Allergic reaction

[rhan101277]

9 y/o male presents with diffuse itching, urticaria, erythema and anxiousness. Pt has no known allergies, although he had an episode last year and was prescribed hydralazine, prednisone oral liquid medication in case he has a problem again. Pt is talking, asking to please stop the itching. His bottom lip is double the size of the top. No PMHx, rarely needs to take above mentioned medicines, no allergies to medications.

Vitals:

B/P: 120/82
Pulse: 120
Lungs: -wheezing, -stridor, diminished at bases
Pulse ox: 100
RR: 32

 

[Deltachange]

The stridor definitely pushes me in the way of allergic reaction, could be an unknown toxin. Vitals don't seem bad though, so I can't say for sure, but with hives and diffuse itching, I am definitely thinking systemic allergic reaction to something.

 

[rhan101277]

The stridor definitely pushes me in the way of allergic reaction, could be an unknown toxin. Vitals don't seem bad though, so I can't say for sure, but with hives and diffuse itching, I am definitely thinking systemic allergic reaction to something.

That is a negative sign beside stridor and wheezing, meaning that it is not present.

 

[MediMike]

Any palliation with medications listed? With a rapidly inflating lip (heh heh) I would be concerned regarding possible angioedema. Toss some benadryl at him and see what happens. See if Mom has some Zantac sitting around for him.

 

[samiam]

Any palliation with medications listed? With a rapidly inflating lip (heh heh) I would be concerned regarding possible angioedema. Toss some benadryl at him and see what happens. See if Mom has some Zantac sitting around for him.

What would giving him Zantac do or so you mean if he is taking zantac?


I have seen all of the above mentioned when taking Compazine. Especially swelling of the lips and tongue

 

[MediMike]

Ranitidine is a H2 antagonist and works great for hives

 

[Shishkabob]

What was the kiddo doing prior to the reaction?

 

[samiam]

Ranitidine is a H2 antagonist and works great for hives

Interesting... With my limited knowledge If zantac is a H2 antagonist wouldn't that only affect H2 receptors at the parietal cells in the stomach I.E the ones that secrete gastric acid.. not the H1 receptors in the smooth muscle/skin etc cells that would cause hives? Then again I vaguely remember that skin has both receptors? Can you school me on this topic please?

 

[boingo]

Epinephrine.

 

[MediMike]

H2 receptors are principally found in the parietal cells of the stomach, you are correct. They are prevalent in other regions as well, such as vascular smooth muscle. Now, my comment was mostly in jest due to the fact that Ranitidine is normally 'scribed in combo with fexofenadrine or other H1 anatgonists as well, normally for chronic idiopathic urticaria ^_^ And in regards to "schooling" you on this...hahaha wish I could, the pharmacodynamics of H2 anatgonists regarding hives is above my head.

 

[samiam]

H2 receptors are principally found in the parietal cells of the stomach, you are correct. They are prevalent in other regions as well, such as vascular smooth muscle. Now, my comment was mostly in jest due to the fact that Ranitidine is normally 'scribed in combo with fexofenadrine or other H1 anatgonists as well, normally for chronic idiopathic urticaria ^_^ And in regards to "schooling" you on this...hahaha wish I could, the pharmacodynamics of H2 anatgonists regarding hives is above my head.

I see.. I was thinking you were implying that if there happened to be some zantac available it should be given to the kid to see if it helps.. which would be out of place if it was not prescribed to him. It could be possible that the reaction was not responding to the H1 antagonist and the lack of giving the H2 was causing the problem.

 

[rhan101277]

What was the kiddo doing prior to the reaction?

He had played outside, ate some blueberries and a crab cake. pt mother did not have enough of the prescribed medication to elicit and effect. He was itching all over, it was strange to see someone itch like that.

Here is my treatment.

O2 10L NRB
ECG MON
22GA LEFT AC, THAT GOD GUIDED
27MG BENADRYL IVP
54MG SOLU-MEDROL

He continued to have a little higher than normal RR was perfusing well. He was initially tachy at 120, with BP high 152/98. After meds and oxygen he was down to the 80's with BP 124/82. He still was maintaining but I had epi ready, he was doing good so I held off. When I brought him in Dr. assessed and gave .3mg IM of epi. Again good RR, he could talk no stridor, no wheezing.

After the fact I believe I should have hung a 500cc bag TKO, instead of just a lock. There was so much going through my mind and I was focused on monitoring his condition. He needed it hung though in case things went south. I went back to facility later and he was discharged with epi pen jr's.

I felt like I may have actually contributed to saving his life. In the back I knew things were bad but I remained calm, although i noticed my hand having tremors while I drew up the solu-medrol, oh well I'm only human.

 

[MediMike]

I see.. I was thinking you were implying that if there happened to be some zantac available it should be given to the kid to see if it helps.. which would be out of place if it was not prescribed to him.

Zantac is OTC B)