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Difficulty: EasyInitial Stabilization and Triage

A 28-year-old woman is rushed into the emergency department by her husband. She is gasping for air and clutching her anterior neck. Her husband states they were eating at a seafood restaurant 15 minutes ago when she suddenly developed severe shortness of breath, lightheadedness, and a diffuse rash. She has no known past medical history and takes no medications. Vital signs show a temperature of 37.1 C (98.8 F), blood pressure of 76/40 mm Hg, heart rate of 132/min, and respiratory rate of 28/min. Oxygen saturation is 88% on room air. Physical examination reveals marked periorbital edema, swollen lips, and loud inspiratory stridor. Which of the following are the most appropriate immediate steps in the stabilization of this patient? (Select all that apply)

  1. Administer intramuscular epinephrine into the anterolateral thighAnswer
  2. Initiate a rapid intravenous infusion of isotonic crystalloid fluidsAnswer
  3. C
    Perform immediate fiberoptic laryngoscopy to assess the extent of laryngeal edema
  4. D
    Draw blood for serum tryptase levels prior to initiating pharmacotherapy
  5. E
    Obtain a 12-lead electrocardiogram to evaluate for ischemia before administering chronotropic agents

Answer

The correct immediate steps are to administer intramuscular epinephrine into the anterolateral thigh and initiate a rapid intravenous infusion of isotonic crystalloid fluids.
The patient is presenting with severe anaphylactic shock, characterized by profound hypotension, stridor, and respiratory distress shortly after allergen exposure. In any hemodynamically unstable patient, the absolute priority in initial stabilization and triage is the ABCs (Airway, Breathing, Circulation). Intramuscular epinephrine is the cornerstone, life-saving treatment for anaphylaxis because its alpha-1 agonist properties reverse peripheral vasodilation (improving blood pressure) and decrease mucosal edema, while its beta-2 agonist properties cause bronchodilation. Simultaneously, rapid intravenous isotonic crystalloid fluid resuscitation is necessary to expand intravascular volume and correct the severe distributive shock caused by massive capillary leak.

Step-by-Step Solution

1
Assess the patient's clinical presentation and vital signs.
The patient exhibits severe hypotension, tachycardia, hypoxia, and stridor rapidly following seafood ingestion.
This constellation of signs and symptoms indicates anaphylactic shock with impending airway compromise.
2
Determine the priority of interventions based on the ABC (Airway, Breathing, Circulation) framework.
The immediate goals are to reverse the massive systemic vasodilation, halt airway swelling, and restore circulating volume.
In unstable patients, definitive resuscitation must occur before diagnostic testing.
3
Select the appropriate immediate stabilization therapies.
Intramuscular epinephrine and rapid intravenous crystalloid fluids are indicated.
Epinephrine provides rapid alpha-1 and beta-2 adrenergic effects to reverse the shock and bronchospasm, while fluids correct the relative hypovolemia.

Key Concept

In anaphylactic shock with impending airway compromise, immediate stabilization requires simultaneously administering intramuscular epinephrine and rapid intravenous fluid resuscitation, prioritizing resuscitation over any diagnostic testing.
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Topics

Initial Stabilization and Triage

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