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Case of the Month
June 2006
35-year-old female — possible allergic reaction
Dispatch
"Aid 22 to a 35-year-old female light-headed, possible allergic reaction"
En route your crew discusses the following considerations:
- Reasons for light-headedness
- Treatment of allergic reactions
- Epinephrine auto-injector protocols
Dispatch updates you reporting that the patient is feeling light-headed after eating a cookie at a friend's house. The cookie contained walnuts which the patient is allergic to.
Scene Size-up
You are met at the front of a small house in a residential neighborhood. A woman leads you to the patient who is on the back patio of the house. The patient is laying on her side and is very pale. The friend states they were relaxing on the patio when the patient took a bite out of a homemade cookie. The cookie was chocolate chip with walnuts. The patient almost immediately became light-headed and started to turn pale. That is when 9-1-1 was called.
Initial Assessment
When approaching the patient you see that she is pale and looks sleepy like she is going to pass out. You reach for a pulse and find none at the wrist. Her skin is moist and cool.
SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?
- Types of treatment needed for this patient?
- Further steps for evaluation?
- Need of ALS care?
Treatment
You decide that the patient is SICK based on her decreased level of consciousness, no peripheral pulse and poor skin signs. You immediately request a medic unit.
You apply a partial non-rebreather mask at 10 liters per minute, raise the patient's legs and locate your Epinephrine auto-injector. Following the protocols, the upper leg is bared and wiped with alcohol, the auto injector is evaluated for dose, expiration date, and clarity of medicine, the safety cap is removed and the injector is placed against the skin. By applying pressure against the leg with the auto-injector, it is activated, piercing the patient's skin and injecting .3 mg Epinephrine at 1:1000 concentration. You hold the injector in place for 10 seconds, remove it and massage the site. The incoming medic unit is advised and post injection vitals are taken.
Your partner completes an assessment:
CC/NOI |
— |
35-year-old female, possible allergic reaction to walnuts |
RR |
— |
28/min |
Pulse |
— |
130 at the brachial, very thready, still no radial |
Mental Status |
— |
Patient is obtunded, almost unconscious |
Skin |
— |
Very pale and cool, but dry |
Body Position |
— |
Laying on her right side on the patio |
Physical Exam
Your partner notes the following information:
HEENT |
— |
Skin is cool, pale, and moist. Pupils are equal, but sluggish to react. |
Chest |
— |
Patient has some hive on the front of the chest, lungs are clear with moderate tidal volume. |
Abdomen |
— |
Unremarkable |
Extremities |
— |
Some hive on the forearms |
Neuro |
— |
Patient obtunded, only reacting to loud voice or noxious stimuli |
SAMPLE
S |
What are the signs and symptoms? |
Sudden onset of extreme light-headedness a minute or so after eating a cookie that contained walnuts. |
A |
Are you allergic to any medication? |
Patient is allergic to walnuts, but has never had this bad of a reaction. Her primary care physician has never issued her an epinephrine auto-injector. |
M |
Are you currently taking any medication? |
None. |
P |
Any medical history I should know about? |
Walnut allergy. |
L |
When was the last time you ate or drank anything? What was it? |
The patient had a cookie about 8 minutes prior to EMS arrival. Last meal was 3 hours ago. The last meal consisted of a hamburger with BBQ potato chips, a pickle and a diet soda. |
E |
How did this happen? |
The patient started having light-headedness after eating a cookie. She was able to ease her way to the ground, but was very weak. |
Vital Signs
Respirations |
— |
24 without labor |
Pulse |
— |
Radial at 130—weak |
BP |
— |
80/P |
Breath Sounds |
— |
Clear with moderate tidal exchange |
Pulse Oximetry |
— |
Unable to obtain due to peripheral vascular shutdown |
The patient was immediately classified as SICK and high flow oxygen initiated. The crew realized the patient was suffering from an anaphylactic reaction (defined by respiratory distress along with hypotension) and immediately deployed an epinephrine auto-injector. Fortunately the patient reacted quickly and her blood pressure started to rise.
Over the next 10 minutes the patient continued to improve. By the time the medic unit arrived her blood pressure was 92/P with a heart rate of 110. She was also regaining consciousness and color. After beginning to stabilize, a quick trauma survey was performed to discover if any injuries occurred when the patient went to the ground. No trauma is found.
Presentation and Treatment of Anaphylaxis
A normal, mild allergic reaction can present with localized swelling, hives, and itching among others symptoms. An Epipen would not be appropriate in this case. Anaphylaxis is a 'run-away' allergic reaction (respiratory distress and/or hypotension) that can be life-threatening.
Anaphylaxis has more dire signs and symptoms. These include airway swelling, severe wheezes, and/or profound hypotension. Many people believe that an allergic reaction must include some sort of severe airway compromise to be considered anaphylaxis, however often these patients will present with a sudden, extreme drop in blood pressure with no impact on their breathing.
The field treatment for anaphylactic shock includes an immediate request/update to the medic unit, ABC’s, high flow oxygen, treatment for shock, and the use of an epinephrine auto-injector.
Recent changes in Washington State EMT Basic Field Protocols (updated September 2005) allow an EMT to utilize an epinephrine auto-injector whether the patient has a prescription or not. Use of the auto-injector also is allowed in patients under 18 without parental consent. For more information about these changes, see the 2006 EMS Provider Updates here.
In other words, there are no contraindications when used in a life-threatening situation.
Remember there are two sizes of auto injector; Adult (0.3mg epinephrine) and Child/Infant (0.15mg epinephrine) with the dose being determined by the patient's body weight. For patient 30 kg (66 lbs.) or higher the Adult injector is used, less than 30 kg (66 lbs.) patients receive the Child/Infant injector.
Take the time to become familiar with the location and use of these life saving tools! |
