A 12-year-old girl is brought to the emergency department due to rash and difficulty breathing. Symptoms started acutely after she was stung by a bee while playing soccer. Her coach says that the patient developed full-body hives, difficulty breathing, and vomiting before the ambulance arrived. She has a history of moderate persistent asthma. Medications include inhaled fluticasone twice daily and inhaled albuterol PRN. On arrival, temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 114/min, and respirations are 28/min. Pulse oximetry is 91% on room air. Examination shows a thin girl in moderate respiratory distress with hives on the trunk and extremities. Diffuse wheezing is heard on auscultation, and the patient has mild tenderness to abdominal palpation. Intramuscular epinephrine is administered, with resolution of symptoms and normalization of vital signs. However, an hour later, she has worsening hives, mild wheezing, and an additional episode of emesis. Repeat respiratory rate is 18/min and pulse oximetry is 97%. Which of the following is the most appropriate next step in management of this patient?

Question

A 12-year-old girl is brought to the emergency department due to rash and difficulty breathing.  Symptoms started acutely after she was stung by a bee while playing soccer.  Her coach says that the patient developed full-body hives, difficulty breathing, and vomiting before the ambulance arrived.  She has a history of moderate persistent asthma.  Medications include inhaled fluticasone twice daily and inhaled albuterol PRN.  On arrival, temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 114/min, and respirations are 28/min.  Pulse oximetry is 91% on room air.  Examination shows a thin girl in moderate respiratory distress with hives on the trunk and extremities.  Diffuse wheezing is heard on auscultation, and the patient has mild tenderness to abdominal palpation.  Intramuscular epinephrine is administered, with resolution of symptoms and normalization of vital signs.  However, an hour later, she has worsening hives, mild wheezing, and an additional episode of emesis.  Repeat respiratory rate is 18/min and pulse oximetry is 97%.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d16e_5b1f_bc81_59e4c2e7be3d_MD0003_00 This patient with recurrence of anaphylactic symptoms (eg, hives, wheezing, emesis) after initial resolution is having a biphasic anaphylactic reaction and should be treated with an additional dose of intramuscular (IM) epinephrine. Anaphylaxis is an acute, life-threatening, IgE-mediated, type I hypersensitivity reaction characterized by allergic symptoms affecting ≥2 organ systems or sudden hypotension after allergen exposure (eg, bee sting). It often resolves quickly and completely after epinephrine administration (ie, uniphasic\ anaphylaxis). However, symptoms may recur or persist despite treatment, according to the following patterns: allergic symptoms Biphasic anaphylaxis, as seen in this patient, is characterized by an initial anaphylactic reaction followed by an asymptomatic period (typically 1-30 hr) and then a recurrence of symptoms. Protracted anaphylaxis (less common) is characterized by anaphylactic symptoms that last hours or days despite treatment. Patients with biphasic or protracted anaphylaxis (or those unresponsive to the initial dose) should receive additional IM epinephrine. If symptoms persist after 3 IM doses, intravenous epinephrine infusion may be required. Adjunct therapies may target specific symptoms of anaphylaxis (eg, inhaled albuterol for bronchospasm, antihistamines for hives). However, only epinephrine, which has both beta-2 agonist (eg, bronchodilation, ↓ release of inflammatory mediators) and alpha-1 agonist (eg, vasoconstriction, ↓ upper airway edema) effects, can treat all components of anaphylaxis. Therefore, it takes priority over adjuncts (Choice B). (Choice A) Patients with anaphylaxis and prominent upper airway edema (eg, oropharyngeal swelling, stridor, voice alteration) may require endotracheal intubation. However, this patient's recurrent respiratory symptoms (eg, wheezing) are from lower airway bronchospasm and are mild; intubation is not indicated. (Choice D) Additional vasopressors (eg, dopamine) may be required for refractory hypotension despite maximal therapy with epinephrine (eg, intravenous epinephrine infusion). However, this patient is not hypotensive and has not received maximal epinephrine. (Choice E) Glucocorticoids (eg, methylprednisolone) are frequently administered as an adjunct treatment for anaphylaxis due to their anti-inflammatory effect; however, their onset is delayed by several hours, and unlike epinephrine, they do not provide immediate treatment for recurrent symptoms. (Choice F) Venom immunotherapy is a highly effective desensitization therapy for patients with anaphylaxis to bee (or other Hymenoptera) stings; however, it takes months to years to be effective and is not an appropriate treatment for acute anaphylaxis. Educational objective: Biphasic (symptoms resolve then reoccur) or protracted (persistent symptoms despite treatment) anaphylaxis may require additional doses of intramuscular (IM) epinephrine or intravenous epinephrine infusion if multiple (ie, 3) IM doses fail to relieve symptoms. References: Epinephrine and its use in anaphylaxis: current issues. (http://www.ncbi.nlm.nih.gov/pubmed/20543673) Venom immunotherapy for preventing allergic reactions to insect stings. (http://www.ncbi.nlm.nih.gov/pubmed/23076950)

A 12-Year-Old Girl Is Brought to the Emergency Department Due