Lifesaving Intravenous Bolus Epinephrine Administration in a Case of Severe Refractory Anaphylactic Shock

A potentially fatal reaction to various allergies is anaphylaxis. Reducing mortality requires early detection and management. In this case study, a 31-year-old man with a history of hypertension is profiled. He visited the emergency room with headache, nausea, vomiting, discomfort in his right flank, and an elevated blood pressure (BP) of 212/134 mmHg. The patient was started on stat captopril 12.5 mg tablet and stat amlodipine 5 mg tablet for his high BP and stat diclofenac 75 mg (1 mg/kg) intramuscular (IM) for his flank pain. The patient's mucosal membranes began swelling two minutes later, but there was no urticaria or rash. Additionally, his BP abruptly fell and became unrecordable. First-line treatment was started right away, and two typical adult IM epinephrine dosages were given five minutes apart. The BP remained undetectable and a third IM epinephrine dose of 500 mcg was administered along with an intravenous (IV) epinephrine drip initiated at a rate of 4 mcg/min. The BP reached 60/40 mmHg but kept falling, thus an IV epinephrine bolus of 300 mcg (4 mcg/kg) was given and the IV epinephrine drip continued. BP risen to 126/75 mmHg and then dropped to 88/59 mmHg; a second IV epinephrine bolus of 200 mcg (2.6 mcg/kg) was administered, and BP was restored to 140/90 mmHg. Emergency situations demand quick identification and action. IM epinephrine is currently the main course of treatment for anaphylaxis. Multiple IM epinephrine injections might be required depending on the patient’s response. By describing a case where IV bolus epinephrine was successfully administered to avert impending cardiovascular collapse, we hope our case report adds to the body of knowledge on severe refractory anaphylaxis. Highlighting the need for appropriate escalation of management given the availability of physicians with expertise.