SANDMEDIC Posted August 24, 2008 Posted August 24, 2008 I have to try my hand at this.. You are EMS unit stationed in the rural Midwest. Approximately 30 minutes from the nearest hospital. It is a sunny summer day. Hanging out at the station the tones drop. “6417, 6410 respond to an EMS call from card 8322 map 4. Difficulty breathing, 13244 County Road 462.” You are dispatched to a residence 10 miles from your station for a 48 y/o male that was mowing his grass when he was “stung” by multiple bees. Dispatch advises fire is also responding due to the high volume of bees still swarming outside the residence. Dispatch also advises you have a "Conscious and alert male c/o difficulty breathing and severe rash".
akflightmedic Posted August 24, 2008 Posted August 24, 2008 Send next unit due. I am allergic. No unit available, I quit.
SANDMEDIC Posted August 24, 2008 Author Posted August 24, 2008 The patient waited nearly 4 hours before calling 911 as he thought he “was fine”. Pt. c/o rash, difficulty speaking, and difficulty breathing. Pt advises he used his EpiPen without success. As you stage a safe distance the fire department used the old dish soap in the water tank trick and has since made the scene safe. As you enter the home you can hear the wheezes from the patient in the kitchen. Upon arriving at the patient you find a 48 y/o male A/O x 4 speaking short word sentences, profound uticaria over his entire body. Pt /c profound edema to upper and lower lips. Pt in obvious respiratory distress. Pt’s wife states he was just fine and they were waiting for the exterminator to arrive. She states it has been nearly 4-5 hours ago. Pt’s wife advises the pt. used his EpiPen just prior to your arrival. Pt’s wife provides you his complete medical history. Hx: HTN, hyperlipidemia, BPH, Medication: Zocor, Tenormin, Altace, ASA Allergies: PCN, Sulfa Primary assessment as follows: Male A/O x 4 speaking short stridorous sentences. Face: Pale skin color. Eyes: PERRL @ 3mm Chest: (=) rise & fall, labored resp., accessory muscle use Lungs: Inspiratory/ expiratory wheeze bilat x 4, diminished @ bases. Ext: CMS intact x 4, uticaria to upper and lower extremities. Skin: Pale, hot, diaphoretic.
mobey Posted August 24, 2008 Posted August 24, 2008 Sorry not too interested in Hx yet.... lets get him breathing more comfortably first. SPO2? Pulse rate, and regularity? Partner applies monitor while I draw up EPI. 0.5mg EPY IM, deltoid. 5.0mg Ventolin in nebulizer. Get a line in start diphenhydramine protocol
ERDoc Posted August 24, 2008 Posted August 24, 2008 I just want to make sure I'm clear on this. He was stung 4-5 hours prior and the bees are still swarming? They were taken care of by FD. He took his epipen just prior to calling? Did he take anything immediately after he was stung? Why did he take the epipen so late? What new symptoms was he having just prior to the epipen? What symptoms started after he used the epipen?
mobey Posted August 24, 2008 Posted August 24, 2008 I just want to make sure I'm clear on this. He was stung 4-5 hours prior and the bees are still swarming? They were taken care of by FD. He took his epipen just prior to calling? Did he take anything immediately after he was stung? Why did he take the epipen so late? What new symptoms was he having just prior to the epipen? What symptoms started after he used the epipen? Ya I was getting to this....... I am kind of doubting this episode has much to do with the bees. What has he done since the multiple stings? Eaten? Drank? Showered?
SANDMEDIC Posted August 24, 2008 Author Posted August 24, 2008 The patient was stung multiple times (unknown amount). The bees were still there swarming when the fire department arrived 4 hours later. The patient had no immediate response to the bee stings. He used his EpiPen just prior to you arrival due to his difficulty breathing "getting worse" No changes for better or worse after use of EpiPen. This is gonna be a quick one all. We've all done the Anaphylaxis protocol and it varies some but I was schooled on this early in the career and it something you never forget. I'm going to present this exactly how I treated the patient. Your Partner places the pt on O2 -NRB@ 15lpm Your partner obtains a set of vitals as follows: BP 88/50 Pulse: 122 Resp: 30 irregular. SaO2: 92% on NRB @ 15lpm You place the patient on the ECG monitor: LDII RSR@ 130 /s ectopy. You administer Epinephrine 1:1,000 0.3mg-0.5mg SQ And begin SVN/ nebulizer Albuterol 2.5mg/ Atrovent 0.5mg. You establish an IV NS 1000ml wide open rate You administer 50mg of Benadryl IV. You administer 125mg Solu-Medrol IV.
mobey Posted August 24, 2008 Posted August 24, 2008 So did our treatment end the "crisis" If so I would like to know what he did after the bee stings. Oh and why does he have an EpyPen? For Sulfa and PCN allergy??
SANDMEDIC Posted August 24, 2008 Author Posted August 24, 2008 The patient used his wifes EpiPen which was not expired. She is severely allergic to bees. Pt thought "But thought it would work". The patient denies eating, he stated he drank a soda and took a shower. The patient states he does not feel any better. You load him on the stretcher and begin the journey 30 minutes to the hospital. Pt states his “throat is getting tighter”. Racking your brain you administer an additional dose of Epinephrine 1:1,000 0.5mg SQ. 10-15 min since initial dose. And continue the SVN/ Nebulizer Albuterol/ Atrovent (Ud). Second set of vitals: BP: 90/48 (after 750ml NS IV) P:132 R: 28 irregular SaO2: 88%
SANDMEDIC Posted August 24, 2008 Author Posted August 24, 2008 So at this point i'm growing more and more concearned as the miracle Epi & Benadryl is not doing the trick. It is at this point I hop on the radio with our base hospital (Something rarely done) for guidance. You are the base hospital, what are you gonna advise. or You are in my position, what are you gonna do. SaO2 continues to drop and there was no RSI to use.
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