Allergic reaction: epi yay or nay

CbrMonster

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I’m gonna keep this simple

2 year old male
-Itchy
-obvious hives to back, abdomen, chest
-Significant facial redness from chin to nose circling the mouth. (Think gnarly sunburn) not just mildly pink
-No swelling to lips or tongue
-No sob, wheezing, drooling

This can very on county protocols as to what they consider anaphylaxis, but with that would you administer epi?

I’ve always been under the impression that with the significant redness around the mouth and nose to be an anaphylactic reaction.

Per my protocol it is yes, but wife (er rn) would hold off on epi. Just curious what y’all would do.
 

DrParasite

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single system involved (skin), no airways issues, I'd go with benedryl and monitor for the trip to the ER, unless there was additional information about the patient.
 

EpiEMS

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NomadicMedic

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I’d also go with Benadryl Unless things went sideways. Think about what the epi does and why you’d need it. Vasoconstriction and bronchodilator. Neither of those are indicated in this instance.
 

DesertMedic66

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Ehh. I’d probably just do Benadryl to start with but also pull out my epi and have my dose calculated out and ready to go.
 

E tank

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any protocol aside, po benadryl, given the facts provided. But if someone gave 10/kg epi to a kid like that it wouldn't be the end of the world.
 
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CbrMonster

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Thanks for all the responses, I’ll try to answer all questions:

Unfortunately that’s all the signs symptoms and info I have. I wasn’t hands on with the patient was kind of a hypothetical between me and my wife. No vitals no lung sounds ect.

yes of course Benadryl 100000% no brainer there.

The redness around the mouth and nose is what concerned my most in my mind with what Info and what we could see. As usually this turns into full blown angioedema in my previous experiences
 

Tigger

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Anyone considering giving decadron or other steroid to this patient?
 

DesertMedic66

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Anyone considering giving decadron or other steroid to this patient?
It seems like every year there are new studies or information that are pushing away from the standard use of steroids. I have it in my protocols but the odds are I wouldn’t give it. My local hospitals have also stopped routinely giving it since ~2018.
 

E tank

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AAAI seems to be lukewarm at best on corticosteroid admin, they’re adjunctive but not great evidence supporting use. See, for example: https://www.aaaai.org/allergist-res...d-ask-the-experts/corticosteroids-anaphylaxis and https://www.pharmacytoday.org/article/S1042-0991(19)31376-3/fulltext
Good info...but giving steroids is so ingrained and the circumstances like these that folks give them in are frequently so stressful, patients get the kitchen sink before you know what's happened. A whack of steroid is pretty harmless tho...something to do while waiting for the epi, benadryl and fluids to work I guess...
 

EpiEMS

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Good info...but giving steroids is so ingrained and the circumstances like these that folks give them in are frequently so stressful, patients get the kitchen sink before you know what's happened. A whack of steroid is pretty harmless tho...something to do while waiting for the epi, benadryl and fluids to work I guess...

Seems like it can’t hurt? I had always been told that steroids are beneficial but outside of the prehospital timeline - so maybe they’d help by the time the patient is hanging out in the ED or up on the floor.
 

E tank

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Seems like it can’t hurt? I had always been told that steroids are beneficial but outside of the prehospital timeline - so maybe they’d help by the time the patient is hanging out in the ED or up on the floor.
Sure...recrudescence can happen and if the reaction is severe enough, there are recommendations for oral steroids when discharged home. But as you pointed out, for acute, prehospital treatment, they can wait.
 

DrParasite

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Sure...recrudescence can happen and if the reaction is severe enough, there are recommendations for oral steroids when discharged home. But as you pointed out, for acute, prehospital treatment, they can wait.
If I remember correctly, you aren't giving steroids to fix the problem NOW, but you are giving them because an hour or so later, they will help. not really an acute treatment, but it helps make things better once they patient is in the hospital. they have a delayed onset, but the sooner they get administered, the sooner they take affect. def not a priority, but if you have a 30-45 minute transport time, that's 45 minutes less that the patient needs to wait for the steroids to take effect.
 

E tank

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If I remember correctly, you aren't giving steroids to fix the problem NOW, but you are giving them because an hour or so later, they will help. not really an acute treatment, but it helps make things better once they patient is in the hospital. they have a delayed onset, but the sooner they get administered, the sooner they take affect. def not a priority, but if you have a 30-45 minute transport time, that's 45 minutes less that the patient needs to wait for the steroids to take effect.
Steroids, in the setting we're talking about, apparently don't have any meaningful value.

J Allergy Clin Immunol. 2020;145(4):1082. Epub 2020 Jan 28

"Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis"
 

ffemt8978

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Steroids, in the setting we're talking about, apparently don't have any meaningful value.

J Allergy Clin Immunol. 2020;145(4):1082. Epub 2020 Jan 28

"Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis"
Then why carry them on the ambulance?
 
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