# 情境 6歲(20 kg)兒童於ED接受IV ampicillin第一劑。5分鐘內出現蕁麻疹、唇與舌腫脹、可聞喘鳴、BP 70/40、HR 150。最優先的介入為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375217&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 題目

情境 6歲(20 kg)兒童於ED接受IV ampicillin第一劑。5分鐘內出現蕁麻疹、唇與舌腫脹、可聞喘鳴、BP 70/40、HR 150。最優先的介入為何?

## 選項

1. 將ampicillin輸注速率降低至每分鐘10毫克，輸注1小時，給予diphenhydramine 1毫克/公斤靜脈注射，透過非再呼吸型面罩提供高流量氧氣，將孩童置於半坐臥姿勢，給予10毫升/公斤生理食鹽水靜脈推注，15分鐘後重新評估；若症狀改善，繼續輸注，並在未來給藥前以prednisolone 1毫克/公斤口服作為前導藥物。
2. 停抗生素、啟動rapid response、給epinephrine 0.01 mg/kg(0.2 mg = 1 mg/mL的0.2 mL) IM於大腿前外側、高流量氧氣維持氣道、平躺抬腿、IV NS 20 mL/kg bolus、必要時5~15分鐘重複給epinephrine、備H1、H2及類固醇為輔助。 **✔ 正確答案**
3. 給予20毫升/公斤生理食鹽水靜脈推注，將床傾斜成垂頭仰臥姿勢，給予高流量氧氣，測量生命徵象，並通知提供者準備diphenhydramine 1毫克/公斤靜脈注射和famotidine 0.25毫克/公斤靜脈注射；1小時後重新評估，若症狀未改善，則給予epinephrine 0.01毫克/公斤肌肉注射。
4. 給予diphenhydramine 1毫克/公斤口服，在蕁麻疹處塗抹calamine洗劑，讓孩童坐直且雙腿下垂，提供安撫，並觀察30分鐘；若喘鳴或腫脹持續，呼叫快速反應小組，然後在大腿給予epinephrine 0.01毫克/公斤肌肉注射。

**正確答案: 2**

## 解析

此為anaphylaxis — 接觸抗原數分鐘內由IgE介導的致命多系統(皮膚、呼吸、循環、腸胃)過敏反應。第一線藥物為肌肉注射epinephrine；延誤或單用抗組織胺/類固醇是常見錯誤，會增加死亡率。小兒劑量：1 mg/mL (1:1000) 0.01 mg/kg IM於大腿前外側，青春期前單次最高0.3 mg、成人0.5 mg，必要時每5~15分鐘重複。同步處置：停止致敏抗生素、啟動rapid response或code、以氧氣支持氣道並備插管、若呼吸困難容許可平躺抬腿、低血壓給NS 20 mL/kg IV、支氣管痙攣給albuterol nebulization、H1 (diphenhydramine)、H2 (famotidine)及類固醇 (methylprednisolone)僅作epinephrine後輔助。觀察雙相反應至8~12小時、記錄、出院時開立epinephrine自動注射器並衛教，並安排過敏門診追蹤。單用diphenhydramine、減速、單純輸液皆危險，會錯過epinephrine優先。

## 深入解析

Anaphylaxis = 先打肌肉內epinephrine。抗組織胺與類固醇為輔助，不是替代。大腿前外側為首選位置。

## 重要概念

- **epinephrine 0.01 mg/kg IM** — anaphylaxis第一線，1 mg/mL，大腿前外側，必要時5-15分鐘重複
- **anaphylaxis criteria** — IgE介導，多系統，皮膚加上呼吸或循環，立即epinephrine
- **biphasic reaction** — 在epinephrine後8-12小時內可復發，需觀察，並開立自動注射器

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