Anaphylaxis: recognition and emergency management — branching viva

Opening question

Examiner: Take me through this adolescent. What is the diagnosis, and what is your frame for managing her? ^[1]

Candidate: This is anaphylaxis. She has acute respiratory compromise — wheeze and dizziness — and a distributive-shock picture — pallor and presyncope — after a likely food allergen in a known peanut-allergic child. That meets the NIAID/FAAN criteria for anaphylaxis even though she has no rash. My frame is simple: give intramuscular adrenaline now, without waiting for a rash or a test, then support the airway, breathing and circulation, escalate if she does not respond, and keep her for observation because a biphasic reaction can recur. ^[1]

Examiner: She has no skin signs at all. Does that worry you, or reassure you? ^[1]

Candidate: It worries me. Up to a fifth of anaphylactic reactions have no skin or mucosal signs, and this girl is exactly the high-risk profile — the asthmatic adolescent with food anaphylaxis. The absence of a rash is the pitfall that delays adrenaline in fatal cases, so it is the reason to act faster, not to pause. ^[1]