Allergic reaction?

[P_Instructor]

Tiered in with EMT squad. Enroute information is female with complaint of throat swelling closed.

Get on scene and enter their ambulance and see female sitting upright on cot, respiratory rate 40, accessory muscle use. Pt. awake, color pink, skin warm/dry. No adventagious sounds heard. Pt. on oxygen per NRB, sats 97%, BP 170/100, HR 120 per machine.

Initial contact shows scared look from patient, 1-2 sentance wording. Best info from squad is possible allergic history to flowers where patient was helping setting up for funeral. Onset of slight symptoms 1 hr prior.

Listen to breath sounds which are clear. Auscultate trachea, no stridor heard. With the lung sounds, no evidence of uticaria anywhere on torso, no evidence of swelling/edema. Only complaint is throat swelling. Oral cavity normal.

Monitor placed sinus tach without ectopics. Patient very anxious and moving around on cot. Epi 0.3mg given IM. IV then established by partner. 25mg Diphenhydramine given IV. Pateint states a little better approximately 2 mins later. Reassessed lungs, etc. without change. Vitals BP 150/100, HR 110, RR 34, sats 99%. Pt. is exhibiting beginning s/s of hyperventilation. Pt. breathing pattern coaxed with some success.

Calling in radio report and patient start again to become very scared as gestures throat again swelling up. 0.1mg Epi 1:10000 given IV. 10 seconds later patient begins screaming and shows Levine sign. No changes in monitor, ST. Episode lasts 10-15 seconds. Pucker factor is 15 on 1-10 scale. No time or conditions available for 12-Lead as patient very unsettled. Pt. verbally calmed for remainder of 2 minute transport.

Arrive hospital and off load to ER. ER doc meets you at door, report given. Upon doc assessment, ativan given to calm pt. but then pt. again has throat swelling sensations and doc administers Epi with same screaming/Levine sign gesture.

You leave to go back in service. Find out later pt. goes to cath lab with suspected MI.

Later in evening, Cath reveals all vessels open.

Hummmm....allergic reaction or atypical MI????

Thoughts.

[Kiwiology]

The fail ... it is so strong.

You state yourself this patient showed no signs of anaphylaxis and yet you jack her up with adrenaline, worse yet, IV adrenaline?

Please don't use eponymous; I had to look up what Levine's sign was ... and if she is clutching her chest do you think it might have had something with that IV adrenaline you put into her?

Sounds to me like a little bit of pseudo anaphylaxis and certainly not something that is a candidate for IV adrenaline or DPH; if the patient actually had angioedema with stridor but without systemic involvement (which is not unheard of) then some nebulised adrenaline is appropriate.

There is good empirical evidence that adrenaline is overused in patients with asthma and anaphylaxis. Yes, early administration of adrenaline is critically important in patients with anaphylaxis but if you're giving this sort of patient adrenaline then I would very seriously hope you are not teaching this same clinical approach to your students.

There was a case here a few years ago of a Doctor giving a patient adrenaline for "anaphylaxis", the patient ended up suffering myocardial damage and the case was referred to the Health and Disability Commissioner as a breach of the patient's right to receive care with appropriate care and skill.

[P_Instructor]

Reference scenario. Case of trying to understand the problem at hand and assessing the patient. Limited classical signs/symptoms yet presents with potential laryngeal closure due to allergen per history. You may not have availability due to geography, but would be case to bounce off on-line medical control. There was some relief of symptoms with initial EPI as well as subsequent Benadryl. Combination of the respiratory alkalosis with EPI probably did cause the cardiac symptom. Sorry for the 'Levine sign' blurb. No, don't teach just do, but assess and analyze what you have (differetial diagnosis) and treat to do no harm.

[ERDoc]

The epi was overboard and several doses even worse. What was it that made them suspect an MI (EKG changes, troponin)?

[Kiwiology]

Case of trying to understand the problem at hand and assessing the patient.

Which is no different than any other patient

Limited classical signs/symptoms yet presents with potential laryngeal closure due to allergen per history.

The history is piss poor; did you ask for further information?

but would be case to bounce off on-line medical control.

No it's not, that is the bitches way out ... do you know that in South Africa, New Zealand, Australia and the UK there is no medical control?. What do you think we do? We use our brains

There was some relief of symptoms with initial EPI as well as subsequent Benadryl. Combination of the respiratory alkalosis with EPI probably did cause the cardiac symptom. Sorry for the 'Levine sign' blurb. No, don't teach just do, but assess and analyze what you have (differetial diagnosis) and treat to do no harm.

Remind me again how adrenaline causes respiratory alkalosis? or how respiratory alkalosis causes cardiac symptoms?

If you want to do no harm perhaps you need to seriously invest in a greatly expanded education of pathophysiology and pharmacology; in a very similar case the treating clinician was found to have acted without reasonable care and skill having inappropriately administered adrenaline to a patient he thought was having "anaphylaxis".

Of all the drugs in the ambo bag of tricks adrenaline is one of the most dangerous but also the most life saving. You must use it wisely. .

[croaker260]

Slow down all.. remember hind sight is 20/20.

I agree that epi was a little much, but I also recall that up to 40 + % present with no external skin signs or swelling. Anaphylaxis can be very difficult to Dx due to its huge variability in presentations and causes among patients, yet life threatening when severe.

If the medic withheld epi and she dies would we be singing the same tune?

Instead of slamming, lets break this down piece by piece with pro's and cons and learn from it.

Now...I want to state this respectfully...its always tough to arm chair quarterback....here are my thoughts:

The subjective history you presented (I cant speak to what you actually obtained) is a bit thin. A detailed subjective assessment would be useful to you figuring out what is/isn't going on, including AMPLE history. This would give insight into the ongoing medical conditions the patient has and what (if any) impact they had on your call. A patient on B-blockers, ACE inhibitors (which have their own Anaphylaxis mimic properties) and statins would imply a pre-existing CAD, and therefore a more cautions approach in regards to the EPI. By contrast, a patient with anti-depressants, benzo's/anti-anxiety meds, and SSRI's would imply an anxiety component, and therefore perhaps administering some Benzo's of your own. Finally, a more detailed PMhx, especially regarding her allergy to flowers would be useful. If she simply has hay fever, this is one thing. If she has been intubated before..that is another.

Her physical assessment is essential too. I will take you at face value when you say lungs are clear, although I will state I have seen numerous providers tell me that when the lung sounds were not clear, merely silent. You paint a clear clinical picture of a patient who is either quite ill, or quite anxious, or both....presenting in severe respiratory distress, yet shows no signs of actual anaphylactic/anaphylactoid reaction. An ETCO2 waveform would be very useful...and impartial/objective assessment, of her respiratory distress as well. Looking for ETCO2 levels and waveform morphology would be useful to rule out some things. Given the vitals, combined with your physical exam, and the presentation in congruent with an anaphylactic/ioid reaction... I am leaning toward a very dramatic and convincing anxious reaction. But I wasn't there and a more detailed AMPLE history would be useful in looking for pitfalls. I cant rule our chemical exposure (cleaning compunds, floral agents, something unaccounted for), stress, etc.

In this case, Obviously all the basic VOMIT medicine is called for ( VOMIT as in Vitals, O2, Monitor, IV and Transport) I cant speak for the practice in your area, but without convergent validity indicating other more serious pathology...more targeted treatment is not advised.

I would be very tempted to try a low dose of ativan or valium to clear up the anxiety / drama, and see what symptoms (if any) the anxiety was masking. In our service, we can medicate severe anxiety (refractory to other interventions) , especially when it is becoming an obstacle to the care of the same patient.

NOW, with that said, I want to state that there are too many unknowns. I think this stresses the importance of a good environmental, physical, and subjective assessment.. and that how we all..all of us...some times can have a call run us instead of us running a call.

And with that, I think this brings a scene from a movie to mind.

I think you got caught up in quicksand. We all can sympathize, even if we dont admit it.

[ERDoc]

Doing an adequate exam is essential in a case like this. You have a pt that is presenting in extremis from what is presumed to be anaphylaxis. Someone that is truly as sick as this woman presents is going to have abnormal lung sounds. You are going to hear wheezing or stridor, you are going to see some drooling. You are not going to have a pt who has clear lungs and can tolerate an exam of her pharynx. This sounds like a case of provider anxiety due to lack of experience.

[croaker260]

Please don't use eponymous; I had to look up what Levine's sign was ... and if she is clutching her chest do you think it might have had something with that IV adrenaline you put into her?

Actually Kiwi, Levine's sign is something that used to be quite common in the texts over here in the US, not so much anymore...unfortunately.... I can't speak for elsewhere. One of those things instructors like to torment their students with. Kinda like Grey-turner's and Cullen's sign. So I don't think he was pretentious, just using the common vernacular of the area.

[ERDoc]

Actually Kiwi, Levine's sign is something that used to be quite common in the texts over here in the US, not so much anymore...unfortunately.... I can't speak for elsewhere. One of those things instructors like to torment their students with. Kinda like Grey-turner's and Cullen's sign. So I don't think he was pretentious, just using the common vernacular of the area.

Good point croaker. Let's just hope she didn't have a positive Throckmorton.

[P_Instructor]

From what I obtained from the providers, ER EKG was suspicious with T-wave abnormalities suggestive of MI. I don't know the particulars of labs, etc....