Adrenaline overdose in pediatric anaphylaxis: a case report

Background: Adrenaline is the standard treatment for anaphylaxis but appropriate administration remains challenging, and iatrogenic overdose is easily overlooked. Despite the established importance of pediatric blood pressure measurement, its use remains inconsistent in clinical practice. Case presentation: We report a case of adrenaline overdose in a 9-year-old white boy with anaphylaxis, where signs of adrenaline overdose were indistinguishable from progressive shock until blood pressure measurement was taken. Conclusions: The consequences of under-dosing adrenaline in anaphylaxis are well-recognized, but the converse is less so. Blood pressure measurement should be a routine part of pediatric assessment as it is key to differentiating adrenaline overdose from anaphylactic shock.