A young man has walked into your hospital after having had lunch at a Sea Food restaurant.

He claims
to be allergic for shells and that’s why he has asked for a shells free meal, he doubts that the chief may
have accidentally added some. He feels tight-chested. On examination, he is normal except a slightly
high Respiratory Rate.

ABCDE

 A : Clear

 B : RR 19 min-1

 C : P 90 min-1, BP 110/60 mmHg

 D : Alert, anxious

 E : Normal

Over the next 10 min, he becomes very short of breath with widespread wheeze, he develops an
urticarial rash, and feels light headed.

ABCDE

 A : Complains of tightness in throat

 B : RR 28 min-1, widespread wheeze
 C : P 120 min-1, BP 80/60 mmHg
 D : Very anxious
 E : Widespread urticarial

1. What is the most probable diagnosis? Why?

2. At this stage, describe the assessment and management of this patient following the ABCDE
approach.

All of a sudden, the patient stopped responding.

3. Why will you do now?

4. Discuss the role of IM Adrenaline in the management of this patient?
5. What is the most probable diagnosis? Why?

The most probable diagnosis: Anaphylaxis

Anaphylaxis is likely when all of the following there criteria are met:
1. Sudden onset and rapid progression of symptoms (this patient has severely deteriorated on
the course of only 10 minutes)
2. Life-threatening Airway and/or Breathing and/or Circulation problems (this patient has life-
threatening airway problem: tight throat, life-threatening breathing problem: high
Respiratory Rate and widespread wheeze, and life-threatening circulation problem: low
Blood Pressure and High Pulse “signs of shock”)
3. Skin and/or mucosal changes (flushing, urticaria, angioedema) (this patient has widespread
Urticaria)

6. At this stage, describe the assessment of this patient and the anticipated problems in his case.
This is a critically ill patient and should be assessed following the ABCDE approach:
A: Assessing the airway patency put him on high flow Oxygen. Establish an airway. Airway
obstruction due to laryngeal edema is anticipated in this case
B: Assessing the patient’s breathing and put a pulse Oximeter to assess his Oxygen saturation.
Anaphylaxis causes bronchoconstriction which results in wheezes and chest tightness
C: Assessing the patient’s circulation, IV fluid challenge of 500-1000 ml is given, administer IM
Adrenaline, and draw blood for ABG and serum Electrolytes analysis. Anaphylaxis causes
vasodilation which results in distributive shock.
D: Assessing the patient’s consciousness. Anaphylactic shock with confusion and disturbed
consciousness may result.
E: Exposing the patient looking for hidden insults and abnormalities. Widespread skin reactions
are anticipated.
ERC Algorithm
7. Why will you do now?
The patient does not respond, he may be in Cardiac Arrest.

ERC Algorithm
8. Discuss the role of IM Adrenaline in the management of this patient?

Adrenaline works on both Alpha and Beta receptors with the following actions:

1. Alpha-receptor agonist: reverses peripheral vaso-dilatation and reduces edema

2. Beta-receptor activity: dilates bronchial airways, increases the force of myocardial
contraction, and suppresses Histamine and Leukotriene release