A 28-year-old man is rushed to the emergency department by his friends after abruptly deve… — USMLE Step 3

A $28$ -year-old man is rushed to the emergency department by his friends after abruptly developing extreme difficulty breathing and facial swelling at an outdoor seafood festival. He appears lethargic and is visibly gasping for air. Vital signs include a temperature of $37.2^\circ\text{C}$ ( $99.0^\circ\text{F}$ ), blood pressure of $70/38\text{ mm Hg}$ , pulse of $142/\text{min}$ , and respiratory rate of $32/\text{min}$ . Oxygen saturation is $84\%$ on room air. Physical examination reveals marked lip and tongue edema, pronounced inspiratory stridor, and diffuse expiratory wheezing. His skin is cool to the touch, and there is a widespread erythematous, raised rash across his torso. Large-bore intravenous access is rapidly established. Which of the following initial stabilization steps should be ordered and executed simultaneously? (Select three)

Intramuscular administration of epinephrineAnswer
Endotracheal intubationAnswer
Rapid intravenous infusion of crystalloid fluidAnswer
D
Intravenous administration of methylprednisolone
E
Computed tomography of the soft tissues of the neck

Answer

The critical simultaneous interventions are intramuscular administration of epinephrine, endotracheal intubation, and rapid intravenous infusion of crystalloid fluid.

The correct answers identify the three critical pillars of immediate stabilization for a patient in severe anaphylactic shock with impending airway loss. Intramuscular epinephrine is the definitive life-saving therapy that reverses vasodilation and bronchoconstriction. Endotracheal intubation is immediately required due to lethargy and prominent stridor, which signal an inability to protect the airway and imminent total obstruction. Concurrently, rapid intravenous crystalloid fluid infusion is necessary to counteract the massive capillary leak and distributive shock characterizing severe anaphylaxis.

Step-by-Step Solution

Evaluate the patient's airway and respiratory status.

The patient exhibits marked lip and tongue edema, inspiratory stridor, lethargy, and hypoxia (

84\%

These findings confirm impending total airway obstruction, dictating the immediate need for endotracheal intubation.

Assess the patient's hemodynamic status.

The patient is in profound distributive shock, evidenced by a blood pressure of

70/38\text{ mm Hg}

and a pulse of

142/\text{min}

This profound hypotension requires immediate, aggressive fluid resuscitation with rapid intravenous crystalloids.

Identify the underlying etiology to guide specific systemic therapy.

The combination of shock, airway compromise, and a widespread urticarial rash following allergen exposure confirms severe anaphylaxis.

This dictates the immediate administration of intramuscular epinephrine to halt and reverse the anaphylactic cascade.

Key Concept

Immediate stabilization of severe anaphylactic shock requires simultaneous airway securement, epinephrine administration, and aggressive fluid resuscitation.

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