# Allergic to Exercise



## NPO (Nov 18, 2016)

See if you can figure this out. Don't Google it, and if you do, don't spoil it. If you do legitimately know what it is, let me know what you know about it. I had never heard about it and I had to look it up after the call.

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You respond to a residence for an allergic reaction. The FD is not on scene yet, and you're met by a very angry woman who said you took too long. 

She takes you inside where you find a mid 30s female laying on the bathroom floor near the toilet. There is liquid vomit on the floor and she is clinging to the toilet bowl. She is wearing workout clothes and appears sweaty. She states she administered an EpiPen in her thigh. She states her only history is an allergy to exercise. 

She states she was out running when she felt ill. This has happened before but she powered through it. When she got home she used her epi pen. 

Her last meal was about 1-2 hours ago. She has no other medical history and takes no medications on a regular basis. 

Vitals are all within normal limits, with the exception of being slightly tachycardic at 110bpm. 

Whatcha got?

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## StCEMT (Nov 18, 2016)

This does sound oddly familiar. There is only one other thing I can think of that I know is legit, but it isnt an allergy.


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## CALEMT (Nov 18, 2016)

NPO said:


> allergy to exercise.



Ex...er...cise
Ex...are...size
Eggs...are...sides...
For...bacon...
Bacon. 

She's allergic to bacon!


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## SpecialK (Nov 18, 2016)

The most important thing we do not miss is anaphylaxis which honestly it almost sounds like she has got.

Make sure she has an adult adrenaline autoinjector and not a children's one.  If she has a child one then she's not received enough IM adrenaline.

I'd sit her up, put her on high flow oxygen and gain IV access.  

After five minutes or so if she's not deteriorated then I would provide no other specific treatment.  If she gets worse I'd give her 0.5 mg of IM adrenaline.

If she rapidly improved and had normal vital signs and her GP could see her today I would consider referring her to the GP.  If not, she needs to go to ED.


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## Handsome Robb (Nov 19, 2016)

Exercise induced anaphylaxis. 

Or she's fat. 

One or the other. 


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## DesertMedic66 (Nov 19, 2016)

Handsome Robb said:


> Exercise induced anaphylaxis.
> 
> Or she's fat.
> 
> ...


Maybe she's fat because she can't work out due to the exercise induced anaphylaxis


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## EpiEMS (Nov 19, 2016)

NPO said:


> You respond to a residence for an allergic reaction. The FD is not on scene yet, and you're met by a very angry woman who said you took too long.











NPO said:


> She takes you inside where you find a mid 30s female laying on the bathroom floor near the toilet. There is liquid vomit on the floor and she is clinging to the toilet bowl. She is wearing workout clothes and appears sweaty. She states she administered an EpiPen in her thigh. She states her only history is an allergy to exercise.
> 
> She states she was out running when she felt ill. This has happened before but she powered through it. When she got home she used her epi pen.
> 
> ...



As a BLS unit, a couple things I'm going to do. In addition to requesting ALS, get baseline V/S, as you've said. What's her SPO2 and ETCO2? Lung sounds? Skin signs - any urticaria? Is her ENT exam remarkable?

What was her last meal? Has she ever had a rescue inhaler for exercise induced asthma? What happened last time that she felt ill - nausea, vomiting, urticaria, dyspnea, etc.?

At this point, (exercise induced) anaphylaxis is #1 on my list. She appears to meet diagnostic criteria for anaphylaxis - she's been exposed to a potential allergen (exercise causes physiologic changes, for sure, and maybe the food is interacting with that, too), and is having GI symptoms. She might also be compensating for hypovolemia with her mild tachycardia?

No question that I'm encouraging transport to the ED. This warrants a physician evaluation, even if previously diagnosed.


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## NPO (Nov 19, 2016)

The answer is Food-Dependent Exercised-Induced anaphylaxis. 

I had never heard of such a thing. The patient knew what it was and told us right away. Even the ER doctor was like whaa.

According to the patient and a brief Google search of reputable sources, it's a condition where you're allergic to some foods, only if you exercise after eating them. 

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## EpiEMS (Nov 19, 2016)

NPO said:


> The answer is Food-Dependent Exercised-Induced anaphylaxis.
> 
> I had never heard of such a thing. The patient knew what it was and told us right away. Even the ER doctor was like whaa.
> 
> ...



WHO identifies it. Very cool.

Thanks!


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## CALEMT (Nov 19, 2016)

NPO said:


> it's a condition where you're allergic to some foods, only if you exercise after eating them.



So I was right. She's allergic to bacon!


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## EpiEMS (Nov 19, 2016)

CALEMT said:


> So I was right. She's allergic to bacon!



It's totally possible. If you want to keep eating meat, avoid ticks, apparently!


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## cprted (Nov 19, 2016)

http://emedicine.medscape.com/article/886641-overview

www.uptodate.com/contents/exercise-induced-anaphylaxis-clinical-manifestations-epidemiology-pathogenesis-and-diagnosis


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## SpecialK (Nov 19, 2016)

EpiEMS said:


> No question that I'm encouraging transport to the ED



As an aside, this is a common point I see.

We need to *firmly recommend *to the patient based on our diagnosis rather than "encourage".  I've seen people say "so what do you want to do?" or "do you wanna go to the hospital?" and sometimes the answer from the patient is "well um gee I dno" at which point most people just say "oh ok then bye!" and don't entertain any further discussion, especially if it's time for lunch, or you've had your rest break broken or it's almost time to go home, or because cognitively they have checked that mental box which says "we have done our bit and can leave now".

You can encourage somebody who is declining your firm recommendation for sure, but I see people who sort of leave the decision making up to the patient rather than make a professional recommendation to the patient and let them decide whether or not they wish to follow it.


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## EpiEMS (Nov 20, 2016)

SpecialK said:


> As an aside, this is a common point I see.
> 
> We need to *firmly recommend *to the patient based on our diagnosis rather than "encourage".  I've seen people say "so what do you want to do?" or "do you wanna go to the hospital?" and sometimes the answer from the patient is "well um gee I dno" at which point most people just say "oh ok then bye!" and don't entertain any further discussion, especially if it's time for lunch, or you've had your rest break broken or it's almost time to go home, or because cognitively they have checked that mental box which says "we have done our bit and can leave now".
> 
> You can encourage somebody who is declining your firm recommendation for sure, but I see people who sort of leave the decision making up to the patient rather than make a professional recommendation to the patient and let them decide whether or not they wish to follow it.



In this case, for sure, I feel that the patient needs a physician's evaluation and management - or at the very least, I want a paramedic to say they're OK to refuse care (because this patient needs an assessment more complete then mine). Thus, for a patient like this, I would say: "I believe that you need a physician's evaluation," or something to that effect. If they want to refuse interventions and transport, I would try and get medical control on the line to talk to them. This is a high-risk refusal in my mind: medical control needs to be involved. If this were a child (or some other type of person who isn't competent) and the parents/caretakers wanted to refuse care, I would also get medical control on the line.


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## SpecialK (Nov 20, 2016)

I was meaning in general not this specific case.

We are quite fortunate it is not codified in law at what age somebody may make their own healthcare decisions in that "child" is not defined by age whereas I know elsewhere in the world it is.  We are also fortunate advance directives do not have to be in writing and can include clearly articulated oral directives.


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## GBev (Nov 21, 2016)

SpecialK said:


> As an aside, this is a common point I see.
> 
> We need to *firmly recommend *to the patient based on our diagnosis rather than "encourage".



Without hijacking the thread, I always ask, "Which hospital do you want to go to?" It gives the PT power over their healthcare decisions (or at least the illusion) while aggressively implying that going to see a physician is non-negotiable


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## EpiEMS (Nov 21, 2016)

GBev said:


> Without hijacking the thread, I always ask, "Which hospital do you want to go to?" It gives the PT power over their healthcare decisions (or at least the illusion) while aggressively implying that going to see a physician is non-negotiable



I like the phrasing, for sure! I bet there's some good underlying psychology for this!


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## NPO (Nov 21, 2016)

GBev said:


> Without hijacking the thread, I always ask, "Which hospital do you want to go to?" It gives the PT power over their healthcare decisions (or at least the illusion) while aggressively implying that going to see a physician is non-negotiable


This isy go to as well. Patients who truly don't want to go will generally object when they hear this.

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## FLMedic311 (Nov 21, 2016)

Interesting case, thanks for sharing!


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