A patient of anaemia with haemoglobin of 7 gm percent has been advised iron injections as the preferred therapy by the physician. On being given the prescribed injection by intramuscular route, the patient suddenly develops breathlessness, nausea, and hypotension. What would be the most probable cause?

1. A

   Wrong site of injection

2. B

   Wrong technique of injection

3. C

   Anaphylaxis

4. D

   Heart attack

Appeared in: GMCH Chandigarh - 2022

Explanation

• The combination of sudden breathlessness (respiratory system), nausea (gastrointestinal system), and hypotension (cardiovascular system) points to a multi-system, systemic reaction.
• This clinical triad occurring immediately after the administration of a parenteral iron preparation is the classic presentation of anaphylaxis.
• Parenteral iron, particularly iron dextran, is a known trigger for anaphylactic and anaphylactoid reactions, which can result in vascular collapse and death.
• The reaction is caused by a massive release of histamine and other inflammatory mediators from mast cells and basophils.

Why Other Options Were Wrong

• Option A: A wrong injection site would cause localized symptoms such as pain, nerve damage, hematoma, or an abscess. It would not cause a sudden systemic collapse involving respiratory and cardiovascular systems.
• Option B: An improper injection technique, such as failing to use the Z-track method, primarily leads to local complications like skin staining or leakage of the medication into subcutaneous tissue, causing irritation. It does not trigger systemic symptoms like breathlessness and hypotension.
• Option D: While a heart attack (myocardial infarction) can cause breathlessness and hypotension, its hallmark symptom is typically severe chest pain or pressure. The immediate onset after an injection, coupled with nausea without prominent chest pain, makes anaphylaxis a much more likely diagnosis.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Adverse Drug Reactions and Anaphylaxis Management to guide bedside assessment, documentation, and the next nursing action.
• Nurses must be able to rapidly distinguish anaphylaxis from other adverse reactions because immediate administration of epinephrine is life-saving.
• Emergency resuscitation equipment and medications (epinephrine, antihistamines, corticosteroids, oxygen) must be readily available whenever parenteral iron is administered.
• What if? If the patient had only developed a painful, swollen, and pigmented area at the injection site over the next few hours, the most probable cause would be a local site reaction due to improper technique or irritation, not anaphylaxis.

How to Approach the Question

• First, analyze the clinical scenario for key information: the patient's condition (anaemia), the intervention (IM iron injection), and the outcome (sudden onset of symptoms).
• Identify the specific symptoms: breathlessness, nausea, and hypotension. Note that these affect multiple body systems (respiratory, GI, cardiovascular).
• Consider the timing. The symptoms occurred 'suddenly' after the injection, which points to an acute event directly related to the drug.
• Evaluate each option based on this cluster of information. Ask yourself which condition best explains a rapid, multi-system collapse following an injection.
• Eliminate options that cause only local effects (wrong site/technique) or have a different classic presentation (heart attack typically involves chest pain).
• Conclude that the constellation of symptoms is the hallmark of anaphylaxis, a known risk of parenteral iron.

Concept Tested & Keywords

• Concept Tested: Adverse Drug Reactions and Anaphylaxis Management
• Stem keywords: anaemia, iron injections, intramuscular route, breathlessness, nausea, hypotension
• Lead-in keywords: most probable cause
• Clinical cues: The sudden onset of symptoms immediately after the drug administration is a key indicator of an acute hypersensitivity reaction.

Question ID

Qrj3cDauqy2fj8_cPjLTw_

Copy ID

Reference Book

E6 Pharmacology KD Tripathi Essentials 9e Part 2 pp. 276-278, 277-279

E6 Pharmacology Nurses Shanbhag 3e p. 232-234