Skip to content Case: Anaphylaxis
Clinical Setup
- Presentation: 24-year-old female 15 minutes after peanut exposure: lip/tongue swelling, stridor, diffuse urticaria, wheezing, BP 84/50, HR 126, SpO2 90%.
- Location: Emergency Department.
Optimal Order Pathway
- Immediate Orders (Minute 0–1):
- Pulse oximetry, continuous cardiac monitoring, BP q5–15min.
- 2 large-bore IVs, Normal saline 0.9% IV wide-open bolus.
- Epinephrine 0.3–0.5 mg IM into mid-outer thigh stat (FIRST and most important — do not delay); high-flow O2.
- Prepare difficult-airway equipment; call anesthesia early.
- Focused Exam (Minute 1–2):
- Airway exam (angioedema, stridor, voice change), lung exam (wheeze), skin (urticaria/flushing).
- Diagnostics (Minute 2–5):
- Diagnosis is clinical — do not delay treatment for labs.
- Serum tryptase within 1–3 hours (supports diagnosis retrospectively); CBC, BMP after stabilization.
- Therapeutics (Minute 5–15):
- Repeat epinephrine IM every 5–15 min if no improvement; start epinephrine IV infusion if refractory hypotension.
- Adjuncts (never substitutes for epi): IV H1 antihistamine (diphenhydramine), H2 blocker (famotidine), IV methylprednisolone, nebulized albuterol for bronchospasm.
- IV fluids continued; vasopressors (norepinephrine) if shock persists despite epi + fluids.
- Observe minimum 4–6 hours (longer if severe, on beta-blockers, or biphasic risk); intubate early if progressive airway edema.
- Disposition (Minute 15–20):
- Admit to monitored unit/ICU for observation after stabilization.
- Allergy consult; identify and document trigger.
- Final 2 Minutes:
- Prescribe epinephrine auto-injector x2 with trainer teaching; action plan and MedicAlert discussion.
- Counsel on strict allergen avoidance, biphasic reaction warning signs; schedule allergy follow-up for testing.