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Emergency Medical Minute


Nov 27, 2023

Contributor: Dr. Taylor Lynch

Educational Pearls:

  • Time of arrival until intubation was 26 minutes but nobody tried anterior neck access like a cricothyrotomy until his dad arrived

  • Traditional ACLS protocol is not enough for anaphylactic respiratory arrest

    • Circulating O2 from compressions alone is not enough to sustain the brain

    • Patients need a definitive airway and endotracheal tube is the best method

    • BVM ventilation is not enough to get patients the oxygen they need

  • Time to anoxic brain injury during a respiratory arrest is 4 minutes

  • Definition of anaphylactic shock:

    • Acute laryngeal involvement with bronchospasms after known exposure to an allergen

    • Do not need to have skin symptoms like the classic wheal and flare

    • Must also have either hypotension (from vasodilation or end-organ hypoperfusion) or severe GI symptoms (crampy abdominal pain or repetitive vomiting)

  • Treatment of anaphylactic shock:

    • Push-dose IV epinephrine is better than IM epinephrine because IM epinephrine takes 4 minutes to circulate and get to the lungs

    • Ketamine has broncho-dilating properties so it can be used as an induction agent for intubation

    • Albuterol and ipratropium as continuous bronchodilators

    • Magnesium and IV steroids

  • AMAX4 acronym

    • Adrenaline, Muscle relaxant, Airway, Xtra (bronchodilators, ventilation, vasopressors, and consideration of pneumothorax), 4 minutes to anoxic brain injury


  1. Commins SP. Outpatient Emergencies: Anaphylaxis. Med Clin North Am. 2017;101(3):521-536. doi:10.1016/j.mcna.2016.12.003

  2. Ring J, Beyer K, Biedermann T, Bircher A, Duda D FJ et al. Guideline for acute therapy and management of anaphylaxis. S2 guideline of DGAKI, AeDA, GPA, DAAU, BVKJ, ÖGAI, SGAI, DGAI, DGP, DGPM, AGATE and DAAB. Allergo J Int. 2014;23(23):96-112.

  3. McKenzie B. AMAX4: Every Second Counts. Accessed Sunday, November 26, 2023.

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII