A-Typical Anaphylaxis

[mobey]

I do not have alot of info for this pt but I will post what I can. I am thinkin Anaphylaxis.

21 y/o female. Helping friend move when suddenly got very hot and short of breath. Walked into hospital with audible wheezes and stridor. Stridor on inspiration, acc muscles very involved, resps around 36 maybe more. Very pale, unable to speak.

BP 102/68 P98 Spo2 79.

Air entry silent in bases, obvious wheezes in apex's, upper airway stridor.

That's it, no edema, no swollen anything, no uticaria, no nothin!

No PMHx. No asthma, No known allergies.

This has never happened before.

Tx, epy (unknown amount), ventolin 10mg, a steroid. There may be more, but this is all I was told.

I assessed the girl, but got a call and was not there for Tx.

So anaphylaxis? Please clue me in!

(originally I thought first asthma attack, but the stridor and the rapid onset and speed of progression threw me off)

[Capman]

We are lacking a bit of information. I'd like to know more history. What was she around, what did she eat.... You know all that "SAMPLE" stuff! Something as simple as dust could be a respiratory irritant.

As you know, anaphylaxis is an exaggerated immune response. What you are describing does have some of the symptoms of an immune response. an immune response (especially a secondary immune response, or anaphylaxis) would result in a massive release of histamine. You would expect a low blood pressure, and airway obstruction from bronchial constriction. This could be present without the classic swelling and urticaria.

You didn't get the diagnosis? Not to harp, but I would really like more information before I make a call on anaphylaxis or not.

[mobey]

Unfortunatly I did not get too much history, patient was unable to speak and friend was very upset.

last meal unknown. no chemicals or cleaners being used in the area. Patient was helping a friend move handling furniture and boxes. Her only complaint was a hot flash and SOB. Then she had sudden onset difficulty breathing.

Husband (who was at work all day) states she has been healthy with no illness recently.

I was loading a patient in the ER when this girl came in and just offered a hand until other staff were able to assist. I had to leave before much treatment was initiated.

[afib]

shooting from the hip... sounds anaphalaxis but, exercising caution.

[nypamedic43]

This is just a guess, but are we absolutely sure that there werent any chemicals in the area at the time, or had been used in the recent past.

Heres my thinking. Sudden onset SOB, with a hot flash. She isnt tachycardic nor is she hypotensive. O2 sat is low. Im thinking a possible toxic inhalation, because of the wheezes caused by bronchospasm and the stridor caused by layngospasm. No history of recent illness, asthma or allergy to anything. Several cleaning supplies can cause this and if the house wasnt well ventilated, the residual effect could cause all these symptoms. Or the chemicals used to make the cardboard for the boxes, especially if they were brand new.

Just a thought

[firedoc5]

At 21yrs. old, it's unlikely, but not unheard of, but she could possibly have acute on-set of late development of asthma. First treat the SOB and find out possible trigger of it. It could be Anaphylaxis due to developing a new allergy. Had she taken anything with aspirin lately? Or any kind of anti-biotic.?

[Kaisu]

I'm probably exposing my ignorance again, but isn't asthma characterized by expiratory wheezes indicatingbronchiole constriction? This upper airway stridor is generally inspiratory. I have seen sudden onset angioedema only once, and it was due to an allergic reaction. (the patient had eaten shellfish). If it was my patient, they would be getting epi. I'm goiing with anaphylaxis.

[Eydawn]

Also keep in mind this could be something other than an inhalation type exposure... what if she got bitten by a centipede or spider, or other nasty creepy bug? When you're moving furniture, sometimes you find things you never expect...

I also would like to know if she has any seasonal allergies, or family history or allergy/asthma.... and what her friend uses to clean the carpet. And if either of them is a smoker.

Did you look for signs of any sort of bite or sting anywhere? I know you didn't see any obvious urticaria.

I'd probably be giving Epi as well (were I educated well enough to do so!)... but I'd have a high index of suspicion for other causes.

Wendy

CO EMT-B

[firedoc5]

I forgot to mention Diphenhydromine (Benadryl). Along with Epi. and breathing tx. of doc's choice will usually get them through.

[zzyzx]

From what I understand, 20% of anaphylaxis patients will present WITHOUT the typical skin signs (hives, redness, edema, itching.)

(I don't remember the source for this statistic; otherwise I'd include it.)