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Difficulty: MediumInitial Stabilization and Triage

A 34-year-old woman is brought to the emergency department by paramedics after collapsing at a seafood restaurant. Her partner states she began complaining of an itchy throat and difficulty breathing shortly after eating a shrimp appetizer. Her past medical history is significant for asthma and a known shellfish allergy, but she did not have her epinephrine autoinjector with her. Upon arrival, she is lethargic and gasping for air. Physical examination reveals diffuse erythematous hives, marked periorbital edema, and audible inspiratory stridor. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 72/42 mm Hg, pulse of 142/min, respiratory rate of 32/min, and oxygen saturation of 86% on room air. Which of the following interventions should be ordered simultaneously as the immediate next steps in management? (Select all that apply)

  1. Intramuscular administration of epinephrineAnswer
  2. Rapid intravenous infusion of isotonic crystalloidAnswer
  3. High-flow supplemental oxygen therapyAnswer
  4. D
    Intravenous administration of methylprednisolone
  5. E
    Lateral soft-tissue radiograph of the neck

Answer

The correct interventions are intramuscular administration of epinephrine, rapid intravenous infusion of isotonic crystalloid, and high-flow supplemental oxygen therapy.
Severe anaphylaxis presents with distributive shock and impending airway compromise. Immediate stabilization requires a coordinated, simultaneous approach: high-flow oxygen addresses the immediate hypoxia, isotonic crystalloids counter massive vasodilation and capillary leak to restore perfusion, and intramuscular epinephrine reverses bronchoconstriction and induces critical vasoconstriction. These must be executed concurrently to prevent cardiac arrest.

Step-by-Step Solution

1
Assess the patient's clinical presentation and vital signs.
The patient is experiencing distributive shock (hypotension, tachycardia) and impending airway compromise (hypoxia, stridor, lethargy) following allergen exposure.
Rapid recognition of severe anaphylaxis is required to initiate life-saving therapy before complete cardiovascular collapse or airway loss.
2
Prioritize immediate life-saving stabilization over diagnostic workup or adjunctive medications.
Select simultaneous interventions that directly reverse the pathophysiology and address the ABCs (Airway, Breathing, Circulation).
Initial stabilization and triage protocols require immediate action for critical abnormalities without delaying for imaging or delayed-onset medications.
3
Select the specific agents for simultaneous administration.
Choose IM epinephrine to reverse bronchoconstriction and vasodilation, IV crystalloids for distributive shock, and high-flow oxygen for hypoxia.
These three interventions work synchronously to stabilize the patient's critical parameters.

Key Concept

Immediate simultaneous resuscitation in anaphylactic shock requires intramuscular epinephrine, airway management, and aggressive intravenous fluid resuscitation.
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Topics

Initial Stabilization and Triage

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