over adjunctive therapies or imaging.
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Topics

Initial Stabilization and Triage

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