Worst Anaphylaxis I've seen in a while...

[emtchick171]

Working a stand-by at the local county fair...when my partner and I were hanging around at the "first aid" tent. We noticed a girl rushing up to us, and behind her was a female with extreme swelling of her lips, also noticed up her left arm was breaking out with hives. Once we got her on the truck, started an IV, gave .5 of Epinephrine, 3 Albuterol neb treatments, 50mg of Benadryl, and 125mg of Solumedrol. By the time we made it from the parking lot at the fairgrounds to the main highway, she had broken out with hives all over her body, including her feet. Also, her neck began swelling large enough it was noticeable to my partner and I. Her O2 sats never dropped below 97%, her b/p trended initial: 116/64, 110/62, and upon arrival at the hospital 106/50. We rushed her into a trauma room and she was sitting up talking by the time the doctor came in. She was kept in the hospital 2 nights, and released on the third day; due to her having a secondary anaphylaxis reaction 24 hours after we brought her in. She told us that she had been stung by a bee and that is what caused the anaphylaxis, however she said she had been stung many times before and never had any type of reaction.

---anything to add and/or take away??

 

[fast65]

Working a stand-by at the local county fair...when my partner and I were hanging around at the "first aid" tent. We noticed a girl rushing up to us, and behind her was a female with extreme swelling of her lips, also noticed up her left arm was breaking out with hives. Once we got her on the truck, started an IV, gave .5 of Epinephrine, 3 Albuterol neb treatments, 50mg of Benadryl, and 125mg of Solumedrol. By the time we made it from the parking lot at the fairgrounds to the main highway, she had broken out with hives all over her body, including her feet. Also, her neck began swelling large enough it was noticeable to my partner and I. Her O2 sats never dropped below 97%, her b/p trended initial: 116/64, 110/62, and upon arrival at the hospital 106/50. We rushed her into a trauma room and she was sitting up talking by the time the doctor came in. She was kept in the hospital 2 nights, and released on the third day; due to her having a secondary anaphylaxis reaction 24 hours after we brought her in. She told us that she had been stung by a bee and that is what caused the anaphylaxis, however she said she had been stung many times before and never had any type of reaction.

---anything to add and/or take away??

Sounds like you all did a pretty good job of managing her. But, did you two do a thorough physical exam? Did you find the stinger and remove it? Able to obtain any sort of medical history/medications?

 

[emtchick171]

Stinger had been removed prior to her arrival at EMS tent, and according to her mother she had zero medical history of any kind.

 

[mycrofft]

Pretty classic.

1. Folks will sometimes react despite earlier exposures without reaction.
2. A bee is not a bee...sometimes it is a wasp, or even a wasp bite (not a sting). And there are different types of wasps, including the little wingless fuzzy one called velvet ant that hurts like blazes.
3. All the field drugs except maybe the steroids wear off relatively quickly in the face of a determined reaction.
4. NEVER risk a reaction just because you have benedryl and epi at hand.
5. Just because she was stung by something doesn't mean she did not eat the peanuts, didn't drink the sulphite-laced wine spritzer, or whatever else.
6. Even if it is a sting or topical exposure, the localized reaction can be less dramatic than the hives which shortly ensue. This is especially true with urushiol contact (so called poison oak/ivy/sumac), the point of contact may look pretty ok but rashes break out everywhere.

 

[Fish]

Did she have any airway specific complaints? Or are we talkin mostly hives, rash, and swelling of Dermal layers?

What area of North Carolina?

 

[emtchick171]

Her airway was swelling, she went unresponsive at one time. She was also having extreme hives. The south east part of NC

 

[akflightmedic]

Sounds like good management, do you guys carry Tagamet or Zantac (cimetidine or ranitidine)?

H2 blockers have been shown to help when used in conjunction with benadryl.

This is a good time to also remind everyone about the use of glucagon in allergic reactions--especially for those on beta blockers who are not responding to epi as well.

 

[Handsome Robb]

This is a good time to also remind everyone about the use of glucagon in allergic reactions--especially for those on beta blockers who are not responding to epi as well.

I'm wondering more about this. We talked about it in class the other day but I'm having trouble grasping it. Is the glucagon actually having an inotropic and chronotropic effect or is it allowing the meds administered prior to and concurrently with the glucagon to take effect by opening a 'back door' to surpass the beta blockade?

 

[emtchick171]

Sounds like good management, do you guys carry Tagamet or Zantac (cimetidine or ranitidine)?

H2 blockers have been shown to help when used in conjunction with benadryl.

This is a good time to also remind everyone about the use of glucagon in allergic reactions--especially for those on beta blockers who are not responding to epi as well.

No we do not carry Zantac or anything of the sorts. However when we arrived at the hospital, that's the only thing the doc gave her. He ordered 300 of Pepcid for a drip.

---good point with the glucagon that's often forgotten. Do y'all have standing orders for that? (I know we have to call when giving it for anything other than hypoglycemia w/o IV access).