paramedic anaphylaxis scenario
The number needed to treat (NNT) to prevent one ED relapse visit was 176. EMS report: 10 -year-old riding on ATV was thrown off at about 30mph when the driver hit a log in tall grass, crying, complaining of pain to the R forearm and R hip area and nausea. Did this man have underlying coronary disease that you should have asked about as a contraindication to epinephrine? The diagnosis and management of anaphylaxis practice parameter: 2010 update. The diagnosis is in this case is Kounis Syndrome. A 65 year old female called her family doctor complaining of pain in her shoulder. If you are currently a TANF (Temporary Assistance for Needy Families) recipient with an open child support case, you may receive a letter explaining the pass-through of child support payments that begins February 1, 2021. The study found a higher progression to anaphylaxis in the patients who were not treated. Push Dose: 10 mL every 2-5 minutes (10 mcg), Dose of epinephrine given via infusion: 1mL/min (1 mcg/min) and titrate to a maximum of 20mL/min. CASE 1: A 37 year-old otherwise healthy woman comes in to your ED complaining of an itchy red rash that started soon after eating some seafood at a restaurant. 2000;36(5):462-8. Transferred to ambulance. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Vasopressin dose: 1-5mg IV bolus followed by infusion of 1-5mg/hr. Triaged as Category 1 (Life-Threatening Condition) with Anaphylaxis. Effects: Antihistamine and anticholinergic Doctor left house. Type I – normal coronary arteries and no cardiovascular risk factors, Type II – pre‐existing coronary artery disease, Type III – coronary stent thrombosis due to anaphylaxis. After administration of epinephrine (0.5 mg) the patient complained of chest pain. How effective are steroids at preventing biphasic reactions in anaphylaxis? What is Anaphylaxis? }); If the “scratching feeling in her throat” is deemed by you to be a significant respiratory symptom that indicates any compromise, then according to the definition, this patient fulfills the diagnostic criteria for anaphylaxis. 12 Lead ECG – to identify any life-threatening arrhythmias or ECG changes indicative of myocardial damage (secondary to hypoxia etc. Ann Emerg Med. Histamine–can it cause an acute coronary event? It is recommended for patients to carry 2 epinephrine auto-injectors as the adult ones only contain 0.3mg of epinephrine, and many patients will require 2 doses. showURL: false Anaphylaxis is a potentially life-threatening medical emergency and a challenge for emergency healthcare providers. They found that the combination of 50mg of diphenhydramine plus 50mg of ranitidine compared to diphenhydramine plus placebo was significantly more likely to result in absence of urticaria at 2 hours (91.7% in the ranitidine group vs 73.8% in the placebo group). Epinephrine 1:1,000 0.5mg IM administered. Purpose: This category provides general information regarding crisis intervention including but not limited to, planning, implementation and available resources that may be able to assist a client in a crisis situation. It is used to prevent deterioration post-anaphylaxis treatment. jQuery(document).ready(function() { Death can occur in minutes! Administration: IM }, We are Canada’s most listened to emergency medicine podcast with thousands of subscribers, well over 12 million podcast downloads since 2010 and are proudly part of the #FOAMed community. 2015;49(2):e39-43. Ambulance responded from base approximately 30 minutes from incident. Acute ST-segment elevation myocardial infarction after amoxycillin-induced anaphylactic shock in a young adult with normal coronary arteries: a case report. 1993 May;70(5):396-8. jQuery(document).ready(function() { SKIN REACTIONS– symptoms include urticaria (smooth, elevated patches of skin with itchiness), erythema and angioedema RESPIRATORY REACTIONS– symptoms include bronchospasm, local edema of larynx leading to airway obstruction ANAPHYLAXIS– the most acute and life threatening! 4, pp. Effects: Alpha & beta adrenergic stimulant. BMC Res Notes. The electrocardiogram showed an elevation of ST segment in inferior leads. She complains of a scratchy feeling in her throat, but denies any difficulty breathing, speaking or swallowing. 1. }, Dr. Helman and Dr. Carr have no conflicts of interest to declare. However, as per Chase et al. The scenario will reflect either a pediatric, geriatric or adult patient. Anaphylaxis and cardiovascular disease: therapeutic dilemmas. jQuery(document).ready(function() { Emergency call is made by patient at 1800. There is evidence to suggest that histamine release and indeed the general process of anaphylaxis have the potential to cause myocardial damage through coronary vasculature spasm (Gupta et al., 2001). Only after the completion of scenario-based training may a ... 5. A 12-lead ECG showed no obvious changes. Time of Onset and Predictors of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-analysis. Scenario: You are called to a local residence for a woman in respiratory distress. Q9: What counseling do you provide patients who are discharged from the ED after anaphylaxis? Ann Emerg Med. Administration: IV/IM This site complies with the HONcode standard for trustworthy health information: verify here. jQuery("#cit11580784").tooltip({ Luckily we got the epi in soon enough to avoid an airway. As outlined above in the diagnostic criteria of anaphylaxis, isloated hypotension after exposure to a presumed allergen is enough to make the diagnosis of anaphylaxis. Obervational studies show that up to 20% of patients do not have a rash with their anaphylaxis. “Nice job,” he says with a smile. There was no history of chest pain, SOB, palpitations, headache, back pain or fever, vomiting or diarrhea and no melena. In this scenario, we found a wide variation in practice for the determination of epinephrine dosing. Abstract. Anaphylaxis, can present with isolated hypotension, or hypotension plus vomiting, or hypotension plus wheezing without rash. Blood tests – to identify any electrolyte imbalances etc. PMID: 11580784. A bit of basic pathophsyiology is helpful to understanding how one ends up with a STEMI after anaphylaxis: There is a high density of mast cells present in the coronary arteries in people with coronary artery disease. Prognostic value of symptoms during a normal or nonspecific electrocardiogram in emergency department patients with potential acute coronary syndrome. The scenarios may be used with other curricula with little or no modification. Brought directly to Resus room. Allergy. }); Corona […] While there is no good evidence in the literature that the addition of steroids to epinephrine has a mortality benefit or prevents a biphasic reaction, it is still recommended by our expert, but only if the setting of true anaphylaxis. Sampson HA, Muñoz-furlong A, Campbell RL, et al. Terms of Use, Advertising & Privacy Policy. Note that starting May 2016, the current 1:1,000 vs 1:10,000 concentration of epinephrine will be replaced by 1mg/mL and 0.1mg/mL respectively to minimize confusion leading to medication dosing error. Epinephrine should be administered as soon as the diagnosis of anaphylaxis is made intramuscularly in the anterolateral thigh. return jQuery("#cit16973638 .abstr").text(); A case of a 30-year-old man who developed a myocardial infarction after self-administering an Epi-Pen for an episode of idiopathic anaphylaxis is reported. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education. jQuery("#cit15733315").tooltip({ return jQuery("#cit8498731 .abstr").text(); He quickly developed diffuse erythema with itching, wheezing, and GERD-like syx before we pushed epi. He was given epinephrine 0.5mg IM, and soon after started complaining of chest pain. Previously on the blog, we brought you a post with four scenarios for your Ambulance Operations class.While we gave you some some gnarly details about creating elaborate moulage, we didn’t offer you the specific data (BP, pulse, medications, etc.) Upon arrival to the scene, a neighbor greets you and states that they saw the person cleaning gutters earlier. The correct dose of epinephrine for the treatment of anaphylaxis is 0.01mg/kg (to a max of 0.5mg) IM, repeated after 5 mins if there’s no clinical improvement. Steroids can take 4-6 hours to take effect, but the quick administration of IV steroids can prevent a biphasic response from developing at a later stage. BP 100/p, HR 120, deformity and laceration to R mid forearm noted – bandaged and splinted. }); Consider anaphylaxis in every patient who presents in shock, because anaphylaxis can present with isolated hypotension. What route, what location, what dose? Additional Info: If thrombolysis indicated, do not administer IM, The IM administration of diclofenac has rare, but severe, and often fatal side effects in some patients. A 59-year-old male presents to the ED with anaphylaxis. PMID: 15733315. While traditionally patients with anaphylaxis are obvserved in the ED for 4-6hrs before discharge, there is no literature to support this practice. Patient developed anaphylactic reaction to IM diclofenac administered by family doctor 30 minutes prior. Aspirin 300mg PO chewed and GTN 1.2mg SL administered with good effect. BMC Cardiovasc Disord. showURL: false Dosage: 0.5mg IM every 3-5 minutes if required This hands-on, intensive training course educates students in a wide range of skills and real-world scenarios. Case Continued: You give your push dose epinephrine and you’ve maxed out on 20mL/min infusion and the patient remains hypotensive. Blood sugar is 15. Cochrane Database Syst Rev 2007; CD006160. Scenarios. }, First, aggressive fluid resuscitation is indicated for patients with anaphylactic shock via rapid infuser or short large peripheral IVs with pressure bags. The administration of epinephrine in acute anaphylaxis can precipitate an acute coronary event through coronary spasm induced infarct and through vasospastic angina (Saff et al., 1993; Caballero et al., 1999). }, Clin Cardiol. Five minutes later, she collapsed and developed coma and re […] For more on anaphylaxis and anaphylactic shock on EM Cases: Do not underestimate profound vasodilatory shock that occurs in anaphylactic shock. 2010 Sep;126(3):477-80. All prior scenarios will be listed here in running chronological order. Family states she has had a high fever and trouble breathing for a couple of days. DISPATCH . return jQuery("#cit10217970 .abstr").text(); Second, consideration may be given to a second vasopressor. What causes it? Along with members from the EMSC EMS Committee and pediatric advocates throughout the state, the Kansas Pediatric Scenario Guidebook was developed. Ralapanawa DM, Kularatne SA. Given, a simulated patient with signs of anaphylaxis or impending respiratory failure due to asthma or COPD; EMS partner(s); an applicable scenario; the Epi-Kit; and additional EMS equipment provided by … En-route patient reported easing of chest pain, and breathing effort. She ap-pears to be gasping for air. Additional Info: Double check concentrations on pack, Presentation: Vial 10mg/1ml The Remote Emergency Medical Technician (REMT) course meets and exceeds wilderness medical standards by covering all Wilderness EMT (WEMT) curriculum, while also incorporating select higher-level capabilities. I had just listened to the ‘master clinician’ catch of isolated hypotension and mentioned anaphylaxis to the staff. They are based on the Alaska Skill Sheets and the 1994 Revision of the United States Department of Transportation EMT-Basic curriculum. Recent literature has found that the rate of biphasic reactions may be lower than previously stated. Q10: Besides 2 epinephrine auto-injectors, what other medications will you prescribe on discharge from the ED? The patient was collapsed in an armchair, semi-conscious upon arrival of ambulance crew at 1825. Observational data have shown that biphasic reactions in anaphylaxis can occur any time between 1 hour and 7 days after the initial anaphylactic episode in approximately 2-5% of patients. Patient placed on 100% O2 via non-rebreather. Dental Hygienist - Nurse's - Medical Office Personnel - EMT's - Firefighters - Coach'sAnyone with a … 2006;47(4):373-80. jQuery("#cit11288975").tooltip({ EMT Scenario: M002. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. There are no absolute contraindications to epinephrine in severe anaphylaxis. Sheikh A, Ten Broek VM, Brown SG, et al. No endorsement of . A second peripheral line is started, more saline under pressure bags is infused, a quick cardiac, respiratory and belly exam are unremarkable and an ECG and POCUS don’t show any striking abnormalities except that the LV looks hyperdynamic and the IVC looks collapsed. This is the Great Lakes EMS Academy / Davenport University Consortium Paramedic ALS Psychomotor Skills ... scenario-based training at the earliest time possible. It is therefore imperative not only to give the patient a script for epinephrine auto-injectors on discharge from the ED, but to take the time to counsel patients on the use of them. 1 Rapid-onset respiratory compromise, skin/mucosal … Improved markedly over the next 10 minutes and stated that he also had a ‘marble in his throat’. Did you cause an MI with your IM epinephrine? return jQuery("#cit15733315 .abstr").text(); Hypoxic brain damage after intramuscular self-injection of diclofenac for acute back pain. Nonetheless, corticosteroids are standard care for patients with anaphylaxis. Until large validated RCTs can show definitely that steroids are not effective in this respect, it still remains standard care to administer steroids along with epinephrine for patients with true anaphylaxis. Hypotensive to 60s/40s so initially worried about AAA or GI bleed (FOB+). Not recognizing this in a timely manner can lead to misdiagnosis and death. Her voice is normal, lips and tongue do not appear swollen, there’s no stridor and her chest is clear. jQuery("#cit16973638").tooltip({ Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. The authors hypothesized that patients with a normal or nonspecific ECG during symptoms have a lower risk for ACS than do […] (Haskell, 2006), Chlorphenamine is an antihistamine commonly used in the treatment of anaphylaxis as a secondary therapy to Epinephrine 1:1,000 IM and as a first choice therapy for allergic reactions that are not life threatening, but with symptoms that are causing the patient distress, such as urticaria. Unfortunately, no guidelines exist for the management of patients with acute coronary events in the setting of anaphylaxis. chlorphenamine), Inhaled β2-agonists (i.e. J Allergy Clin Immunol 2001; 108:871‐6. showURL: false However, there appears to be differences between the two groups – most notably, 7.8% of the antihistamine group, as compared to only 2.8% of the non-treatment group, were treated with epinephrine “before the development of anaphylaxis”. The AAAAI and the […] Again, the issue with this study, was that only a small proportion of patients actually fulfilled the criteria for true anaphylaxis, with only 54% receiving epinephrine. 2014;69(6):791-7.Regis AC, Germann CA, Crowell JG. Massachusetts: Jones & Bartlett. The most common cause of death in anaphylaxis, is not giving epinephrine at the right time at the correct dose. Patient began to complain of a pain in her chest post Epinephrine administration. }); Gikas A1, Lazaros G, Kontou-Fili K. Acute ST-segment elevation myocardial infarction after amoxycillin-induced anaphylactic shock in a young adult with normal coronary arteries: a case report. EMS sees an adult pt (50 M) lying on cement driveway supine outside home. Second dose of Epinephrine 1:1,000 0.5mg IM administered with good effect. In each, Quick Hits 15 Pediatric COVID, Human Factors, Quick Hits 16 COVID Oxygenation, Trauma, Cardiac, The importance of epinephrine timing, location and dose in anaphylaxis, Epinephrine auto-injector instructions for patients being discharged from the ED after anaphylaxis, Steps for drawing up epinephrine for push dose epinephrine and epinephrine infusion, Take home points for Anaphylaxis and Anaphylactic Shock, https://media.blubrry.com/emc/p/content.blubrry.com/emc/EMC-078-Mar2016-Anaphylaxis-Live-EM-Cases-Course.mp3, Rapid Reviews Video on Anaphylaxis & Anaphylactic Shock, SGEM#57: Should I Stay or Should I Go (Biphasic Anaphylactic Response), EM Quick Hits 26 LAST, Sodium Nitrite Poisoning, Post-intubation Care, Tetracaine for Corneal Abrasion, ST Segment in Occlusion MI, Coping with COVID, POCUS Cases 9 Abdominal Free Fluid in Trauma, Ep 152 The 7 Ts of Massive Hemorrhage Protocols, The Schwartz/Reisman Emergency Medicine Institute (SREMI), Reduced blood pressure or associated symptoms of end‐organ dysfunction, Reduced blood pressure or associated symptoms of end‐organ dysfunction d. Persistent gastrointestinal symptoms, Infants and children: low systolic blood pressure (age‐specific) or >30% decreased in systolic blood pressure, Adults: systolic blood pressure 30% decrease from that patient’s baseline, patients taking anti-hypertensive medication, early symptom onset and late treatment initiation, Remove the safety release mechanism, making sure that the blue end points away and the orange end points to the thigh (“, Firmly push the auto-injector against the middle of the outer thigh (through the pants if necessary) until a clicking sound is heard, Hold the auto-injector firmly in place against the thigh for 10 seconds to deliver the medication, Remove the device from the thigh and call 911, Draw up 10mL from the 1L bag in a 10mL syringe (The concentration of epinephrine in the syringe is, note that the onset = 1 minute and duration = 5-10 minutes. }, Doctor called to house, and administered 40mg diclofenac (Difene) IM at 1720. any product or service should be inferred or is … These side effects would not be seen in the PO or PR administration of diclofenac, yet these routes provide similar absorption rates. Q7: How long to do you need to keep patients with allergic reactions with or without anaphylaxis in the ED? Case continued: This patient gets 0.5mg of 1:1000 epinephrine IM in the antero-lateral thigh and his pressure is still 70/palp, and so 5 minutes later he gets a second dose, and his pressure is still only 70 on palp. Sometimes patients do not self-administer the epinephrine auto-injector (even if they are carrying it on their person) or do not administer it properly. Myocardial Infarction in the Setting of Anaphylaxis to Celecoxib: A Case of Kounis Syndrome. Myocardial necrosis was ruled out. Learners will be expected to provide repeat dosing of epinephrine as well as to start an epinephrine infusion in order for the patient to improve. EMS started a bolus of normal saline in a peripheral IV and in the ED his BP remains around 70 on palp. Ann Allergy. }); Rev Esp Cardiol. Ambulance responded from base approximately 30 minutes from incident. Emergency department corticosteroid use for allergy or anaphylaxis is not associated with decreased relapses. The following two tabs change content below. Prehospital Emergency Care: Vol. 527-534. He complained of nausea, vomited once and some shortness of breath along with his urticarial rash. Emergency department (ED) patients with symptoms concerning for acute coronary syndrome (ACS) and a normal electrocardiogram (ECG) are at risk for adverse cardiovascular events. On arrival, he will be wheezing and hypotensive with angioedema. Some experts recommend observing patients until they become asymptomatic regardless of time. jQuery(document).ready(function() { It can also be used in the treatment of severe and life-threatening asthma and Addisonian Crisis. The emergency provider must treat both the allergic and cardiac manifestations of anaphylaxis. Patient diagnosed with anaphylactic reaction to diclofenac. J Allergy Clin Immunol. Upon scene size up a ladder is found on the ground outside a 2 story (~20 ft.) family home; bushes in front emergency medical services (EMS) handbook, personal memory and recently implemented colour-coded stickers. Lee S, Bellolio MF, Hess EP, Erwin P, Murad MH, Campbell RL. First medical code was 56y male who came in with acute ‘dizziness’ in addition to vague abdominal pain. Q1: Is this anaphylaxis or is this simply an allergic reaction that we don’t have to treat aggressively? The management of patients with Kounis syndrome can be challenging. Pitfall: Assuming the patient does not have anaphylaxis just because they don’t have a rash. Admitted to high-dependency unit on medical ward for observation overnight. In one case series, 24% of patients with Kounis syndrome received epinephrine and there were no deaths. He has previously worked and studied across Europe, North America and the Middle East. Grunau BE, Li J, Yi TW, et al. }); Lieberman P1, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, Bernstein JA, Burks AW, Feldweg AM, Fink JN, Greenberger PA, Golden DB, James JM, Kemp SF, Ledford DK, Lieberman P, Sheffer AL, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D. The diagnosis and management of anaphylaxis practice parameter: 2010 update. While there is no good evidence that steroids decrease the relapse rate or rate of biphasic reactions. In addition, the simulation scenario included paedi … Therefore, we cannot assume from these studies that steroids play no role in preventing relapses or biphasic reactions in anaphylaxis. That means, the patient needs to disrobe in order to access the thigh. Rohacek M, Edenhofer H, Bircher A, Bingisser R. Biphasic anaphylactic reactions: occurrence and mortality. }); Hydrocortisone is a glucocorticoid medication (steroid) that reduces inflammation and suppresses immune response. bodyHandler: function() { C.R.A.S.H.E.D – A model for structured reflection in prehospital care. The addition of prednisone did not improve the symptomatic and clinical response to levocetirizine. While it is tempting to conclude from this study that biphasic reactions are so rare that they become almost irrelevant, this study was not confined to patients with anaphylaxis. Patient began to appear less confused, reported dizziness resolving. One of the more common reasons for death in anaphylaxis, Ann Emerg Med. Does your training institution utilise simulation for prehospital education? Podcast: Play in new window | Download (Duration: 50:53 — 46.6MB), Written Summary and blog post written by Anton Helman, March 2016, This podcast was recorded live at The EM Cases Course, at North York General Hospital in Toronto February 2016. Two or more of the following that occur rapidly (minutes to hours) after exposure to a likely antigen for that patient: 3. He’s otherwise healthy except for a history of hypertension.