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Simon, Failure of any signs of resolution, or progression of airway obstruction (upper or lower), despite having stopped SK and replaced with TpA, I would have a VERY low threshold for titrating IV adrenaline (1:200,000 solution made up in 20 mls - 5 UG boluses) until desired effect achieved in the first instance. I would not wish to wait for any secondary cardio-respiratory insult to compromise her cardiovascular status at such a vulnerable time. Hence the need for an experienced ED clinician on the shop floor! I must add that I am increasingly reluctant to use SK in any patient with borderline perfusion - I will accept the slightly higher cerebrovascular risk of such a strategy........ For discussion purposes, in the absence of the rash, why did you bother with the H1 antagonist? Did you consider oral steroids as opposed IV hydrocortisone (where there is also a low but well recognised risk of inducing acute anaphylaxis......)I assume there was no possibility of known PMH of C1 esterase deficiency etc. John Black -----Original Message----- From: s.carley [mailto:[log in to unmask]] Sent: 24 August 2002 18:44 To: [log in to unmask] Subject: catecholamine dilemma 45 year female presents 4 hours post central chest pain suggestive of myocardial ischaemia. 12 lead ECG shows inf.lateral infarction. P-70 BP-110/60 Decision is made to thrombolyse with streptokinase Patient not given B blockers at any stage 10 min after start of thrombolysis Complains of 1. tightening of throat 2. SOB 3. Tongue swelling 4. Hoarse voice. Examination confirms patient in distress and fearful slight wheeze hoarse voice P-90 BP 105/60 RR up No rash Anaphylaxis suspected. Strep is stopped. Hydrocort (200) and chlorpheniramine (10) given tPA was started in place of strep There was a question of what to do next 1. Watch and wait 2. Adrenaline a. IM b. neb c. IV Any thoughts? Simon Simon Carley SpR in Emergency Medicine [log in to unmask] Evidence based emergency medicine http://www.bestbets.org