This case involves a male patient who had an anaphylactic reaction to cashew nuts. Initial management included Benadryl and steroids. The patient’s condition deteriorated and the decision to administer epinephrine was made. The nurse started an IV and the physician gave orders for a specific dosage of epinephrine. There was some uncertainty as to the exact dosage necessary. As a result, the patient was given 1 mg. The infant immediately became tachycardic in the 180s.