What is the next treatment step for an asthmatic patient with throat itching, chest tightness, shortness of breath, hypotension, tachycardia, tachypnea, stridor, and diminished breath sounds who is non-responsive to epinephrine (adrenaline)?

Management of Epinephrine-Refractory Anaphylaxis in an Asthmatic Patient

This patient requires immediate intravenous fluids (normal saline bolus), repeat intramuscular epinephrine every 5-15 minutes, consideration of intravenous epinephrine infusion for refractory shock, and preparation for emergent intubation with ICU transfer. 1, 2

Critical Recognition: This is Anaphylaxis, Not Asthma Exacerbation

The clinical presentation—throat itching, stridor, hypotension, and tachycardia—indicates anaphylaxis rather than isolated asthma exacerbation, despite the patient's asthma history. 1 The combination of respiratory and cardiovascular involvement with hypotension defines this as a life-threatening anaphylactic reaction requiring aggressive management beyond standard asthma protocols.

Immediate Management Algorithm for Epinephrine Non-Response

First-Line Interventions (Simultaneous Administration)

• Repeat intramuscular epinephrine 0.3-0.5 mg every 5-15 minutes until signs and symptoms resolve, as there are no absolute contraindications to epinephrine in anaphylaxis. 1

• Aggressive intravenous fluid resuscitation with normal saline should be initiated immediately with the first epinephrine dose in patients with cardiovascular involvement (hypotension). 1 Repeat fluid boluses if lack of response occurs.

• High-flow oxygen 40-60% to address respiratory distress and hypoxia. 1

• Place patient supine to optimize cardiovascular perfusion when presentation is primarily cardiovascular (hypotension). 1

Second-Line Interventions for Persistent Symptoms

• Inhaled beta-2 agonists (salbutamol 5 mg or terbutaline 10 mg nebulized) should be administered following initial epinephrine treatment for lower respiratory symptoms including chest tightness, wheezing, and shortness of breath. 1

• Intravenous epinephrine infusion should be initiated for patients in refractory shock, either as bolus or continuous infusion, as intramuscular absorption may be inadequate in profound hypotension. 2

• Additional vasopressors may be necessary for shock that remains refractory to epinephrine. 2

Critical Airway Management Considerations

Early intubation must be considered given the presence of stridor and potential for complete airway obstruction. 2 The combination of upper airway edema (stridor) and hypotension creates a high-risk scenario where delayed intubation may become impossible as airway edema progresses.

• Prepare for emergent intubation if respiratory distress worsens, stridor progresses, or patient develops exhaustion, confusion, or deteriorating mental status. 1

• ICU transfer should be arranged immediately for patients requiring multiple epinephrine doses or showing signs of respiratory failure. 1

Adjunctive Therapies (NOT Substitutes for Epinephrine)

• Antihistamines may be used for cutaneous symptoms but should never be administered before or in place of epinephrine. 1

• Glucocorticoids (prednisolone 30-60 mg or IV hydrocortisone 200 mg) are frequently used but have no proven role in acute anaphylaxis treatment due to slow onset of action and should not delay epinephrine administration. 1

• Neither antihistamines nor glucocorticoids reliably prevent biphasic anaphylaxis. 1

Common Pitfalls to Avoid

Do not confuse this presentation with pure asthma exacerbation. While the patient has asthma history, the constellation of throat itching, stridor, and hypotension indicates anaphylaxis requiring different management priorities. 1

Do not delay repeat epinephrine doses. The most common error in anaphylaxis management is inadequate or delayed epinephrine administration. 1 Non-response to initial epinephrine mandates repeat dosing, not switching to alternative therapies.

Avoid sole reliance on nebulized bronchodilators in this hypotensive patient, as cardiovascular collapse is the immediate life threat requiring epinephrine and fluid resuscitation. 1, 2

Monitoring and Disposition

• Extended observation (minimum 4-6 hours, potentially longer) is required for patients receiving multiple epinephrine doses due to risk of biphasic anaphylaxis. 1

• Predictors of biphasic reactions include severe initial presentation, administration of >1 dose of epinephrine, wide pulse pressure, and unknown trigger. 1

• Continuous monitoring of vital signs and preparation for further deterioration is essential. 1