Case Summary: Refractory Anaphylaxis & Type II Kounis Syndrome   Initial Presentation & Vitals: Patient presented in severe anaphylactic shock secondary to an ant bite. Initial vitals were critically unstable: HR 54 bpm (profound bradycardia), BP 80/60 mmHg, SpO2 75% on room air, and RR 28 breaths/min. The patient had a known difficult airway anatomy consisting of a Mallampati Class 4 and a short neck. Initial Emergency Treatment: Immediately initiated aggressive resuscitation before the airway completely failed. Administered a heavy pharmacological cocktail: Intramuscular (IM) Adrenaline (twice), followed by an Adrenaline Nebulisation, a Levolin (Levosalbutamol) Nebulisation, high-dose systemic corticosteroids (Dexamethasone 16 mg and Hydrocortisone 200 mg), and started a continuous Adrenaline Infusion.With iv fluid boluses Airway Management: Encountered an impossible Cormack-Lehane Grade 3/4 view due to rapid, severe tongue and glottic angioedema. Following two early esophageal intubations, successfully rescued the airway on the third attempt by adapting equipment to a Size 3 Macintosh blade and downsizing to a 7.0 ETT over a bougie. Cardiac Arrest & ROSC: Patient suffered a hypoxic cardiac arrest (SpO2 down to 60s), achieving ROSC after two cycles of CPR. Post-ROSC, the patient developed unstable Ventricular Tachycardia (VT) with a pulse, requiring three synchronized cardioversions to successfully restore sinus tachycardia. Hemodynamic Stabilization: Managed a post-cardioversion blood pressure crash into the 50s by rapidly securing a right femoral central venous line. Administered an aggressive 2000 mL fluid bolus via pressure bag to correct severe distributive shock, and stabilized the patient on low-dose Adrenaline (5 mL/hr) and Noradrenaline (5 mL/hr) infusions. Diagnostics (POCUS): Pre-arrest ECG showed acute anterior ST elevations with downsloping T waves. Bedside POCUS confirmed Regional Wall Motion Abnormalities (RWMA) in the LAD territory, establishing a diagnosis of Type II Kounis Syndrome (allergic plaque rupture). Neuroprotection & Ventilation: Initiated Fentanyl and Vecuronium for deep sedation, paralysis, and cardiac protection. High peak airway pressures on Volume Control prompted an immediate, successful switch to Pressure Control Ventilation (PCV) (IP 25, PEEP 8, FiO2 100%, RR 15, I:E 1:2), which corrected compliance failure and stabilized SpO2 at 92–93% with protective tidal volumes in the 350s. Disposition: Administered an ACS antiplatelet loading dose and initiated a Heparin infusion. Successfully transferred the patient in stable condition to MMC Chennai Cardiology for emergent coronary angiography, presenting a comprehensive, coherent handover directly to the cardiology team

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