Itching all over

[Jambi]

I will provide information as it's asked because it's more fun that way. This is mostly BLS with a dash of ALS tossed in.

You respond the a 64 year old female complaining of itching all over. General impression is of a women in a moderate amount of distress due to discomfort from what it obviously itching skin. She oriented and is breathing normally and is without any obvious skin redness, hives, or other visually appreciated disorder.

She complains of the itching, then immediately goes into how she ate some nuts about an hour ago and had one shot of tequila. She says her itching is driving her crazy.

 

[DesertMedic66]

Vitals, allergies (reaction with allergies), med history, current meds, has this issue happened in the past, how many nuts?

 

[exodus]

I would run down the basis of an allergic reaction as it's what is presenting. In the field we shouldn't be looking for zebras until our standard obvious treatment fails.

 

[Jambi]

Vitals - B/P: 164/88 Pulse: 104 S/R Resp: 20 Lungs: clear Skins: Normal and warm
allergies- Denies
reaction with allergies- denies
med history- Hysterectomy 15 years ago
current meds- Denies
has this issue happened in the past- never
how many nuts- about 2 ounces worth

 

[Jambi]

I would run down the basis of an allergic reaction as it's what is presenting. In the field we shouldn't be looking for zebras until our standard obvious treatment fails.

Agreed. This was a fairly straight forward call.

 

[DesertMedic66]

Yep. Patient would have most likely been given some diphenhydramine.

 

[exodus]

Agreed. This was a fairly straight forward call.

The no past hypersensitivity does make me believe that it *wasn't* the nuts that caused the allergic reaction, but something else in the enviroment. We don't really care as it's all treated the same way.

I would say this though to new guys on calls like these. Treat what your patient is presenting with and don't base your treatment on their past history 100%. They may have developed new conditions or sensitivities. If they say they ate nuts, but have never had an allergic reaction, but are now presenting with what would appear to be one. Treat it! Worst case scenario, they get a nice nap from the benadryl and they call in a dermatologist.

 

[Wes]

I'd be curious to see waveform capnography and also do some questioning to find out if she's had any new environmental exposures. I've actually had a patient who had a mild reaction to a change in laundry detergent.

 

[Medic Tim]

I'd be curious to see waveform capnography and also do some questioning to find out if she's had any new environmental exposures. I've actually had a patient who had a mild reaction to a change in laundry detergent.

I see this all the time from camp staff and workers. I work in a clinic out in the oilfields.

 

[Jambi]

The no past hypersensitivity does make me believe that it *wasn't* the nuts that caused the allergic reaction, but something else in the enviroment. We don't really care as it's all treated the same way.

I would say this though to new guys on calls like these. Treat what your patient is presenting with and don't base your treatment on their past history 100%. They may have developed new conditions or sensitivities. If they say they ate nuts, but have never had an allergic reaction, but are now presenting with what would appear to be one. Treat it! Worst case scenario, they get a nice nap from the benadryl and they call in a dermatologist.

Good point and that was the approach to this patient.

I'd be curious to see waveform capnography and also do some questioning to find out if she's had any new environmental exposures. I've actually had a patient who had a mild reaction to a change in laundry detergent.

Capnography was not obtained on this patient. For what it's worth her SpO2 was 94% RA (heavy smoker) that was brought up to 96% by N/C @ 2lpm. She denied any respiratory distress, lungs were clear, and without discomfort or swelling to her mouth or throat.

Her most recent environmental exposure was having sat out by the pool (in the sun) for a couple of hours. This was a normal activity for her. Interesting note though is that her itching was ultimately found to be confined to her exposed skin. anything under her clothes were unaffected. She also denied laundry detergent change or recent dry cleaning.

 

[Jambi]

I should add that ALS treatment ultimately consisted of an 18GA IV, NS 1000ml bag, and one dose of 50mg Diphenhydramine that resolved her itching within 2 minutes of administration.

For me, the biggest issue with this patient as she presented, was her comfort. Benadryl addressed that issue and fortunately she had no other appreciated conditions or concerns, but then that's why we transport to the hospital after all.

I saw her later that day and she volunteered the information that the ED Dr thought that it was likely a combination of things that ended with the sun exposure precipitating the reaction. She still has an appointment with an allergist to determine sensitivity.

 

[mycrofft]

Pruritis and urticaria.

There are meds and chemicals which cause itching upon exposure to sunlight or high intensity UV sources. Used to see that with the very first sunscreen/UV blocker lotions which were clear, when they outdated. Sunburn only where the stuff HAD been applied.

When people complain of itching, I used to observe where they have been scratching and how hard, especially versus where they complain of the itching. I'd watch how they scratched too.

If pt VS were accelerating, maybe entertain potential for onset of alcoholic withdrawal. Also, psych. If it's alcohol, benadryl won't help and might mask acceleration of complaints. Anything else, including drug seeking, it'll work. But watch out for weird psych reactions to large IM or any IV diphenhydramine.



What would you say if the itching were only nocturnal?

 

[NBFFD2433]

The no past hypersensitivity does make me believe that it *wasn't* the nuts that caused the allergic reaction, but something else in the enviroment. We don't really care as it's all treated the same way.

I would say this though to new guys on calls like these. Treat what your patient is presenting with and don't base your treatment on their past history 100%. They may have developed new conditions or sensitivities. If they say they ate nuts, but have never had an allergic reaction, but are now presenting with what would appear to be one. Treat it! Worst case scenario, they get a nice nap from the benadryl and they call in a dermatologist.

I agree.