What is the appropriate emergency management for a patient who develops tongue swelling after eating, including airway assessment, medication, observation, and follow‑up?

Emergency Management of Tongue Swelling from Food

Immediately administer intramuscular epinephrine 0.3-0.5 mg (adults) or 0.01 mg/kg up to 0.3 mg (children) into the anterolateral thigh at the first sign of tongue swelling after food ingestion, as this represents anaphylaxis with potential airway compromise and delayed epinephrine administration is associated with fatal outcomes. 1, 2

Immediate Airway Assessment and First-Line Treatment

Early recognition of airway compromise is paramount. Tongue swelling (lingual edema) represents upper airway involvement that can rapidly progress to complete obstruction 2. Look specifically for:

• Hoarseness, stridor, or difficulty speaking - these indicate laryngeal edema and impending airway obstruction 2
• Oropharyngeal swelling - examine the posterior pharynx for edema 2
• Respiratory distress or inability to swallow - signs of critical airway narrowing 3

Epinephrine administration must not be delayed to give antihistamines or other medications 1, 2. The intramuscular route in the anterolateral thigh provides rapid absorption and is preferred over subcutaneous administration 2. Doses may be repeated every 5-15 minutes if symptoms persist or progress 2.

Plan immediately for advanced airway management, including surgical airway (cricothyroidotomy), if hoarseness, stridor, or progressive tongue swelling is present 2. Intubation should be attempted before the airway becomes completely obstructed, but have equipment ready for emergency cricothyroidotomy 4.

Adjunctive Medications (Secondary to Epinephrine)

After epinephrine administration, provide:

• H1 antihistamine: Diphenhydramine 25-50 mg IV or oral (adults) or 1-2 mg/kg up to 50 mg (children) - oral liquid absorbs faster than tablets 2, 1
• H2 antihistamine: Ranitidine 1-2 mg/kg (maximum 75-150 mg) or famotidine for enhanced effect 2, 1
• Supplemental oxygen via face mask or nasal cannula 2
• IV fluid resuscitation: Large volume boluses of normal saline or Ringer's lactate (10-20 mL/kg) if hypotension or orthostasis develops 2, 1
• Position patient supine with legs elevated if tolerated, to improve venous return 2, 3

Corticosteroids (prednisone 1 mg/kg up to 60-80 mg orally or IV methylprednisolone) are commonly given to prevent biphasic reactions, though evidence supporting their use is limited 2, 1.

Hospital-Based Escalation for Refractory Cases

If tongue swelling or hypotension persists despite initial IM epinephrine:

• IV epinephrine infusion: 5-15 mcg/min titrated to effect, with continuous hemodynamic monitoring 2
• IV epinephrine bolus: 0.05-0.1 mg (50-100 mcg) - this is 5-10% of cardiac arrest dosing and requires careful monitoring to avoid fatal overdose 2
• Additional vasopressors if shock is refractory to epinephrine 5
• Glucagon 1-5 mg IV for adults (20-30 mcg/kg for children) if patient is on beta-blockers, as epinephrine may be ineffective 1, 6

Mandatory Observation Period

All patients who receive epinephrine must be transferred to an emergency facility for observation of 4-6 hours minimum 2, 6. Prolonged observation or hospital admission is warranted for:

• Severe initial presentation with significant tongue swelling or respiratory compromise 2
• Refractory symptoms requiring multiple epinephrine doses 2
• History of biphasic reactions (symptom recurrence occurs in 1-20% of cases, typically around 8 hours but up to 72 hours later) 2

Critical Discharge Planning

Before discharge, provide:

1. Two epinephrine auto-injectors with hands-on training in proper administration technique 2
2. Written anaphylaxis emergency action plan 2
3. Prescription for 2-3 day course: Diphenhydramine every 6 hours, H2 antihistamine twice daily, and prednisone daily 2
4. MedicAlert bracelet or wallet card 2
5. Referral to allergist for allergen identification testing and long-term management 2, 3
6. Education on checking auto-injector expiration dates regularly 2

Common Pitfalls to Avoid

• Never substitute antihistamines for epinephrine in tongue swelling - antihistamines have dangerously slow onset and are ineffective for anaphylaxis 1, 6
• Do not delay epinephrine while waiting for IV access or attempting to identify the specific food allergen 1, 2
• Avoid intubation attempts by inexperienced providers once severe tongue swelling develops - proceed directly to cricothyroidotomy if airway expertise is unavailable 2, 4
• Do not discharge patients after brief observation (less than 4 hours) even if symptoms resolve, due to biphasic reaction risk 2, 6
• Never administer epinephrine subcutaneously or into buttocks, digits, hands, or feet - only anterolateral thigh provides adequate absorption 1