Approach to the Critical Patient

Airway and breathing

Airway threat recognition

Oxygenation targets

Circulation and hemodynamics

Shock recognition and response

Refractory anaphylaxis

Monitoring and escalation

Mandatory monitoring bundle

Escalation triggers

Team activation

Consult triggers

History

Sting event details

Insect identification

Symptom timeline

Onset timing after sting

Symptom characterization

Cutaneous symptoms

Respiratory symptoms

Cardiovascular symptoms

Gastrointestinal symptoms

Neurologic symptoms

Prior sting history

Previous systemic reactions

Venom immunotherapy history

Medications and risk modifiers

Beta-blockers

ACE inhibitors

Prior autoinjector availability

Risk factors

High-risk patient features

Physical Exam

Vital signs

Hemodynamic assessment

Cutaneous exam

Skin findings

Airway exam

Upper airway

Pulmonary exam

Respiratory auscultation

Cardiovascular exam

Cardiac and perfusion assessment

Neurologic exam

Mental status

Differential Diagnosis

Anaphylaxis mimics

Vasovagal syncope

Panic or anxiety attack

Allergic spectrum disorders

Large local reaction

Urticaria without anaphylaxis

Angioedema variants

Hereditary angioedema (HAE)

ACE inhibitor-induced angioedema

Envenomation syndromes

Toxic or massive envenomation

Cardiac mimics

Kounis syndrome

Cardiogenic shock

Other mimics

Mastocytosis or mast cell activation syndrome

Scombroid fish poisoning

Vocal cord dysfunction

Laboratory Tests

Serum tryptase

Diagnostic utility

Complete blood count

CBC indications

Metabolic panel

BMP and renal function

Cardiac biomarkers

Troponin

Rhabdomyolysis screen

CK and LDH

Lactate and blood gas

Tissue perfusion markers

Venom-specific IgE

Outpatient diagnostic testing

Diagnostic Tests

Scoring Systems

World Allergy Organization anaphylaxis grading

Mueller classification for systemic reactions

Biphasic reaction risk stratification

MRI

MRI in anaphylaxis context

CT

CT chest indications

CT neck indications

Ultrasound

Point-of-care ultrasound (POCUS) applications

Disposition

Observation requirements

Minimum observation periods

Admission criteria

Indications for hospital admission

Discharge criteria

Safe discharge requirements

Transfer criteria

Transfer indications

Follow-up

Post-discharge follow-up

Treatment

Epinephrine (first-line)

Epinephrine IM — first-line, no contraindications in anaphylaxis

Epinephrine IV (refractory)

IV epinephrine for refractory anaphylaxis

Airway management

Airway interventions

Fluid resuscitation

IV fluids for distributive shock

Antihistamines (adjunctive)

H1 antihistamines — adjunctive only, do not replace epinephrine

H2 antihistamines — adjunctive

Corticosteroids (adjunctive)

Corticosteroids — limited evidence for biphasic prevention

Glucagon (beta-blocker reversal)

Glucagon for epinephrine-resistant anaphylaxis

Vasopressors (refractory)

Vasopressor protocol for refractory anaphylactic shock

Stinger removal

Honeybee stinger removal

Long-term prevention

Epinephrine autoinjector prescription

Venom immunotherapy (VIT)

Special Populations

Pregnancy

Anaphylaxis in pregnancy

Geriatric

Anaphylaxis in older adults

Pediatrics

Anaphylaxis in children

Background

Epidemiology

Prevalence and incidence

At-risk populations

Pathophysiology

IgE-mediated sensitization and activation

Mediator effects

Biphasic reaction mechanism

Venom composition

Therapeutic Considerations

Epinephrine pharmacology

Beta-blocker and epinephrine interaction

Venom immunotherapy evidence

Patient Discharge Instructions

copy discharge instructions

What happened to you today

Your medications

Warning signs — return to the emergency room or call 911 immediately

Avoidance strategies

Medical alert identification

Your follow-up appointments

References

Guidelines and key sources

Golden DBK, Wang J, Waserman S, et al.

Golden DB, Demain J, Freeman T, et al.

Pflipsen MC, Vega Colon KM.

Casale TB, Burks AW.

Herness J, Snyder MJ, Newman RS.

Stoevesandt J, et al.

Long B, Gottlieb M.

McMurray JC, Bingemann TA, Golden DBK.

Giovannini M, Mori F, Barni S, et al.

Campbell RL, Li JT, Nicklas RA, Sadosty AT.

Gaudio FG, Johnson DE, DiLorenzo K, et al.