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Anaphylaxis shock

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anaphylaxis emergency epinephrine guidelines emergency services CDC

Anaphylactic shock is a life-threatening allergic reaction causing airway swelling, breathing difficulty, and/or dangerously low blood pressure. Common triggers include foods, medicines, insect stings, and latex.

If this may be happening now

  1. Use epinephrine (adrenaline) immediately if available. Use the prescribed auto-injector in the outer mid-thigh, through clothing if needed.
  2. Call emergency services now (911/112/your local number), even if the person improves.
  3. Lay the person flat with legs raised. If breathing is difficult, they may sit with legs outstretched. Do not let them stand or walk. If vomiting or unconscious but breathing, place on their side.
  4. If symptoms persist or return and emergency help has not arrived, give a second auto-injector dose after 5-15 minutes.
  5. If they are unresponsive and not breathing normally, start CPR if trained.
Signs include trouble breathing or wheeze, throat tightness/voice change, tongue or facial swelling, widespread hives, severe dizziness/fainting, pale clammy skin, collapse, or repeated vomiting after allergen exposure.
Epinephrine is first-line treatment and has no absolute contraindication in suspected anaphylaxis. Antihistamines and asthma inhalers may help selected symptoms but must not delay epinephrine or emergency care. CDC emergency guidance supports prompt intramuscular epinephrine and EMS activation. ROSEN's Emergency Medicine states that epinephrine should be given immediately and is first-line treatment for anaphylaxis.
In hospital, management includes airway and oxygen support, repeated IM epinephrine as needed, IV fluids for shock, continuous monitoring, and observation because symptoms can recur. IV epinephrine infusions are reserved for medically supervised refractory shock, not home use. CDC guidance notes that airway support, oxygen, IV saline, and emergency transfer may be necessary.

Myasthenia gravis

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https://www.ninds.nih.gov/health-information/disorders/myast…

Myasthenia gravis (MG)

Myasthenia gravis is an autoimmune disorder of the neuromuscular junction that causes fluctuating, fatigable weakness of voluntary muscles. Antibodies, most often against the postsynaptic acetylcholine receptor (AChR), impair transmission from nerve to muscle. Weakness typically worsens with repeated use and improves after rest. Bradley and Daroff's Neurology in Clinical Practice, p. 2770.

Typical features

  • Drooping eyelid(s), called ptosis
  • Double or blurred vision
  • Facial weakness or altered facial expression
  • Nasal or slurred speech
  • Difficulty chewing or swallowing
  • Neck, arm, or leg weakness
  • Shortness of breath in severe disease
Eye symptoms are often the first manifestation. Sensation is normal, and MG generally does not cause numbness, pain, or loss of reflexes.

Diagnosis

A neurologist usually combines:
  • Clinical evidence of fatigable weakness
  • Blood tests for AChR antibodies, and sometimes MuSK or other antibodies
  • Repetitive nerve stimulation or single-fiber EMG
  • Chest CT or MRI to assess for a thymoma, a tumor of the thymus gland
  • Selected bedside tests for ocular symptoms
Single-fiber EMG is the most sensitive electrodiagnostic test for MG, according to the NINDS overview.

Treatment

Treatment depends on severity, antibody subtype, and whether disease is ocular or generalized:
  • Pyridostigmine: improves nerve-to-muscle signaling and symptoms.
  • Corticosteroids and steroid-sparing immunosuppressants: reduce autoimmune activity.
  • Thymectomy: indicated for thymoma and helpful for selected people with generalized AChR-positive MG.
  • IV immunoglobulin (IVIG) or plasma exchange: used for significant worsening, before certain surgeries, or crisis.
  • Targeted biologic therapies may be considered for refractory generalized MG under specialist care. A 2025 systematic review compared newer biologics, but treatment selection remains individualized (PMID 40346603).

Emergency: myasthenic crisis

Seek emergency care immediately for:
  • Increasing breathlessness, weak cough, or inability to clear secretions
  • Difficulty swallowing saliva or repeated choking
  • Rapidly worsening speech, neck, or generalized weakness
This can be myasthenic crisis, in which respiratory muscles become too weak and ventilatory support may be needed. Infection, surgery, stress, and some medicines can trigger it. Do not stop or change MG medicines without clinician advice.
Some drugs can worsen MG in certain patients, including particular antibiotics, magnesium-containing products, beta-blockers, and neuromuscular-blocking anesthetics. Always tell clinicians, dentists, and pharmacists that you have MG.
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