Saturday, August 9, 2008

Case 11

A 28 years old male with no significant past medical history presented to the emergency room with left lower extremity swelling and tenderness secondary to dog bite. His vaccination history is up-to-date.

The intern on call did a complete evaluation and admitted the patient to the general medical floor for treatment for cellulitis.He was started on intravenous Ampicillin and sulbactam.

One hour later, the nurse on the general medical floor called urgently the intern urgently to see this patient who becomes very unwell minutes after being given intravenous Ampicillin and sulbactam. He started to wheeze and complain of chest tightness. His blood pressure is 92/60, pulse is 128/min and he is cyanosed.


  1. What are the best next 3 steps in management? (name drug.dose,and route of administration)



Ranjitha said...

stop ampi-sulbactam
Epinephrine 0.5 mg IM stat. Rpt every 10 mts as needed
O2, intubation as angioedema can compromise airway
rapid infusion of NSS
Methylprednisolone IV
Albuterol nebs?

prabodh said...

1.)Epinephrine 0.3-0.5 ml IM in the anterolateral aspect of thigh.
Repeat q 3-5 minutes, if still no reponse, IV infusion 2-10 micrograms per minute.
2.)Intubation, 100% O2, Albuterol nebs.
3.)Normal saline IV boluses.
4.)Benadryl IV 25-50 mg.
5.)Solumedrol 125 mg IV.

uchit said...

considering this as impending anaphylaxis; we should give him epinephrine 1:1000 intramuscularly or subcutaneously. later on, steroids can also be used.

Clinical Medicine said...

Epinephrine, 0.3-0.5 mg 0f 1:1000 dilution subcutaneously every 5-10 minutes as needed.
-Oxygen by phase mask.
-Establish a peripheral or central (most likely) and give IV fluids
-Histamine antagonists such as diphenhydramine-
- Intravenous pressor agents such as dopamine
-Corticosteroids such as hydrocortisone to prevent late-phase manifestation
-SC epinephrine 0.3-0.5 mg of 1:1000) is first line treatment for anaphylaxis
-IV epinephrine (1:10000) is reserved for ` anaphylactic shock with no initial response to SC doses
This is one of the few medications which you need know the dose for the board exam. The epinephrine can be given SC or IM (SC is easier), but not IV. Obviously this patient needs oxygen because he is cyanosed (some times you need to intubate)