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Refractory paediatric anaphylaxis — MRCEM SBA MCQ

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HardPaediatric emergenciesRefractory paediatric anaphylaxisMRCEM SBA

An 8-year-old child weighing 25 kg develops wheeze and becomes faint within minutes of eating a biscuit containing sesame. He has no rash. In the emergency department, his blood pressure is 72/38 mmHg, capillary refill time is 5 seconds and oxygen saturation is 91% on air. He receives high-flow oxygen, two 300-microgram intramuscular adrenaline doses 5 minutes apart, and a 10 mL/kg intravenous crystalloid bolus. Five minutes after the second adrenaline dose, he remains wheezy and hypotensive, although he is breathing spontaneously and has a pulse. Intravenous access and continuous monitoring are in place; senior anaesthetic and paediatric critical care help has been requested. What is the most appropriate management plan now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Arrange critical care transfer, give further crystalloid, and continue intramuscular adrenaline until a titrated intravenous adrenaline infusion is running.

The abrupt wheeze and shock after a likely allergen exposure indicate anaphylaxis despite the absence of a rash. Persistent respiratory and cardiovascular compromise after two appropriate intramuscular adrenaline doses meets the definition of **refractory anaphylaxis**. The child needs further crystalloid, ongoing intramuscular adrenaline every 5 minutes until a specialist-led, titrated intravenous adrenaline infusion is established, and paediatric critical care support. Intravenous adrenaline requires continuous monitoring and clinicians experienced in its use. ([sort.nhs.uk](https://www.sort.nhs.uk/Media/Guidelines/Anaphylaxis-Refractory.pdf)) **A** retains appropriate interim treatment but delays the infusion beyond the threshold already reached. **B** addresses shock, but noradrenaline is a potential *additional* vasopressor if an adrenaline infusion proves insufficient, not its replacement at this stage. **D** may help persistent bronchospasm as an adjunct but does not replace adrenaline for concurrent shock. **E** substitutes a corticosteroid for urgent resuscitation; corticosteroids are not part of routine emergency treatment for anaphylaxis. Once stabilised, this severe reaction requires continued hospital observation rather than early discharge. ([sort.nhs.uk](https://www.sort.nhs.uk/Media/Guidelines/Anaphylaxis-Refractory.pdf))

Reference: Anaphylaxis (Refractory) (Date not stated) — https://www.sort.nhs.uk/Media/Guidelines/Anaphylaxis-Refractory.pdf Anaphylaxis in Adults and Children Clinical Guideline, version 3.0 (December 2025) — https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/CorporateClinical/AnaphylaxisInAdultsAndChildrenClinicalGuideline.pdf Anaphylaxis: assessment and referral after emergency treatment (NG258) (27 May 2026) — https://www.nice.org.uk/guidance/ng258/resources/anaphylaxis-assessment-and-referral-after-emergency-treatment-pdf-66144023784133