Anaphylaxis After Ceftriaxone in a Third-Trimester Patient

Anaphylaxis in pregnancy is treated exactly like anaphylaxis in anyone else - epinephrine first, no hesitation.

1. Epinephrine 0.3 mg IM in the anterolateral thigh using the in-date autoinjector. If the only device left is the expired one, use it anyway - an expired autoinjector is far better than no epinephrine, and the risk of untreated anaphylaxis is greater than any potency concern. Repeat every 5-15 minutes as needed.
2. Position: supine with left uterine displacement (or left lateral), legs elevated if hypotensive. Do not let her stand or walk - sudden death in anaphylaxis is associated with upright posture.
3. Oxygen high-flow, even from a low tank; bag-mask if needed. Confirm the time 911 was called.
4. IV access and a normal saline bolus for hypotension.
5. Nebulized albuterol for persistent wheeze as an adjunct to epinephrine, not instead of it.
6. Adjuncts, explicitly not first-line: diphenhydramine 25-50 mg and famotidine; methylprednisolone 125 mg IV or prednisone 60 mg PO. Steroids and antihistamines do not treat airway obstruction or shock.
7. Monitor vitals every 5 minutes and watch for uterine contractions or decreased fetal movement.

Do not give IM epinephrine in the deltoid - absorption is slower and less reliable.

A single dose and a better blood pressure do not end the encounter.

• Biphasic reactions occur in a meaningful minority (roughly 5-20%) and can arrive hours later. Standard observation is 4-6 hours minimum after the last epinephrine dose, longer if she needed more than one dose or was hypotensive.
• She still has pyelonephritis at 28 weeks. She needs IV antibiotics and fetal monitoring regardless of the allergic reaction, and that alone requires the ED.
• If she refuses: assess capacity, then name the specific risks to her and to the fetus - recurrent airway compromise, hypotension, preterm labor, fetal distress. Involve her emergency contact with her permission.
• Offer the safest alternative: a responsible adult drives her to the ED now. She does not go home and she is not left alone.
• Document her refusal in her own words, the alternatives offered, and the follow-up call arranged.
• Do not send her home with oral antibiotics and an epinephrine prescription alone without a documented informed refusal.
• Chart the reaction with drug, lot, route, time to onset, and treatment given - this becomes her permanent allergy record, and ceftriaxone and related beta-lactams must be flagged.

The kit failed on three counts: an expired autoinjector, an empty oxygen tank, and no epinephrine vial with syringes for repeat dosing. There was also no glucagon, which matters for patients on beta-blockers who do not respond to IM epinephrine.

Changes to make:

• Monthly inventory with a signed expiration log and a named owner. Replace anything within 90 days of expiry.
• Restock with two in-date autoinjectors plus 1 mg/mL epinephrine vials, 1 mL syringes and needles, a full oxygen tank with a spare, a bag-mask, and glucagon.
• Drills: at least annual anaphylaxis simulation for all clinical staff, including drawing up epinephrine from a vial and positioning a pregnant patient. Document competency for each staff member.
• Written protocol with weight-based pediatric dosing, observation times, and transfer criteria.
• Post-event review: timeline, expired device, empty tank, and documentation; file an incident report and check whether state licensure requires a specified emergency kit or makes this event reportable.
• Verify whether the patient's allergy was entered into the EHR allergy field before she left the building.

Quality events like this are only useful if they change a checklist, an owner, and a date.