Anaphylactic Shock Management in the Emergency Room || #allergicreaction || #epinephrine ||

Added: 2026-05-25

[00:00:06]Welcome to AET CM the Emergency Medicine Channel. Sir, shall I start?

[00:00:10]A 70-year-old female, known case of CA breast on treatment, presented with sudden onset breathlessness, altered sensorium following administrations of IV contrast dye for CT imaging.

[00:00:23]On initial assessment, patient was drowsy, restless, and in respiratory distress.

[00:00:29]Airway, there was swelling of the lips, but no swelling of tongue or uvula, no stridor or hoarseness of voice, no pooling of secretions.

[00:00:37]Difficult airway cart was kept prepared in case of worsening of edema or stridor.

[00:00:43]Breathing wise, air entry was equal bilaterally with severe bilateral wheeze, respiratory rate of 20 to 30 per minute, and saturation of 91% on room air.

[00:00:53]Oxygen was supplied by a face mask at 4 L.

[00:00:57]Suspecting anaphylactic reaction, injection adrenaline 0.5 mg IM on anterolateral aspect of mid-thigh was given.

[00:01:04]Circulation wise, BP was only 70 over 40 mmHg with pulse rate of 132 beats per minute, CRT more than 2 seconds.

[00:01:12]>> after adrenaline or before it? Uh before adrenaline.

[00:01:17]Uh two large bore IV cannulas were inserted and IV fluids were administered.

[00:01:22]Disability wise, GCS was E4V3M5.

[00:01:27]Uh GRBS 120 mg per deciliter, and patient was eubrile.

[00:01:32]Adjuncts, ABG was taken. It showed respiratory alkalosis from hyperventilation. pH of 7.5, pCO2 of 28, and bicarb of 22.

[00:01:42]Sample history. Okay. 70-year-old female patient who is a known case of CA left breast was admitted for contrast-enhanced CT evaluation. During IV administration of contrast dye, she suddenly developed generalized pruritus, facial puffiness with lip swelling, shortness of breath with wheeze, dizziness and progressive altered mentation and restlessness.

[00:02:05]No history of chest pain, fever, seizure activity, vomiting or dysphagia. Patient was immediately shifted to emergency department.

[00:02:13]Allergy history, no prior documented contrast allergies, no known food allergies.

[00:02:19]Uh vitals, uh pulse was 138, BP was 140 70 over 40, respiratory was 20 to 30 per minute, saturation was 91% on room air and temperature was afebrile.

[00:02:31]Uh local examination, skin and mucosa, flushing present, angioedema of lips and eyelids was present. Respiratory system wise, bilateral diffuse wheeze with accessory muscle use was present. CVS wise, tachycardia was there, cold clammy extremities, delayed capillary refill time, peripheral pulses were feeble.

[00:02:51]CNS wise, patient was drowsy but arousable, no focal neurological deficits.

[00:02:57]Provisional diagnosis, anaphylactic shock secondary to contrast dye exposure in known carcinoma breast patient.

[00:03:05]So we gave adrenaline IM 0.5 mg, was repeated every 5 to 15 minutes around three times we had given until symptoms subsided and wheeze was resolved.

[00:03:16]>> Okay. Uh noradrenaline infusion was started in view of refractory shock.

[00:03:22]>> give adrenaline infusion?

[00:03:24]Adrenaline infusion can cause Takotsubo cardiomyopathy. May may cause tachyarrhythmias. If the patient does not improve, you can give it. We can start. So here you have preferred noradrenaline. Uh in view yes, sir. Was the initial problem subsided with the breathing difficulties subsided?

[00:03:42]>> Subsided. Only hypo- hypotension was there.

[00:03:44]>> Hypotension was there.

[00:03:45]Persisting, so we gave we started noradrenaline infusion at 4 ml per hour in view of refractory shock. Adjunct medications of hydrocortisone, antihistamines were given after resolution of symptoms.

[00:03:59]>> Okay.

[00:04:01]This is how we managed.

[00:04:02]>> Okay.

[00:04:03]Now, I'll talk about anaphylaxis. What are the differential diagnosis you suspect? Could be foreign body. Foreign body. Yes, vasovagal um Vasovagal syncope.

[00:04:16]What are the differential diagnosis uh suspect for a uh anaphylaxis like this. Patient have uh edematous uh lips, tongue but no itching.

[00:04:31]Currently, patient come to emergency >> angioedema. Hereditary angioedema. So, that is a close differential diagnosis.

[00:04:37]Okay. Sometimes, you will miss it and we'll treat it as uh anaphylaxis.

[00:04:42]>> anaphylaxis Otherwise, ACE inhibitor induced Uh ACE inhibitor also can produce this type of symptoms.

[00:04:49]Um Another one is hereditary angioedema.

[00:04:51]ACE inhibitor also can produce angioedema.

[00:04:53]>> angioedema Okay. Okay.

[00:04:56]I'll talk about anaphylaxis.

[00:04:58]Anaphylaxis potential life-threatening allergic reaction. To recognize anaphylaxis, it is based on sudden onset plus rapid progression of symptoms. Then multi-system involvement, airway, breathing, circulation uh affection will be affected with skin or mucosal changes.

[00:05:15]Now, airway wise, can be swelling of throat, tongue, swelling causing difficulty in breathing or swallowing, hoarse voice, uh stridor, high-pitched inspiratory noise caused by upper airway obstruction. Then breathing wise, increased work of breathing, bronchospasm, wheeze, or persistent cough, fatigue, breathing rate decrease.

[00:05:35]>> that just means what?

[00:05:37]Uh airway >> You'll be knowing that. Yes. What is that?

[00:05:40]Could be due to bronchospasm. Severe bronchospasm.

[00:05:43]>> bronchospasm >> So, it's a terminal state means patient is going to arrest. If your patient is having severe breathless and breathlessness and you're not able to get ways means it's a dangerous situation. Yes, sir.

[00:05:55]Uh Other breathing symptoms could be hypoxemia saturation less than 94% respiratory arrest as you told.

[00:06:03]Then circulation by signs of shock, pale, clammy, um significant tachycardia, hypotension, dizziness, uh arrhythmias, cardiac arrest. Patient may also have GI symptoms like uh abdominal pain, vomiting. Yes, some patients come with severe diarrhea.

[00:06:18]>> Diarrhea.

[00:06:19]Uh skin or mucosal changes include generalized rash, angioedema, urticaria.

[00:06:25]Um initial treatment, first we have to assess airway, breathing, circulation, disability, and exposure.

[00:06:31]Then uh diagnosis, uh we have to see if there is any sudden onset, airway, breathing, circulation problem, and skin changes. Then you have to call for help.

[00:06:40]You have to remove the trigger if it is present. Then patient to be lied flat.

[00:06:45]Then I am adrenaline injection over anterolateral aspect of mid thigh. Okay.

[00:06:49]Is what you give.

[00:06:51]Uh establish uh airway, give high flow oxygen, uh apply monitors. If no response, give I am in adrenaline every 5 minutes. Then we have to uh bolus IV fluids.

[00:07:04]>> contains how much? 1 is to 1,000.

[00:07:06]1 mg or 0.5 mg? 0.5 ml.

[00:07:10]1 1 ampule contains uh 1 >> 1 ampule contains 1 mg or 0.5 ml? 1 ml.

[00:07:16]1 mg. 1 ampule contains 1 mg, so [clears throat] you have to take only half.

[00:07:19]>> 0.5, yes. That is very important.

[00:07:21]Sometimes we will not know all these things. We directly give 1 ml 1 mg. Mhm.

[00:07:26]So, you should avoid that. Okay.

[00:07:28]Then if there is no improvement in breathing or circulation problem >> atropine is 1 ampule contains?

[00:07:33]Mhm.

[00:07:34]1 mg.

[00:07:35]1 ml. Huh?

[00:07:37]6 Adrenaline and atropine you should know. Left and right we are using.

[00:07:41]Adrenaline is 1 ml, 1 mg. Atropine 0.6 0.6 was there. Now it is 0.5 mg. And most of the ampules are 0.6. Okay.

[00:07:51]But vial contains Atropine vial is there. We give in OP poisoning.

[00:07:58]Vial contains 1 ml, 1 mg. So these differences you should know. That adrenaline 0.5 mg, atropine 0.6 mg, but vial contains 1 ml, 1 ml, 1 mg.

[00:08:10]Uh now if there is no improvement breathing or circulation problem despite two doses of IM adrenaline, then you have to follow refractory anaphylaxis algorithm.

[00:08:18]What else you can start simultaneously?

[00:08:20]You're tried IM adrenaline. What else you can give?

[00:08:24]In severe wheeze.

[00:08:26]Um Lungs are primarily involved. You are giving IM, it has to go to circulation.

[00:08:31]It has to reach in your uh lungs. Okay.

[00:08:35]What else you directly you can give something else?

[00:08:38]Huh? Nebulization. Adrenaline can be given as nebulization also. So if the patient is not improving, immediately you have to start nebulization. Okay.

[00:08:46]Um Now uh about the treatment, that is adrenaline. Uh it is a first line of treatment. Adrenaline has >> treatment. Yes. What else is Second line is there. No.

[00:08:59]There is only >> Only one line of treatment.

[00:09:02]Uh it has alpha activity and beta receptor activity. Alpha activity reverses the peripheral vasodilation and reduces the tissue edema.

[00:09:11]Beta activity dilates bronchial airway, increases myocardial contraction, suppresses the histamine, and leukotriene release.

[00:09:19]Um now IV adrenaline has adverse effects. That is it can cause myocardial infarction. It can cause takotsubo cardiomyopathy. It can produce severe tachycardia. Some patients may go to uh like myocardial infarction. Some patients will develop cardiomyopathy, enlargement of is called as Takotsubo.

[00:09:40]Then as you said we can give nebulized adrenaline in view of laryngeal edema.

[00:09:44]>> Okay. Like that. Then oxygen should be supplied. Target should be kept at 80 to 88 to 92. Then IV fluids might be administered.

[00:09:54]>> at 82 92. Why?

[00:09:58]According to the UK guidelines. What is this target? You are giving oxygen in anaphylaxis. She is telling target should be kept at 82 92.

[00:10:08]>> till 92. 100 means any problem?

[00:10:13]Any problem or not?

[00:10:14]If you are not treating a COPD patient, how much ever you increase for a short span of time now? So not for permanently. That short span of time, how much ever you increase, there is no issue. Okay. But in COPD patients you have to be very careful. The reason normal person can increase.

[00:10:31]>> Okay, sir. Any guidelines say like that?

[00:10:32]>> RCUK guidelines. Okay.

[00:10:36]IV fluid All right. I think we can make we should maintain maximum because patient when patient is collapsing we should maintain maximum.

[00:10:47]>> Maximum. Okay.

[00:10:48]Then IV fluids should be administered.

[00:10:50]That is because 1/3 of the circulatory circulatory volume may be lost through extravasation. Okay. And fluid redistribution during anaphylaxis. So IV fluids should be administered. Then antihistamines are not recommended as the first line, but you can give as adjuncts after CPR.

[00:11:05]>> further episodes you have to give antihistamines and steroids and all.

[00:11:10]Steroids, yeah. Also routine use of corticosteroids is not Not recommended.

[00:11:14]Yes.

[00:11:15]Other drugs are bronchodilators, cardiac drugs.

[00:11:18]Now refractory anaphylaxis. As anaphylaxis requires ongoing treatment despite two appropriate doses of IM adrenaline. Okay. Then you have to establish peripheral IV access.

[00:11:29]Give rapid IV bolus. Start adrenaline infusion.

[00:11:32]>> will you put >> So, that practically what is given in book is okay. When will you try to put an IV line in anaphylaxis?

[00:11:41]Every time we are repeating the same thing. When will we put try to put an IV line? In any In any condition who is coming to emergency room with hypertension?

[00:11:51]When there is circulatory shock and Immediately you see the patient, first order should be to put an IV. Not like what is given in this guideline. In practice you have to ask the technician or nurse to put an IV line. Otherwise you afterwards you may not get the IV line at all.

[00:12:07]>> Yes, sir. Okay.

[00:12:09]Then we have to give IM adrenaline every 5 minutes till adrenaline infusion has been started.

[00:12:16]Low-dose IV adrenaline infusion can be started. We have to check the heart rate BP because adrenaline overdose should be avoided. Then high-flow nasal oxygen should be given.

[00:12:30]Then you have to monitor the vitals and ECG.

[00:12:34]Then investigation wise we can give mast cell tryptase. So, mast cell degranulation tryptase concentration will increase. So, significant increase under 30 minutes will peak at 1 to 2 hours. So, that is one investigation that we can send.

[00:12:50]This is Normally we don't send any investigation.

[00:12:53]>> No, we don't send.

[00:12:54]>> Just see the ECG is normal, any creatinine elevation like that.

[00:13:00]But C1 esterase deficiency how do they present?

[00:13:05]They also present like this. That is a problem.

[00:13:08]What to What is the difference? Won't respond to adrenaline. And they won't respond to adrenaline and They have only angioedema. They have only lip enlargement. There is no itching.

[00:13:20]So, patient is having family history or past history of swelling of of lips without itching then it is possibly C1 esterase deficiency. So, in that patient you should never try adrenaline.

[00:13:34]They will not have breathing diffi- breathing difficulty can be there because of the laryngeal edema, not wheeze or something like that.

[00:13:42]Okay.

[00:13:43]Anything else you want to add? Nothing.

[00:13:45]Okay. Thank you.

[00:13:46]>> Thank you, sir.