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Difficulty: EasyInitial Stabilization and Triage

A 19-year-old college student is rushed to the emergency department by his roommates. They report he accidentally consumed a cookie containing macadamia nuts 15 minutes prior to arrival. He has a past medical history of mild intermittent asthma but no known food allergies. He is now clutching his throat and struggling to breathe. Physical examination reveals a widespread urticarial rash, significant swelling of the lips and tongue, and audible stridor. He is visibly agitated and using accessory muscles of respiration. Vital signs show a blood pressure of 82/40 mmHg, a heart rate of 138/min, a respiratory rate of 28/min, and an oxygen saturation of 88% on room air. Which of the following are the most appropriate immediate stabilization steps for this patient? (Select all that apply)

  1. Preparation for endotracheal intubationAnswer
  2. B
    Ordering a stat serum tryptase level for diagnostic confirmation
  3. Intramuscular administration of epinephrineAnswer
  4. D
    Obtaining an immediate portable chest radiograph
  5. Rapid intravenous infusion of isotonic crystalloidAnswer
  6. F
    Initiating immediate transfer to the intensive care unit

Answer

The most appropriate immediate stabilization steps are preparation for endotracheal intubation, intramuscular administration of epinephrine, and rapid intravenous infusion of isotonic crystalloid.
This patient is presenting with anaphylactic shock characterized by distributive shock (profound hypotension, marked tachycardia) and impending complete airway obstruction (audible stridor, lip and tongue swelling, accessory muscle use). The immediate priorities in stabilization are simultaneously securing the airway, breathing, and circulation (ABCs). Intramuscular epinephrine is the definitive first-line treatment for anaphylaxis to reduce airway edema and induce peripheral vasoconstriction. Given the patient's active stridor and visible airway swelling, preparation for definitive airway management via endotracheal intubation is essential before total obstruction prevents safe intubation. Finally, rapid intravenous infusion of isotonic crystalloid is required to treat the severe hypotension associated with the massive vasodilation of distributive shock.

Step-by-Step Solution

1
Assess the patient's airway, breathing, and circulation (ABCs) in the setting of suspected severe allergic reaction.
The patient demonstrates impending airway loss (stridor, severe tongue swelling) and hemodynamic instability (profound hypotension, tachycardia).
The primary survey dictates that immediate life-threatening conditions must be identified and managed simultaneously before further diagnostic workup.
2
Select first-line pharmacotherapy for anaphylactic shock.
Intramuscular epinephrine is indicated immediately.
Epinephrine provides crucial alpha-1 mediated vasoconstriction to improve blood pressure and beta-2 mediated bronchodilation to relieve airway obstruction.
3
Address the physical airway compromise and volume depletion concurrently.
Preparation for endotracheal intubation and rapid isotonic crystalloid infusion are initiated alongside epinephrine administration.
Medical therapy takes time to work, and the patient's active stridor warrants proactive airway protection. Distributive shock requires fluid resuscitation to restore intravascular volume.

Key Concept

In patients with anaphylactic shock and impending airway compromise, immediate simultaneous stabilization requires securing the airway, administering intramuscular epinephrine, and providing intravenous fluid resuscitation.
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Topics

Initial Stabilization and Triage

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