Case summary:

An ALS crew responded to a 60s woman for shortness of breath.  When the crew arrived, they found the patient alert, oriented, and sitting in a chair reporting an allergic reaction.  She reports having a history of multiple allergies but is not sure what she was exposed to.  She reports having an itching rash and shortness of breath.  She also reports a history of asthma and tried using her prescribed inhaler while the crew was in route with some relief.  The crew noted hives as well as wheezing in all lung fields.  The crew extricated the patient and once in the ambulance, they gave 0.3mg IM epinephrine while working on obtaining vitals.

Initial vitals: BP 103/82,  HR 59,  RR 22,  Sat 90% on RA

They next placed and IV and administered diphenhydramine and methylprednisolone via that IV. They also gave the patient a nebulized albuterol treatment given the wheezing.  The patient reported feeling significantly better initially.  However, in route they noticed that her blood pressure dropped to 80/50 and she felt more short of breath so they gave a second 0.3mg dose of IM epinephrine, a second albuterol treatment and gave the patient a fluid bolus.  Patient improved after these treatments and care was handed off to the receiving hospital. 

Highlights of the case:

Define Anaphylaxis.

While treating allergic reactions is bread and butter for EMS, it is still worth reviewing cases like this since these are situations where EMS truly can make a difference and save lives.  The most important thing is to identify anaphylaxis.  Anaphylaxis is a severe, life-threatening allergic reaction that involves 2 or more organ systems.  The organ systems we typically think about include skin (hives), airway (angioedema), pulmonary (wheezing), cardiovascular (hypotension), gastrointestinal (angioedema of the GI tract causing nausea and/or vomiting).  Even if the symptoms are mild, anaphylaxis can ramp up quickly see we need to identify it quickly so we can treat it quickly.  This means that if a patient has an exposure to something and develops mild hives and mild wheezing, this is anaphylaxis and should be taken seriously so that it does not rapidly progress to anaphylactic shock or loss of airway.  This crew had a patient with hives and wheezing from a potential exposure which is consistent with anaphylaxis.  He symptoms were moderate at first, but she still worsened despite a dose of epinephrine and it is possible that she could have gone into cardiovascular collapse had the first dose not been given when it was.

Epinephrine is key in anaphylaxis.

The key to treating anaphylaxis is IM epinephrine.  The goal is to get this on board as soon as possible and we should not delay this for anything, including other treatments and extrication.  The reason we do not want to delay getting the first dose of epi on board right away is because the patient is either already critically ill or can become critically ill rapidly.  There are many adjunct therapies that we also often give to patients experiencing anaphylactic as well as non-anaphylactic allergic reactions.  These treatments include antihistamines (diphenhydramine) and corticosteroids (methylprednisolone). While these adjuncts are important, they are not nearly as important as epinephrine.  For this reason, they should never be prioritized over epinephrine in the setting of anaphylaxis, even mild anaphylaxis.  If a patient fails to improve or worsens after epinephrine administration, then we need to give more epinephrine.  In the setting of anaphylaxis, the patient needs as much epinephrine as it takes to control his or her symptoms so have a low threshold to re-dose.  While this crew did get epinephrine on board prior to all other treatments, they delayed its administration until after extrication which is not best practice.  However, they were very quick to re-dose epinephrine when they noticed that the patient was worsening which was great!