Another iteration of our Shadow Boxing series. This one brought up the issues raised in our AMAX4 podcasts.

Prior AMAX4 Episodes

• EMCrit 355 – AMAX4 for Crashing Anaphylaxis and Asthma – Part I Primer
• EMCrit 357 – AMAX4 Crashing Anaphylaxis Explosion with Ben McKenzie

Presenters:

Dominic Nicacio, MD

• Hometown: Seattle, WA
• Training: EM residency at Carolinas Medical Center
• Interests: ED ultrasound and critical care
• Experience: 5 months as an attending

Connor Erickson, MD

• Hometown: Outlook, WA
• Training: EM residency and chief resident at Sinai-Grace
• Interests: EM toxicology
• Experience: 7 months as an attending

Timeline of Events (approximate):

0000: Triaged and wheeled straight back

0001: 0.3 mg IM epi given

0002: On monitors, bilateral IV access established

0003: Initial vitals known (BP 60/30) → 0.5 mg IM epi given

0004: Fluids hung, repeat SBP 70s

0006: Repeat SBP 80-90

0007: IV epi started at 10 mcg/min

0009: Repeat SBP 100-120

0010: Intubation plans arranged

0011: Remainder of anaphylaxis meds + zofran administered

0013: ICU and anesthesia at bedside

0014: Patient waking up, groggy, but stating name

0017: Patient oriented, still groggy, protecting airway, on 2 L NC

0020: Tongue swelling decreasing, breathing comfortably, no further emesis, rash, vitals stable, epi down titrated to 3

0021-0344: Serial reassessments/monitoring

0345: Report to flight crew given

Medications Given:

• IM Epi 0.3 mg, IM Epi 0.5 mg
• IV Epi drip started at 10 mcg/min
• Albuterol neb 5 mg
• Normal saline 2 L IV
• Diphenhydramine 50 mg IV
• Methylprednisolone 125 mg IV
• Famotidine 20 mg IV
• Ondansetron 4 mg IV

Laboratory Results:

• CBC: WBC 6/Hgb 19/Plts 302
• CMP: Na 142/K 3.6/Cl 107/CO2 23/BG 85/BUN 7/Cr 1/AST 24/ALT 8/ ALP 77/TBili 1
• Mg: 2.2

Key Decision Points:

• Choice of epi administration route
• Choice of epi dosing before first BP known, and after obtaining first BP
• Determining his would be proximal cause of death: hemodynamic collapse vs airway obstruction/bronchospasm, and which to address first (although somewhat in tandem)
• How to secure airway: RSI, awake intubation, video laryngoscopy, nasotracheal intubation, surgical airway
• Decision to intubate prior to transfer

Case Discussion Points:

• What would you recommend if sats continued to fall but without a reliable waveform due to underlying shock and could not improve them with BVM or LMA?
  • Continue as long as good EtCO2 tracing?
  • What if you had no EtCO2 waveform monitoring available at the moment this patient hits the door?
  • What would be your exact trigger for a crash intubation (sats falling past a certain number, HR falling, or once bradycardic)?
• What would you do if sats continued to fall with a reliable waveform despite BVM or LMA with current BP of 60/30?
  • Proceed with single best attempt at VL, and if failed proceed to cric?
  • How would that change if you had good waveform end tidal, or if you had no availability of a waveform end tidal device to use?
  • Would you push any RSI meds if cardiac arrest seemed imminent?
• What would you do first if he coded shortly after arrival with his initial vitals provided (did he die because of bronchospasm or upper airway obstruction induced hypoxia or due to hemodynamic collapse)?
  • Would the best plan be to secure a definitive airway while having nursing administer code dose epi, then continue the code as usual once airway secured?
• What would be your recommended tiered approach to intubation strategy in this patient?
  • What critiques or advice would you give on our proposed strategy?
• How would airway management plan change if patient < 8-10 years old where cric becomes (somewhat) contraindicated due to size of cricothyroid membrane? (May be outside scope of EmCrit since peds, but question we had)

Additional New Information

More on EMCrit

Additional Resources

• Author
• Recent Posts

Scott Weingart, MD FCCM

Editor-in-Chief, at EMCrit.org

An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).

Latest posts by Scott Weingart, MD FCCM (see all)

• EMCrit 396 – Some Philosophy of Surgical Airways (Crics) and What to Do When the Doom is Lower Down (Central Airway Obstruction) - March 7, 2025
• EMCrit 395 – Stellate Ganglion Block – Not Whether, but When? - February 23, 2025
• EMCrit 394 – CV-EMCrit – Inotrope Basics Part 2 – Specific Scenarios - February 7, 2025