Emergency Care — दवा रिएक्शन (ADR) की आपातकालीन देखभाल
यह पेज ADR Guide का emergency companion है। Quick links: Anaphylaxis • Airway • IV Fluids • Medicines & Doses • Pediatric Dosing • EMS Handover • Documentation
1) Triage & Red Flags
Red Flags: साँस में तकलीफ़/stridor, voice change, hypotension/syncope, widespread urticaria with facial/tongue swelling, wheeze, cyanosis, altered mental status, rapidly progressive rash/blisters (SJS/TEN), persistent vomiting/diarrhea with dehydration, oliguria.
High-risk बच्चे, बुज़ुर्ग, गर्भवती, अस्थमा/COPD, cardiac रोग, chronic kidney/liver disease, beta-blocker पर चल रहे मरीज।
2) Rapid Algorithm — ABC-DE
- A — Airway: Look for tongue/laryngeal edema; jaw thrust, suction, prep for intubation (see Airway).
- B — Breathing: O2 via non-rebreather 10–15 L/min; bronchodilator neb if wheeze.
- C — Circulation: Two large-bore IV lines; bolus crystalloid; IM epinephrine for anaphylaxis (details).
- D — Disability: GCS, glucose (rule out hypoglycemia), consider seizure control.
- E — Exposure: Full skin exam; remove triggers, tight clothing/jewelry; temperature control.
3) Anaphylaxis Protocol (Life-saving)
First-line = IM Epinephrine (anterolateral thigh).
Adult: 0.3–0.5 mg of 1 mg/mL (1:1000) IM; repeat every 5 min if needed.
Child: 0.01 mg/kg (max 0.3 mg) IM; repeat q5 min if refractory.
Place patient supine with legs elevated unless respiratory distress prevents.
| Therapy | Typical Adult Dose | Notes |
|---|---|---|
| Oxygen | 10–15 L/min NRBM | Target SpO₂ ≥94% |
| IV Fluids | 1–2 L NS/LR bolus, titrate | Hypotension/shock में aggressive fluids |
| Antihistamine (H1) | Chlorpheniramine 10 mg IV or Cetirizine 10 mg PO | Adjunct only; never replace epinephrine |
| H2 Blocker | Ranitidine 50 mg IV / Famotidine 20 mg IV | Urticaria/angioedema में सहायक |
| Steroid | Hydrocortisone 100–200 mg IV | Biphasic risk कम करने हेतु adjunct |
| Bronchodilator | Salbutamol neb 2.5–5 mg q20min ×3 | Wheeze/bronchospasm |
| Refractory shock | Epinephrine infusion 1–4 mcg/min (titrate) | ICU setting, monitor continuously |
| β-blocker on board | Glucagon 1–2 mg IV bolus → infusion | β-blocker refractory anaphylaxis |
4) Airway & Breathing
- High-flow O2, continuous pulse-ox, capnography if available.
- Angioedema/stridor → early call for senior/anaesthesia; prepare video laryngoscope; consider awake intubation. If failed airway → cricothyrotomy (specialist).
- Nebulized adrenaline (5 mL of 1 mg/mL diluted as per local protocol) can help upper-airway edema while preparing definitive airway.
5) Circulation & IV Fluids
Hypotension/shock में crystalloids (NS/LR) से शुरू करें; response के अनुसार titrate करें। Elderly/heart failure में fluid responsiveness पर नज़र रखें.
| Scenario | Initial Bolus | Reassess |
|---|---|---|
| Adult hypotension | 500–1000 mL rapid | BP/mental status/urine output |
| Pediatric hypotension | 20 mL/kg over 5–10 min | Perfusion, HR, cap refill |
| Bronchospasm predominant | Fluids as needed | Beware dynamic hyperinflation |
6) Medicines & Doses (Adult, typical)
| Drug | Dose/Route | Use | Cautions |
|---|---|---|---|
| Epinephrine (IM) | 0.3–0.5 mg IM (1 mg/mL) | Anaphylaxis first-line | Don’t delay or substitute |
| Hydrocortisone IV | 100–200 mg | Adjunct to reduce biphasic risk | Hyperglycemia, infection risk |
| Chlorpheniramine IV | 10 mg slow IV | H1 blockade | Sedation |
| Famotidine IV | 20 mg IV | H2 blockade | Renal adjust |
| Salbutamol Neb | 2.5–5 mg q20 min ×3 | Bronchospasm | Tachycardia |
| Glucagon IV | 1–2 mg bolus → 5–15 mcg/min infusion | β-blocker refractory | Nausea/vomiting |
| Ondansetron | 4–8 mg IV/PO | Anti-emetic | QT prolongation |
7) Pediatric Dosing Quick Table
| Drug | Dose | Max | Notes |
|---|---|---|---|
| Epinephrine (IM) | 0.01 mg/kg of 1 mg/mL | 0.3 mg | Repeat q5 min if needed |
| Hydrocortisone IV | 2 mg/kg | 100 mg | Adjunct |
| Chlorpheniramine IV | 0.2 mg/kg | 10 mg | Slow IV |
| Salbutamol Neb | 0.15 mg/kg per neb | 5 mg | q20 min ×3 |
| Fluids (NS/LR) | 20 mL/kg bolus | — | Reassess after each bolus |
8) Monitoring & Tests
- Vitals q5–15 min; continuous SpO₂, cardiac monitoring.
- Labs: CBC, electrolytes, LFT, KFT; ABG if respiratory compromise.
- 12-lead ECG if chest tightness/arrhythmia.
- Urine output target ≥0.5 mL/kg/h (adult), ≥1 mL/kg/h (child).
- Consider serum tryptase (if within 1–3h of event) for suspected anaphylaxis (where available; not to delay treatment).
9) Observation vs Admission
| Observe & Discharge (consider) | Admit (ward/ICU) |
|---|---|
| Mild urticaria; vitals stable; single dose antihistamine effective; reliable follow-up within 24–48h; education provided. | Airway compromise/angioedema, anaphylaxis (post-resuscitation observation 6–24h), hypotension, comorbidities, SJS/TEN, poor social support. |
10) EMS/ICU Handover Template (SBAR)
S — Situation: Suspected ADR with [rash/angioedema/anaphylaxis], onset [time], current status [stable/unstable].
B — Background: Drug(s) taken [name, dose, time], prior allergies, comorbidities, beta-blocker use.
A — Assessment: Vitals, exam (airway/skin), interventions done (IM epi ×2, fluids 1 L, antihistamine, steroid), response.
R — Recommendation: Continue monitoring, prepare for [intubation/ICU], labs pending, need for epinephrine infusion.
11) Documentation, Reporting & Discharge
- Document suspected drug, timing, lot/batch if known, all interventions/doses/times.
- Issue ADR/Allergy card; write clear avoid list.
- Reporting: National ADR Portal India / hospital pharmacovigilance.
- Discharge prescriptions: non-sedating antihistamine, emergency plan, return precautions; consider epinephrine auto-injector where feasible.
- Arrange follow-up with Allergy/Immunology or Dermatology per presentation.
12) Internal & External Links
- Internal: ADR Guide (Full) • Pharmacology • Dermatology • Allergy
- External (authoritative): WHO — Pharmacovigilance • Resuscitation Council — Anaphylaxis • NCBI Bookshelf — Anaphylaxis