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Difficulty: HardInitial Stabilization and Triage

A 31-year-old woman is rushed to the emergency department triage desk by her colleagues. They report she suddenly developed severe throat tightness, shortness of breath, and dizziness approximately ten minutes after consuming a pastry at a local café. The patient has a past medical history of poorly controlled asthma and a severe peanut allergy. On arrival, she is visibly lethargic, diaphoretic, and grasping at her neck. Her vital signs are temperature 36.9°C (98.4°F), heart rate 148/min, blood pressure 72/42 mm Hg, respiratory rate 34/min, and oxygen saturation 84% on room air. Physical examination reveals audible inspiratory stridor, widespread erythematous urticaria, and perioral cyanosis. Her level of consciousness continues to rapidly decline while in the resuscitation bay. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

  1. Intramuscular injection of epinephrine in the anterolateral thighAnswer
  2. Preparation and execution of rapid sequence endotracheal intubationAnswer
  3. C
    Intravenous administration of methylprednisolone and diphenhydramine
  4. D
    Acquisition of a stat portable chest radiograph to evaluate for mechanical obstruction
  5. E
    Immediate transport to the intensive care unit for specialized airway monitoring

Answer

The correct immediate steps are the intramuscular injection of epinephrine in the anterolateral thigh and the preparation and execution of rapid sequence endotracheal intubation.
The correct answers directly address the primary life threats in this patient. The presentation of audible stridor, perioral cyanosis, and declining mental status indicates an airway that is actively closing, requiring immediate rapid sequence intubation. Concurrently, the profound hypotension and systemic allergic response necessitate intramuscular epinephrine, which is the only pharmacologic agent proven to decrease mortality in anaphylactic shock by rapidly reversing vasodilation and bronchoconstriction.

Step-by-Step Solution

1
Assess the patient's primary life threats based on the primary survey (ABCs).
The patient has a compromised airway (stridor, cyanosis), inadequate breathing (hypoxia, tachypnea), and circulatory collapse (hypotension, tachycardia) due to anaphylactic shock.
Initial triage and stabilization require immediate identification of conditions that will cause imminent death if not rapidly reversed.
2
Determine the necessary interventions for airway and breathing.
Rapid sequence endotracheal intubation must be prepared and executed.
Audible stridor and a declining level of consciousness indicate impending total airway occlusion from laryngeal edema, which necessitates a definitive surgical or endotracheal airway.
3
Determine the necessary interventions for circulatory collapse.
Intramuscular epinephrine must be administered immediately.
Epinephrine is the only medication capable of rapidly reversing the vasodilation, bronchoconstriction, and mast cell degranulation seen in severe anaphylaxis.

Key Concept

In severe anaphylaxis presenting with both impending airway loss and profound shock, simultaneous life-saving interventions (definitive airway management and intramuscular epinephrine) must be prioritized over adjunctive medications, imaging, or patient transport.
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Topics

Initial Stabilization and Triage

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