Risk Mangement Pitfalls:
1. “I didn’t think that patient would deteriorate at home after discharge from the ER.” Patients with life-threatening complications of anaphylaxis (such as respiratory distress or cardiovascular compromise) should be admitted to the hospital for observation and continued therapy, even if the symptoms improve in the first few hours of treatment. Patients with incomplete response to therapy, debilitated patients, and those with serious underlying cardiac or pulmonary illness should also be admitted. These patients are at increased risk for deterioration at home if discharged prematurely from the ER.
2. “I should have used epinephrine earlier for that patient with the anaphylactic reaction.” Epinephrine should be administered immediately for patients with evidence of an anaphylactic reaction, upper airway obstruction, or cardiovascular collapse. The intramuscular route provides faster onset of action and more reliable blood levels than subcutaneous administration, while the intravenous route should be reserved for patients in extremis since it may be associated with cardiac ischemia or dysrhythmias. Delays in administering epinephrine may allow airway obstruction or cardiovascular collapse to progress to the point of irreversibility and death.
3. “I should have intubated that patient with upper airway obstruction sooner.” If epinephrine and other immediate interventions fail to improve respiratory distress from anaphylaxis-induced upper airway obstruction, early endotracheal intubation should be strongly considered. A delay in airway control may result in progressive angioedema, making it impossible to intubate the patient and, therefore, necessitating a surgical airway.
4. “I wish I had checked the patient’s blood pressure sooner.” Intractable hypotension is the second leading cause of death in anaphylaxis after laryngeal edema associated with upper airway obstruction. Early recognition is of key importance. Patients with such cardiovascular collapse require early treatment with epinephrine, aggressive volume resuscitation with intravenous crystalloid, and continuous infusions of vasopressors.
5. “I was so busy treating the other aspects of the envenomation that I forgot to ask about tetanus immunization status.” Although it is easy to focus on treating the more impressive local and systemic reactions to these envenomations, it is important not to forget the basic principles of wound care, such as tetanus prophylaxis.
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