Mistaken for anaphylaxis?

[emt58]

Had a practical yesterday. Patient was stung by a bee and has a history of being allergic to them. Pulse was 112, resp at 21, BP almost perfect, and patient had hives all over his body but no weezing in the lungs. Also he kept saying throughout the scenario that he could not breathe. I administered his Epi after going through my assessment then clearing 5 rights and calling med control because the patients condition could have rapidly deteriorated... but after it was over I wondered if they were just leading me to believe it was anaphylaxis, not an allergic reaction. Was this a mistake?
I know it's important to determine between the two but I felt it was safe to give the dose because of how quickly things can turn very bad in a matter of minutes. What made me believe it was anaphylaxis was the patient kept complaining of tightness in the chest making it hard to breathe and the hives all over his body, plus the tachycardia... but the non-weezing patient baffled me.

 

[exodus]

Diff breathing + hives + known allergen + known exposure to said allergen = epipen.

 

[RocketMedic]

Anaphylaxis has a very wide set of symptoms, sounds like this patient hit some of them. You're not wrong for treating him. I would only add that ALS intercept, IV benadryl, fluids and solumedrol would be considered. Good job though- how did he react to the epi?

 

[unleashedfury]

What did they tell you lung sounds where?
or was he leading you for another treatment option you may have overlooked. Hi Flow 02 Pulse oximietry or any of the such.

I do believe he was trying to lead you towards anaphylaxis, and aiming for you to dart the patient with the pen. especially since you had to do the 5 rights. and make sure it was the patients Epi.

 

[J B]

Had a practical yesterday. Patient was stung by a bee and has a history of being allergic to them. Pulse was 112, resp at 21, BP almost perfect, and patient had hives all over his body but no weezing in the lungs. Also he kept saying throughout the scenario that he could not breathe. I administered his Epi after going through my assessment then clearing 5 rights and calling med control because the patients condition could have rapidly deteriorated... but after it was over I wondered if they were just leading me to believe it was anaphylaxis, not an allergic reaction. Was this a mistake?
I know it's important to determine between the two but I felt it was safe to give the dose because of how quickly things can turn very bad in a matter of minutes. What made me believe it was anaphylaxis was the patient kept complaining of tightness in the chest making it hard to breathe and the hives all over his body, plus the tachycardia... but the non-weezing patient baffled me.

Anaphylaxis IS an allergic reaction - just an acute, over-exaggerated one.

Following your ABC's you should have put him on O2 via NRB immediately. After that, realistically, they probably wanted you to just hit the guy with epipen. That said, I think there's a bit more we can think about here...

According to the text books anaphylaxis is generally defined by bronchoconstriction and vasodialation. Epinephrine is a wonder drug in this case because it is a bronchodialator and vasoconstrictor... But interestingly, in this situation the patient is not really overtly presenting either of the symptoms that epinephrine fixes.

On the other hand, is it possible/likely he did actually have vasodialation going on, and was in compensating shock? His heart is working much harder to compensate and keep the blood pressure where it needs to be despite the vasculature having been blown wide open. Or, he could just be panicking due to it being hard to breathe... I was just thinking, it might actually be better to treat this patient with a straight bronchodialator that has fewer of the cardiac effects attached to it - maybe put him on an albuterol nebulizer?


I'm probably way over-thinking this. While epinephrine does/can have serious adverse side effects, in this situation I think the potential benefits of using it far outweigh the risks. Even if the patient is not actually in anaphylaxis, he's probably not going to suffer any great injury if you do administer epi. If he does end up having serious negative side effects from the epi, I think you should be covered legally given the signs, symptoms and history of the patient.

 

[Onceamedic]

An allergic reaction is an autoimmune response to a trigger with the involvement of only one body system - IE a rash

An anaphylactic reaction is an autoimmune response to a trigger with the involvement of more than one body system IE - hives, difficulty breathing.

With the previously described symptoms, the dx is anaphylaxis and the epi was appropriate and correct. (the tachycardia is disturbing, suggesting compensated shock prior to one of the most dreaded responses - BP dump and uncompensated shock.)

So - good call - good response.

 

[J B]

An allergic reaction is an autoimmune response to a trigger with the involvement of only one body system - IE a rash

An anaphylactic reaction is an autoimmune response to a trigger with the involvement of more than one body system IE - hives, difficulty breathing.

With the previously described symptoms, the dx is anaphylaxis and the epi was appropriate and correct. (the tachycardia is disturbing, suggesting compensated shock prior to one of the most dreaded responses - BP dump and uncompensated shock.)

So - good call - good response.

Thanks for clarification.

 

[medichopeful]

*snip*
According to the text books anaphylaxis is generally defined by bronchoconstriction and vasodialation. Epinephrine is a wonder drug in this case because it is a bronchodialator and vasoconstrictor... But interestingly, in this situation the patient is not really overtly presenting either of the symptoms that epinephrine fixes.

On the other hand, is it possible/likely he did actually have vasodialation going on, and was in compensating shock? His heart is working much harder to compensate and keep the blood pressure where it needs to be despite the vasculature having been blown wide open. Or, he could just be panicking due to it being hard to breathe... I was just thinking, it might actually be better to treat this patient with a straight bronchodialator that has fewer of the cardiac effects attached to it - maybe put him on an albuterol nebulizer?
*snip*

Can you walk me through your thinking about why you would want to give an updraft to this patient? I'm not trying to be an ***, but I'm legitimately curious about your thought process on this. The way I'm reading it, you have some interesting thoughts, but I'm not sure you're headed down the right track!

 

[J B]

Can you walk me through your thinking about why you would want to give an updraft to this patient? I'm not trying to be an ***, but I'm legitimately curious about your thought process on this. The way I'm reading it, you have some interesting thoughts, but I'm not sure you're headed down the right track!

Yup, I was definitely very wrong - that's why it's good to think about these things before they happen!

Basically the nebulizer came to mind because I'm a basic and that's the only other option at my disposal for someone having difficulty breathing (obviously also O2 and insta-calling ALS as soon as I see what's going on). Fortunately we need to contact med control to do it, and they probably would have yelled at me to give epi.

My thought was that his BP is normal, so maybe we can just target the breathing difficulty. I was thinking that if his heart is already in overdrive at 112bpm, maybe we shouldn't kick it up even higher with epi and risk cardiac complications (I don't really know how possible this is or how worried I should be about it?). As I speculated at the beginning of the 2nd paragraph you quoted, though, and as Kaisu posted, his elevated heart rate is probably due to him being in compensated shock from vasodialation. Hitting him with epinephrine should make it so his heart doesn't have to work as hard, and hopefully keep him from decompensating for longer.

If his HR was elevated due to him just having a panic attack (due to having a hard time breathing), then hitting him with epi would be bad (I think?)... But in this case the benefits of giving epi seem to far outweigh the risks: if he needed epi and we just gave albuterol he decompensates. If he was just having panic attack and we give epi, probably nothing bad happens.

That was my thought process, anyways. Like I said, way over-thinking...

 

[teedubbyaw]

So, as a basic, why would you give a drug thats only indication (at a bls level) is wheezing, to a pt w/ clear lung sounds?

 

[Mariemt]

So, as a basic, why would you give a drug thats only indication (at a bls level) is wheezing, to a pt w/ clear lung sounds?

You don't give asthmatics or pneumonia pts epi and both of them can have wheezes.


Trouble breathing, known allergen, hives.. . Epi

There was a reason for this scenereo and that was to administer epi.

 

[teedubbyaw]

You don't give asthmatics or pneumonia pts epi and both of them can have wheezes.


Trouble breathing, known allergen, hives.. . Epi

There was a reason for this scenereo and that was to administer epi.

You read my question wrong. And the question was for JB.

 

[J B]

So, as a basic, why would you give a drug thats only indication (at a bls level) is wheezing, to a pt w/ clear lung sounds?

Well it came to mind because it's one of only two options I have... But I guess in this case there's really nothing I can do about patient's breathing difficulty beyond O2 and hoping the epi helps. Administering albuterol here would likely be a mistake.

 

[teedubbyaw]

And I'm not sure where you're getting that you can't give epi to a pt with asthma.

 

[teedubbyaw]

Well it came to mind because it's one of only two options I have... But I guess in this case there's really nothing I can do about patient's breathing difficulty beyond O2 and hoping the epi helps. Administering albuterol here would likely be a mistake.

You're thinking outside of the box, which is great. Max HR in a healthy adult is over 200. That's not a problem. As Marie just said, known allergy, and everything else pointing towards anaphylaxis -- give the epi.

 

[J B]

Max HR in a healthy adult is over 200. That's not a problem. As Marie just said, known allergy, and everything else pointing towards anaphylaxis -- give the epi.

Good to know regarding heart rate, thanks.

I think Marie was saying that you "don't" give epinephrine to people having asthma attacks, because we have things that target those symptoms better. But theoretically it seems like you certainly "could" give them epi and it would help them breathe. Could be useful to know in a wilderness situation where you only have an epipen, etc.

 

[RocketMedic]

Good to know regarding heart rate, thanks.

I think Marie was saying that you "don't" give epinephrine to people having asthma attacks, because we have things that target those symptoms better. But theoretically it seems like you certainly "could" give them epi and it would help them breathe. Could be useful to know in a wilderness situation where you only have an epipen, etc.

Sure we do- when albuterol and atrovent have failed. It's an option.

 

[mycrofft]

Back to OP, was this a live actor? It's hard to portray real wheezing without giving yourself the Valsalva heebiegeebies (using a forced end-expiratory wheeze).

I HATE when people confuse stridor with wheezes and all the training videos teach that stridor is wheezing.

Now as to epi versus other meds, do they have as quick an onset as epi? Do they act as a vasopressor as fast as epi? Will they wear off as quickly as epi (nice if you need to go on to other meds, not so nice if it's all you have)?

Will they exacerbate atrial fib like epi?

Epi is a more-commonly available, cheap and simple to administer med for asthma (Primatine MDI is coming back, folks) and anaphylaxis. Quick in, quick out, buy the time for something more definitive.

 

[MSDeltaFlt]

Had a practical yesterday. Patient was stung by a bee and has a history of being allergic to them. Pulse was 112, resp at 21, BP almost perfect, and patient had hives all over his body but no weezing in the lungs. Also he kept saying throughout the scenario that he could not breathe. I administered his Epi after going through my assessment then clearing 5 rights and calling med control because the patients condition could have rapidly deteriorated... but after it was over I wondered if they were just leading me to believe it was anaphylaxis, not an allergic reaction. Was this a mistake?
I know it's important to determine between the two but I felt it was safe to give the dose because of how quickly things can turn very bad in a matter of minutes. What made me believe it was anaphylaxis was the patient kept complaining of tightness in the chest making it hard to breathe and the hives all over his body, plus the tachycardia... but the non-weezing patient baffled me.

It appears as though this is a moulage patient. In this moulaged scenario, you gave them what they wanted, so good job. I say this because if this patient were to be in true anaphylaxis, they'd be showing you more than clear breath sounds, "near perfect BP", mild tachycardia, barely tachypnea, and only urticaria.

The protocols I have available to me classify that as an allergic reaction. Not anaphylaxis. So I would be regulated to diphenhydramine IV or IM for the urticaria And if there were any wheezing, treat with inhaled bronchdilator. Basically treating the patient symptomatically.

 

[unleashedfury]

It appears as though this is a moulage patient. In this moulaged scenario, you gave them what they wanted, so good job. I say this because if this patient were to be in true anaphylaxis, they'd be showing you more than clear breath sounds, "near perfect BP", mild tachycardia, barely tachypnea, and only urticaria.

The protocols I have available to me classify that as an allergic reaction. Not anaphylaxis. So I would be regulated to diphenhydramine IV or IM for the urticaria And if there were any wheezing, treat with inhaled bronchdilator. Basically treating the patient symptomatically.

Highly agreed, However I believe that they wanted to treat this patient at the EMT-B level. aiming for him to dart the patient

On the ALS side of things yes Benadryl and a Bronchodilator, would be the preferred treatment. As far as the scenario goes does not appear to be a anaphylactic reaction. I'd be looking for hypotension, stridor, and severe dyspnea noted with the hives..