# question/poll



## Guardian (Feb 2, 2008)

How many of you think a pt with an allergic reaction--resulting in hypotension as the only symptom--can or should be given epi?


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## Ridryder911 (Feb 2, 2008)

It all depends. What made you think this was an allergic reaction other than hypotension? As well, what other symptoms are there? What was the host/vector or stimulant? 

R/r 911


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## Guardian (Feb 2, 2008)

Hypothetical: god comes down and tells you your pt is having an allergic reaction to medication and the only symptom is hypotension.  It's not a trick question; just a yes or no question.


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## TKO (Feb 2, 2008)

nope.  

Benadryl and an IV (a hypertonic would be nice, wouldn't it?).  Why give Epi otherwise?  Don't get me wrong, SVTs are funny as heck, but until the pt reaches unstable and anaphylactic, allergies are managable.  As for the hypo, the epi will really just constrict the vessels and the fluid is already in the extravasal spaces doing their inflammatory thang.

Or are you going somewhere with this, like a surprise?


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## Guardian (Feb 2, 2008)

No surprises here.  In my own case, my protocols say yes and some of my fellow paramedics agree with the protocol.  I don't want to rush to judgment, so I’d have to say I personally don't know.


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## akflightmedic (Feb 2, 2008)

Here is my confusion.
You say it is in the protocols..but still I have to ask.


HOW do you know it is an allergic reaction? A protocol that is worded as such where it lists the only symptom as hypotension and treat with epi is no good.

There HAS to be other signs or symptoms for you to determine an allergic reaction. Otherwise its just hypotension of unknown etiology.


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## Guardian (Feb 2, 2008)

According to fellow paramedics, it is possible to suffer hypotension as the only symptom of an allergic reaction.  I don't know if this is true and haven't done any research.  For my purposes, I predicated my question on the basis that my protocols were written correctly.  You're smart; I thought you might be able to come up with a scenario where allergic reaction is reasonably suspected based on history and hypotension alone.  If not, then would I be right to assume your answer is "no, I wouldn't give epi"?


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## akflightmedic (Feb 2, 2008)

How does the patient know they have hypotension?

Short of them feeling dizzy or passing out, how do they know (if hypotension is going to be the only symptom for this scenario).

I believe the question is flawed as is the protocol.

Yes, I could take a detailed history and try to correlate the two together, but I do not see how I could justifiably make that assumption.

For example, here is a dialogue:

Me: So whats the problem (to the pt)

Pt: I do not have a problem, but I got stung by bee (or ate nuts, or seafood) 30 minutes ago.

Me: visual inspection reveals nothing anywhere on body( no tongue swelling, no itching, no angioedema, no rashes)
Me: are you allergic to those things?

pt: (insert any anwer here from yes, no to I dont know)

Me: are you having (rash,SOB, CP, etc)

pt: none, nothing

me: Mind if I take your vitals signs?

after taking BP
Me: WOW you are hypotensive, this has to be anaphylaxsis, you need epi!

See what I mean. This just would not ever happen, even with taking a good history. Cause first of all, the patient would never have called as there is no issue, unless something else happens like I mentioned above (dizzy, syncope).

Second of all, as I said previously, I would be on guard watching for a reaction during transport, but I would not be thinking I need to give epi; I would be thinking hypotension for a million other possible reasons, up to and including, uknown etiology, and performing more diagnostic assessments and asking questions more geared to those other potential causes.


So no, I would not give epi at this time.


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## Ridryder911 (Feb 2, 2008)

My question is how and why would one even suspect an allergic reaction just based solely upon hypotension? Without a notice of again the reason why one even be examined or alerted to even suspect an allergic reaction. 

Without any history other than hypotension, why would even anyone suspect allergic reaction? Again, allergic reaction to what? Injection from insect, reaction to medications, food? 

This is an implausible question because it is too vague. One would be a poor practitioner based solely upon that given information, as well I would doubt anyone would suspect the culprit would be a from reaction, just from hypotension alone. 

As well, what you describe as the symptoms would be the "late" signs after mast cells and histamine response has already been delivered. 

Surely, one would not initiate treatment of Epi for just hypotension alone. Treatment of allergic reaction is NOT Epinephrine, rather what you have is anaphylaxis. Allergic reaction would be treated with H2 blockers, fluids, steroid use. 

R/r 911


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## MSDeltaFlt (Feb 2, 2008)

Rid is right.  The question is implausible because it is too vague.  It is physically impossible to come up with ANY diagnosis based soley on hypotension.  You MUST have something else.  

Here's my reasoning:  One of the first signs of any compromise on any otherwise healthy individual is tachycardia.  You have to play the odds here.  If the pt is not tachy, then more than likely they are >40 yrs old with a condition that requires them to take meds to help keep their heart rate in a fixed range which makes SQ Epi, or any Epi, contraindicated except in extreme situations; any of which will manifest other signs and/or symptoms.  Hypotension, in and of itself, is not enough.  You need to dig further.

All this being said, my answer to the original question would be "no".  I would not give Epi for allergic reaction with hypotension as the ONLY symptom because I do not believe that the situation exists.

With respect.


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## Guardian (Feb 2, 2008)

Thanks for the answers.  

What if you were presented with a person who had some signs of allergic reaction?  For example: pale look, slightly diaphoretic, just barely enough hives on the arms and chest to recognize, dizziness, slight visual disturbances, tachycardia at 142, and BP 74/pal despite trendelenburg position and  some fluid.  Breathing is fine, lung sounds clear as a bell, and SaO2 is 99% room air.  Since the pt was having an MRI done and forgot to tell the staff he was allergic to IV dye, you can pinpoint the reaction at 14.623 mins ago.  Epi or no?


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## MSDeltaFlt (Feb 2, 2008)

Benadryl and fluids


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## KEVD18 (Feb 2, 2008)

Guardian said:


> trendelenburg position




oh god, not t-burg again


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## Guardian (Feb 2, 2008)

Guardian said:


> Thanks for the answers.
> 
> What if you were presented with a person who had some signs of allergic reaction?  For example: pale look, slightly diaphoretic, just barely enough hives on the arms and chest to recognize, dizziness, slight visual disturbances, tachycardia at 142, and BP 74/pal despite trendelenburg position and  some fluid.  Breathing is fine, lung sounds clear as a bell, and SaO2 is 99% room air.  Since the pt was having an MRI done and forgot to tell the staff he was allergic to IV dye, you can pinpoint the reaction at 14.623 mins ago.  Epi or no?




Ok, I've given fluids and Benadryl. Now the BP is 64/pal, pt in and out of consciousness, same everything else.  Now what, possibly epi?  

I’m not trying to argue.  I’m just asking as a guy who is unsure whether or not he should follow his protocols.  So lets hear the expert opinions…

Thanks delta, helpful…


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## MSDeltaFlt (Feb 2, 2008)

Well, with BP sys of 64, you're going to have crappy breathing and piss poor lung sounds; IF you still have an airway.  Go for Epi... IV; not SQ.  

This scenario is a zebra instead of a horse.


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## medic3 (Feb 3, 2008)

Benadryl at this point would probably cause furthur hypotension.  Epi would be the choice if not purley to inhibit the hisatamine release, which is what is causing all these problems to begin with.  Also, fluids, fluids, fluids!


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## Ridryder911 (Feb 3, 2008)

medic3 said:


> Benadryl at this point would probably cause furthur hypotension.  Epi would be the choice if not purley to inhibit the hisatamine release, which is what is causing all these problems to begin with.  Also, fluids, fluids, fluids!




Alas, Epi as well can cause hypotension per increased V.R. thus poor filling time, or... increased peripheral vasoconstriction per the alpha effects would raise the B/P. Just want to make one think... as well, the dose of 25 - 50 mg Benadryl may not have that much effect in B/P. One could use alternative H2 blockers such as Pepcid, Zantac, etc... 

Treat the cause not so much the symptom. As you described fluids, fluids yet one has to be careful for fluid overload.... again think!

R/r 911


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## Guardian (Feb 6, 2008)

MSDeltaFlt said:


> Well, with BP sys of 64, you're going to have crappy breathing and piss poor lung sounds; IF you still have an airway.  Go for Epi... IV; not SQ.
> 
> This scenario is a zebra instead of a horse.



Well, I've seen at least one of these zebras here in my hometown, and heard about a few others.  IMHO, the scenario I gave you was entirely plausible, even with clear lungs sounds and a BP of 64.  Anyway, thanks for your input.  I have yet to hear from the other big dogs here...vent, rid, ak, where you at on this?


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## Ridryder911 (Feb 6, 2008)

Personally, I am very hesitant on giving Epi. In fact if you get Epi from me, chances are your not doing to good. Personally, I only have seen Benadryl lower BP when given too fast as well dosage as 50mg instead of the usual 25mg dosage. I like getting steroids on board early on; Solu-Medrol 125 to 250mg SIVP. I have even given Decadron per nebulizer for a faster effect. Yes, it takes time but with fluids and H2 blockers but most reactions can be  curtailed. I will administer Epi on those that are demonstrating angioneurotic edema, severe histamine response that produces wheezes and the blood pressure has dropped (anaphylaxis not reactions). 

I rarely see true anaphylaxis (fortunately) and I am in the South Midwest where we have multiple insects and antigens all year long. 

Again, one has to be careful in either direction they pursue and the key is constant close monitoring. I attempt to stop the antigen-histamine response, then treat the symptoms. Usually, the body will take care of itself once the histamine level has been curtailed. Increasing hive/urticaria as well as the swelling of the pharynx area is key to take more aggressive action. 

R/r 911


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## spidermedic (Feb 6, 2008)

I think folks are too caught up on the 64 pressure. If the person is only complaining of dizziness, then (s)he is still perfusing pretty well in spite of a little hypotension.

I would certainly give 0.3 of epi IM (rather than SC). This pt does not seem to be in extremis, so I would personally not go the IV epi route.

Benadryl: 25-50 is good as well and while it can drop the BP, it's probably not going to. Even if it does, it is unlikely to be a significant drop.

Solu-Medrol: Not a rescue med, but as long as it doesn't prevent you from addressing the acute issues, go ahead and give it.

H2 Blockers: Great in the ED, we don't carry them in the street here.  

Fluids of course.

I have to say that I've never heard of epi being contraindicated in a 40+ y/o regardless of the medications they're on. Is that a local protocol?

I also don't agree that the pressure of 64 automatically means poor lung sounds. 

Cheers all,

Doug


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## Ridryder911 (Feb 6, 2008)

Guardian said:


> Thanks for the answers.
> Since the pt was having an MRI done and forgot to tell the staff he was allergic to IV dye, you can pinpoint the reaction at 14.623 mins ago.  Epi or no?



Better find another culprit. Unlike the majority of IV Dyes MRI does *NOT* use iodine base. MRI dye uses gadolinium. The risk of reaction to this dye is much lower than to x-ray dye. 

From MRI international.._"Since it is not iodine dye and if you have had a serious reaction to x-ray dye, it is still safe for you to have MRI dye."..._
There are very, very few reported reactions to this dye. 

R/r 911


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## Guardian (Feb 6, 2008)

Ridryder911 said:


> Better find another culprit. Unlike the majority of IV Dyes MRI does *NOT* use iodine base. MRI dye uses gadolinium. The risk of reaction to this dye is much lower than to x-ray dye.
> 
> From MRI international.._"Since it is not iodine dye and if you have had a serious reaction to x-ray dye, it is still safe for you to have MRI dye."..._
> There are very, very few reported reactions to this dye.
> ...



Your post doesn’t negate what I wrote one iota, but interesting nonetheless.


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## eggshen (Feb 6, 2008)

Something that lacks common sense....again. Shocker!

Egg


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## RALS504 (Feb 6, 2008)

What about anaphylactoid reactions for which this senario sounds very plausible. I have seen one in the field from a MVC where a pt took some aspirin.


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## bonedog (Feb 7, 2008)

Obviously if one isn't perfusing the vital organs Epi should be THE choice, along with the other choices. As long as you can defend your Tx plan....

Age, cardiovascular disease, diabetics all warrant caution. 

IV epi in 50 mcg aloquats if concerned, after all VT will increase the medic's endogenous catecholamines, fun for all....


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## TKO (Feb 8, 2008)

That's what I'm saying!!  LOL!


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## eggshen (Feb 8, 2008)

Seen them present with NVD only, nothing else.

I can also think of better questions to ask if I ran tranfers all day too, but there you have it. I guess if my aunt had balls she'd be my uncle.

Egg


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## bonedog (Feb 11, 2008)

Or a terrible case of fibriods.....


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## eggshen (Feb 11, 2008)

Word!

Egg


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## fma08 (Mar 13, 2008)

Epi, only if Airway compromise and thats after albuterol and atrovent, so that being said, allergic reaction with only sign of hypotension would get benedryl and solu-medrol from me, oh and removing from the environment if not done already. if they have no breathing problems then no neb from me either.


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