An ALS crew responded to the home of a elderly man who was reportedly stung by a bee and subsequently collapsed on the ground.  The patient was laying on the ground and had hives covering his body, was diaphoretic, eyes were swollen shut, tongue was protruding from his mouth, and he was having a difficult time speaking.  Patient has a known allergy to bee stings and was intubated the last time he was stung.  Patients wife had already given 50mg of diphenhydramine but had not given epinephrine since they did not have it on them.  Crew assessed radial pulse and could not feel one.  The crew immediately gave 0.3mg IM epinephrine and then extricated to the rig. 

Once in the rig they worked on vitals and again could not feel a radial pulse so they gave a second dose of 0.3mg IM epinephrine. 

First set of vitals were: BP: 70/42, HR 99, RR 10, O2 sat 66%, ETCO2 13

The crew placed a NRB on the patient to treat the hypoxia, placed the surgical airway kit at bedside in case the patient lost his airway and started giving pushes of IV epinephrine at a dose of 100mcg per push as well as running fluids in wide open.  After a few doses, they felt radial pulses and obtained a BP of 110 systolic.  The patient started to have decreased tongue swelling and was beginning to be able to speak.  The crew also gave 125mg of IV solumedrol while in route.  Patient arrived to the ED with radial pulses intact and significantly improved vitals. 

Highlights of the case:

The most important thing in anaphylaxis is epinephrine.

This patient had severe anaphylactic shock.  The key thing to remember in anaphylaxis, not just anaphylactic shock, is that the most important thing we can do is administer epinephrine as soon as possible.  This means that epinephrine should be administered BEFORE extrication and ideally within the first minute of realizing the patient is having an anaphylactic reaction.  Many EMS protocols also recommend giving steroids and diphenhydramine, but these are in addition to epinephrine and should never be given before epinephrine.  While our first dose of epinephrine should be given IM, if a patient has evidence of anaphylactic shock (hypotension or lack of a radial pulse), we should rapidly obtain IV/IO access to give the patient IV epinephrine.  The dose that our protocol lists is 100 mcg per push.  It is important to note that this is 1/10th the dose we would give to a patient in cardiac arrest but also twice the upper limit of our protocols dose of push dose epinephrine.  If the patient remains hypotensive despite this dose of IV epinephrine, we should repeat the dose and have a low threshold to involve med control to give even higher doses.  To summarize, IM epinephrine should be given to all patients with anaphylaxis and IV epinephrine should be given to patients with anaphylactic shock.  This crew provided amazing care to this patient and their quick decisions, both to give IM epinephrine right at patient contact and then to quickly escalate to IV epinephrine, absolutely saved this patient’s life.

When it comes to a difficult airway, prepare for the worst and hope for the best.

While this crew did not need to manage this patient’s airway, they correctly identified that this patient had impending airway obstruction and had a high likelihood of needing a surgical airway to obtain an airway should he worsen.  While they did not need to perform a surgical airway, they had their kit out and ready to go in case the patient required this procedure.  In general, we should prepare for the worst and hope for the best, but it is critically important when it comes to difficult airways.  This crew was thinking multiple steps ahead in terms of how they planned to manage things that had not even happened yet.  While they did not need to perform a surgical airway, they were ready to which was key.