Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan; Division of General Medicine, Center for Community Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan.
Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan.
Am J Emerg Med. 2020 Jun;38(6):1297.e1-1297.e3. doi: 10.1016/j.ajem.2020.01.033. Epub 2020 Jan 18.
A previously healthy 60-year-old man presented to our emergency department with anaphylactic shock. We initiated fluid resuscitation with Ringer's lactate solution; injected 0.3 mg epinephrine intramuscularly; and administered d-chlorpheniramine maleate 5 mg, famotidine 20 mg, and methylprednisolone 80 mg intravenously. His symptoms resolved within 10 min. Thirty minutes after the epinephrine injection, he complained of sudden chest discomfort. Physical examination provided no evidence of anaphylaxis. The 12-lead electrocardiogram (ECG) showed ST-segment depression on leads II, III, aVF, and V3-6. Transthoracic echocardiography revealed normal ventricular contraction. After administration of 0.3 mg of sublingual nitroglycerin, his chest pain resolved immediately and his ECG normalized. A coronary angiogram showed normal coronary artery perfusion. The next day, his high-sensitivity troponin I was slightly elevated. We suspected that he had myocardial ischemia caused by coronary artery spasm. The symptoms of biphasic reaction of anaphylaxis are inconsistent, and using epinephrine for myocardial ischemia following anaphylaxis may aggravate the condition. Nonetheless, epinephrine is the drug of choice for treating anaphylaxis with critical airway, respiratory, and circulatory compromise. Thus, physicians should not hesitate to use epinephrine for patients who present with life-threatening conditions due to suspected anaphylaxis. Physicians should observe patients closely following epinephrine administration, and if they develop some symptoms, should carefully examine the patients because the treatments of anaphylaxis and myocardial ischemia differs. Physicians should be alert to the risk of myocardial ischemia after treatment of anaphylaxis, especially following epinephrine administration.
一位 60 岁既往健康的男性因过敏性休克到我院急诊科就诊。我们开始用乳酸林格氏液进行液体复苏；肌肉注射 0.3mg 肾上腺素；并静脉注射马来酸氯苯那敏 5mg，法莫替丁 20mg，甲基强的松龙 80mg。他的症状在 10 分钟内得到缓解。在注射肾上腺素 30 分钟后，他突然感到胸痛。体格检查未发现过敏反应的证据。12 导联心电图（ECG）显示 II、III、aVF 和 V3-6 导联的 ST 段压低。经胸超声心动图显示心室收缩正常。舌下含服 0.3mg 硝酸甘油后，他的胸痛立即缓解，心电图恢复正常。冠状动脉造影显示冠状动脉灌注正常。第二天，他的高敏肌钙蛋白 I 略有升高。我们怀疑他因冠状动脉痉挛而出现心肌缺血。过敏反应双相反应的症状不一致，并且在过敏反应后使用肾上腺素治疗心肌缺血可能会加重病情。尽管如此，肾上腺素仍然是治疗伴有严重气道、呼吸和循环功能障碍的过敏反应的首选药物。因此，对于因疑似过敏反应而出现危及生命的情况的患者，医生不应犹豫使用肾上腺素。在使用肾上腺素后，医生应密切观察患者，如果出现一些症状，应仔细检查患者，因为过敏反应和心肌缺血的治疗方法不同。医生应警惕过敏反应治疗后发生心肌缺血的风险，尤其是在使用肾上腺素之后。
