ZyraDoc #09 - August 11, 2026

A 29-year-old woman presents to the emergency department with acute anaphylaxis following peanut ingestion, exhibiting severe stridor, widespread urticaria, and breathlessness.

She is promptly administered high-flow oxygen, IV fluid resuscitation, and two consecutive standard doses of intramuscular epinephrine (0.5 mg IM, 5 minutes apart).

Despite initial IM epinephrine doses, her upper airway stridor worsens and her blood pressure drops to 74/42 mmHg with persistent obstructive shock.

Case Summary

Clinical Focus:

A 29-year-old female presents with acute severe anaphylaxis refractory to two standard doses of intramuscular epinephrine, demonstrating progressive hemodynamic collapse and upper airway obstruction.

Diagnostic criteria for Refractory Anaphylaxis include:

Persistent or worsening respiratory distress (stridor, wheezing) or cardiovascular collapse (hypotension, shock)
Failure to respond within 10 to 15 minutes after two adequate doses of intramuscular (IM) epinephrine
High risk of rapid asphyxiation or irreversible distributive shock without intravenous titration

When anaphylactic shock fails to respond to initial intramuscular epinephrine boluses, prompt escalation to continuous intravenous epinephrine infusion under close monitoring is the essential life-saving step.

Here is the Management Strategy:

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