A 56-Year-Old Woman in the Emergency Department Waiting Room Develops

A 56-year-old woman in the emergency department waiting room develops shortness of breath and generalized itching.  She was eating a cookie when the symptoms started.  The patient is allergic to peanuts and believes the cookie contained them.  She has a history of emphysema and a 20-pack-year smoking history.  Temperature is 36.7 C (98.1 F), blood pressure is 88/60 mm Hg, pulse is 124/min, and respirations are 26/min.  Pulse oximetry is 92% on room air.  The patient is using the accessory muscles of her neck and shoulder girdle and is exhaling through pursed lips.  There is no tongue swelling or stridor.  Bilateral wheezes are present on lung auscultation.  Skin examination is shown in the exhibit.  The patient is given an intramuscular injection of epinephrine.  Ten minutes later, there is no significant change in her condition.  Which of the following is the best next step in management of this patient?

A)Inhaled albuterol
B)Intramuscular epinephrine
C)Intravenous diphenhydramine
D)Intravenous methylprednisolone
E)Subcutaneous epinephrine

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