need some input

[Margaritaville]

Okay Guys - lets have your opinion -

30 something female with onset of itching around eyes, and neck area. Hx - none relevant. Meds - none, All. Demerol.

PEARL, vitals - within normal limits. other sx - eyelids dark red, no watering from eyes. Throat is "a little scratchy". denies diff. breathing. PTA - 50 mg benadryl po with no relief.

Your assesment? (I will give you more info if you request it)

 

[sarahharter]

when did this start and what was the pt doing and where was the pt when this started? What was pt around, anything not been around before?

 

[sarahharter]

also what are the pt's vitals like and was anyone with the pt that could help answer some q's.

 

[Margaritaville]

1. started about 1:00 pm. Noticed an hour after being at gym and having a shower. Was starting to run errands in the next town.

2. Vitals - P 60, resp - 16, BP - 130/90

3. no one else with pt. Pt A x O x 3

 

[Epi-do]

Do you have a second set of vitals? How long between taking the benadryl and calling an ambo? Appearance of skin - red, hives, etc? Breath sounds? Even though pt is denying any DB, do they look like they are working to breath or in any distress?

 

[EyeOn]

What was her last oral intake? Do you know what the last thing she handled was right before the symptoms? Was there any construction going on along the path of her errands? Did she use any eyedrops prior to symptoms? What was her form of transportation running these errands? Was she rubbing her eyes? Did her hands show any redness? Was she thirsty?

IMO, with the info. given so far and without answers to the questions above, sounds like she may have had contact with a substance that may have caused her eyes and throat to dry. It could have been something blowing around in the air from nearby construction or pollen. Maybe she touched something in her car or a bus or taxi and touched her eyes and throat with this something on her hands.

There could be a wide variety of things this lady was having a reaction to, but it does seem to narrow to an allergic reaction or contact with an irritating substance. Being the Benedryl failed to work, may indicate a topical influence rather than something ingested or inhaled. I don't know if that would be true all the time. I remember when the moment I woke up from having an appendectomy I was shot up with five doses of morphine and it never came close to touching the pain, so meds don't always work for what they are made for.

Do you know how this situation ended up being relieved?

 

[Margaritaville]

1. second vitals - no!
2. an hour between Benadryl and Tx
3. Oral intake - breakfast before 6 am
4. handled - gym equipment, showers, books, went to 100 year old farm house on first errand, then to FD
5. No eyedrops
6. Luxury car - leather seats (regular transportation)
7. No eyedrops or construction
8. yes scratching eyes and throat, no redness to hands
9. stated - "hadn't had enough water lately"
10. Also - just got back from a hiking trip the previous weekend.
11. Eyes became notably swollen, cheeks were puffy.

 

[Margaritaville]

Sorry forgot -

Lungs CTA, little diff. breathing - anxiety?

 

[Epi-do]

I agree with EyeOn that it sounds like either a contact irritation or an allergic reaction. Per our protocols here, that would mean at the BLS level that the pt receives high flow O's. Since this particular patient has no wheezing, stridor, or hypotension, our protocols state no other treatment is required and the pt can be transported.

Typically, the medics I work with would go ahead and ride in on something like this, just incase respiratory problems appeared before getting to the hospital. As long as the pt's condition didn't deteriorate, any ALS procedures would be at the discression of the medic.

If this patient was being transported BLS and began to have wheezing, ALS would be requested. If ALS isn't available, the receiving facility is to be contacted for additional orders. If ALS is available, once they arrive they are to administer albuterol (2.5 mg), IV, monitor, and benadryl IV push (50 mg). Epi 1:1000, 0.01 mg/kg sub-q to a max of 0.3 mg administered only if condition remains unchanged or worsenes.

For stridor/hypotension, at the BLS level, administration of pt's epipen is also permissable. At the ALS level, epi is to be administered prior to benadryl at the same dosage as if the pt were wheezing. After that, if the pt worsens/remains hypotensive, 0.1 mg epi (1:100,000) SIVP q 5 minutes. All other treatments would be the same as if the pt where wheezing.

So, do you know what the outcome was with this pt? What sort of treatments did you give while transporting?

 

[EyeOn]

4. handled - gym equipment, showers, books, went to 100 year old farm house on first errand, then to FD
8. yes scratching eyes and throat, no redness to hands
9. stated - "hadn't had enough water lately"
11. Eyes became notably swollen, cheeks were puffy.

I think this might sum it all up nicely. Who knows what's blowing around at 100 year old farmhouses...LOL. That would be my suspicion without knowing anything else.

 

[JimH]

Just out of curiosity, what was she doing at the gym?
(I just began a swim workout at my gym, and have been swimming since I can remember, now, I find I am dealing with an allergy to chlorine- onset and symptoms sound similar)

 

[Margaritaville]

Good thinking by all. Had me puzzled in a big way.

1. Nothing to do with the farm house
2. while on the hiking trip she bought Neutrogena face wash and used it once. Thought the dry feeling was from the mountain air.
3. After gym work out used again.
4. Went to FD on an errand, not for tx. But did get the basics checked when others noticed the swelling, redness and scratching.
5. Took 3 days to narrow down the cause and after 6 days the swelling is gradually diminishing.
6. definitely topical - but awful looking none the less.
7. Lots of potential - and had us baffled!!

Thanks for the input. (I don't post a great deal, but sometimes I enjoy all of your opinions).

 

[EyeOn]

Wow...a soap product. Was trying to think why her hands didn't react, but then again, the skin on the face is thinner and more sensitive.

Gives good thought for future reference. Thanks for the 'ride along'

 

[Ridryder911]

Ditto in agreement to the above post... I would hold off the epi..unless their is angioneurotic edema such as swollen tongue, throat.. etc..

I would adminster steroid such as Solu-Medrol, or Decadron, try another H2 Blocker such as Pepcid, Tagamet... Benadryl may not be effective enough, or may even increase strength with another additional 25mg. ...

R/r 911

 

[fm_emt]

"Noticed an hour after being at gym and having a shower."

I bet she used the cheap arse shampoo & soaps that gyms often have and some of it got into her eyes.

 

[Jon]

That is different. Thanks for the case study.