drk1980
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A 10-year-old boy is brought to the emergency department because he developed hives and shortness of breath 10 minutes after being stung by an insect. His father tells you that he had a similar episode of dyspnea and urticaria 2 years ago. Physical examination now shows a frightened child who appears out of breath, has generalized urticaria and asks for help in a hoarse voice. Vital signs are: temperature 37.0°C (98.6°F), pulse 120/min, respirations 36/min and blood pressure 70/40 mm Hg.
Which of the following is the most important first step in managing this patient?
A) Administer diphenhydramine, orally
B) Administer epinephrine, subcutaneously
C) Administer oxygen via face mask
D) Establish intravenous access
E) Obtain arterial blood gas values
After 10 minutes there is no change in his condition. At this time, the most appropriate next step is to administer which of the following?
A) Diphenhydramine, orally
B) Dopamine, intravenously
C) Epinephrine, subcutaneously
D) Prednisone, orally
E) Ranitidine, orally
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| Justice
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1. (B) and then (D), please correct if I am wrong
2. (B)
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Don't live in a town where there are no doctors
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| lq2006
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WHAT'S THIS?? C&C
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| lq2006
Forum Elite
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what's this?? B first, then C
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| farnsworth
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the most important emergency drug, most commonly used all over the world: oxygen!
-> 1 (C)
next step would be epinephrine 2 (C).
(if it makes sense to give it subcutaneously, when the patient has generalized urticaria, a low blood pressure, is a completely different thing... if a drug is resorbed given SQ in imminent shock is questionable)
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| WaqasQureshi
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Why oxygen as the MOST IMPORTANT step?
the question is askin for the most important step.When "MOST IMPORTANT" is written, it may not be the first one. The most important step over here wud be S/Q epi....
oxygen wont increase the BP over here nor it will cure SOB.. while epi will do both ... so that will be the first MOST IMPORTANT step over here...
indications for using bag/mask are:
- prehospital treatment (this question is asking for ED setting)
- interim period between arrival and start of rapid sequence intubation (this isnt the case) there is just mucosal edema which is causing hoarsness and epinephrine is very effective in treating this
the response should be seen for some time and in case there is no change:
administer another dose of sub/Q epi
Other drugs that might used alongwith this are
- IV hydrocortisone
- Histamine blockers
They may be started but they arent the choice over here.
One more thing: the question is askin about the MOST IMPORTANT and MOST APPROPRIATE steps, please dont confuse it with INITAL TREATMENTS.
Edited by WaqasQureshi on 05/14/08 - 03:49 AM
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| WaqasQureshi
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my answers are:
B and C
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| WaqasQureshi
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for those who want to learn the algorithm of anaphylactic shock:
evaluate clinical status of patient. Two possibilities:
- life threatening
- not life threatening
For life threatening:
ED care: give epi and consider: initial CPR, oxygen, IV fluids, vasopressors (like dopamine), inhaled bronchodilators, intubation (each has its own indications)
look for clinical response. Usually in 15 min. again two possibilities
- good response
- bad response
bad response should need another assessment and repeat S/Q epi consider: antihistamine, hydrocortisone (dont consider oral over here), glucagon (if beta blocker causing the wheeze, SOB), H2 blockers (if sedation not required)
if good clinical response: monitor for late phase reaction ---> discharge if favourable
refer to allergist if recurrent and advise keeping EPIPEN alongwith the person if high risk for recurrent anaphylactic shocks.
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| WaqasQureshi
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sorry. Forgot the non life threatening:
use antihistamine like diphenhydramine
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