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 number needed to treat (NNT) to prevent one ED relapse visit was 176. Do not underestimate profound vasodilatory shock that occurs in anaphylactic shock. }); 12 Lead ECG – to identify any life-threatening arrhythmias or ECG changes indicative of myocardial damage (secondary to hypoxia etc. While traditionally patients with anaphylaxis are obvserved in the ED for 4-6hrs before discharge, there is no literature to support this practice. Clarifying Information Definition of a Crisis: A disruption or breakdown in a person’s or family’s normal or usual pattern of functioning. Aspirin 300mg PO chewed and GTN 1.2mg SL administered with good effect. 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). Sampson HA, Muñoz-furlong A, Campbell RL, et al. A 12-lead ECG showed no obvious changes. You can find more information here, or call 1-800-742-KIDS. The scenarios may be used with other curricula with little or no modification. Massachusetts: Jones & Bartlett. Chase M1, Brown AM, Robey JL, Pollack CV Jr, Shofer FS, Hollander JE. Upon scene size up a ladder is found on the ground outside a 2 story (~20 ft.) family home; bushes in front }); bodyHandler: function() { Patient commenced on Salbutamol 5mg/2.5ml nebuliser. Grunau BE, Li J, Yi TW, et al. All patient who fulfill the criteria for anaphylaxis require the administration of epinephrine. Corona […] He quickly developed diffuse erythema with itching, wheezing, and GERD-like syx before we pushed epi. return jQuery("#cit16973638 .abstr").text(); Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. 2015;8:97. These side effects would not be seen in the PO or PR administration of diclofenac, yet these routes provide similar absorption rates. Time of Onset and Predictors of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-analysis. 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. That means, the patient needs to disrobe in order to access the thigh. Anaphylaxis, can present with isolated hypotension, or hypotension plus vomiting, or hypotension plus wheezing without rash. Lee S, Bellolio MF, Hess EP, Erwin P, Murad MH, Campbell RL. She appears uncomfortable, scratching at her neck with an obvious raised patchy red urticarial rash all over her neck and torso. Patient arrived to ED Resus at 1926. Ambulance responded from base approximately 30 minutes from incident. Anaphylaxis is highly likely when any one of the following three criteria is fulfilled: Scenario: EMS is dispatched for an adult who fell. 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. However, as per Chase et al. Along with members from the EMSC EMS Committee and pediatric advocates throughout the state, the Kansas Pediatric Scenario Guidebook was developed. She denies lip or tongue swelling, SOB, abdominal pain, vomiting or fever. Eur J Anaesthesiol. He has previously worked and studied across Europe, North America and the Middle East. The emergency provider must treat both the allergic and cardiac manifestations of anaphylaxis. 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. No endorsement of . Which patients might you want to observe for a prolonged period of time in the ED? 1993 May;70(5):396-8. PMID: 16973638. Acute onset of an illness (minutes to hours), with involvement of the skin, mucosal tissues, or both AND at least one of the following: 2. Kounis syndrome secondary to amoxicillin/clavulanic acid administration: a case report and review of literature. This paper reports the case of a 28-year-old woman with no significant risk factors for coronary artery disease who presented with generalized ur […] Improved markedly over the next 10 minutes and stated that he also had a ‘marble in his throat’. Case Continued: You give your push dose epinephrine and you’ve maxed out on 20mL/min infusion and the patient remains hypotensive. Administration: IM If you do give steroids, our expert recommends single dose dexamethasone in the ED, which has the advantage of a long half-life of 53hrs, thus negating the need for prescribing steroids upon discharge. All prior scenarios will be listed here in running chronological order. Q5: What’s the evidence for the effectiveness of the addition of H2 blockers to H1 blockers in the symptomatic relief in allergic reactions and anaphylaxis? First, aggressive fluid resuscitation is indicated for patients with anaphylactic shock via rapid infuser or short large peripheral IVs with pressure bags. Both Chlorphenamine and Hydrocortisone are approved medications for use by State Registered Paramedics in the UK under the JRCALC Guidelines (JRCALC, 2006), Presentation: Vial 1mg/1ml Theoretically, epinephrine may worsen coronary vasospasm and worsen myocardial ischemia. Blood sugar is 15. 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). The study found a higher progression to anaphylaxis in the patients who were not treated. Clin Exp Allergy 2015; 45:1288‐9. Remember that steroids take 4-6hrs to become effective, so (in contradistinction to epinephrine) there is no rush to administer them. There are no upcoming events at this time. Q: What is your next move after maxing out on your IV epinephrine infusion? Q1: Is this anaphylaxis or is this simply an allergic reaction that we don’t have to treat aggressively? There are no contra-indications to epinephrine when it comes to severe anaphylaxis. The authors hypothesized that patients with a normal or nonspecific ECG during symptoms have a lower risk for ACS than do […] 30 minutes post administration, patient felt her throat beginning to swell, developed a rash, and felt dizzy and weak. Haskell G (2006) Paramedic Pearls of Wisdom. Brought directly to Resus room. En-route patient reported easing of chest pain, and breathing effort. After administration of epinephrine (0.5 mg) the patient complained of chest pain. The team must initiate usual anaphylaxis treatment including salbutamol for bronchospasm. [5/13/13] 21 Chapman St — unknown [4/22/13] 720 Mass Ave — MVA [4/8/13] 322 Stowecroft — unknown medical [4/1/13]… This would ensure that the short-term effects of IM Epinephrine would not result in the patient redeveloping an anaphylactic reaction en-route to the ED post treatment. Upon arrival to the scene, a neighbor greets you and states that they saw the person cleaning gutters earlier. is the patient not self-administering the epinephrine auto-injector She ap-pears to be gasping for air. Myocardial necrosis was ruled out. In this scenario, we found a wide variation in practice for the determination of epinephrine dosing. any product or service should be inferred or is … 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. Patient placed on 100% O2 via non-rebreather. Second, consideration may be given to a second vasopressor. 16, No. Therefore it would be prudent for pre-hospital care providers to treat patients presenting with chest pain during anaphylaxis, (pre- or post-epinephrine administration) as per ACS treatment guidelines. Hydrocortisone is a glucocorticoid medication (steroid) that reduces inflammation and suppresses immune response. A 59-year-old male presents to the ED with anaphylaxis. Which patients require steroids in the ED for 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. Hartmann’s solution 1000ml commenced. }, Paramedic candidates are tested on (6) skills, including an integrated out-of-hospital (IOOH) scenario. EMS started a bolus of normal saline in a peripheral IV and in the ED his BP remains around 70 on palp. }); Rev Esp Cardiol. }, He complained of nausea, vomited once and some shortness of breath along with his urticarial rash. 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. CPR AED For Healthcare & Professional Responders February 27th, 2014 Who Needs CPRO? }); Schäbitz WR1, Berger C, Knauth M, Meinck HM, Steiner T. Hypoxic brain damage after intramuscular self-injection of diclofenac for acute back pain. C.R.A.S.H.E.D – A model for structured reflection in prehospital care. Histamine–can it cause an acute coronary event? While the addition of H2 blockers to H1 blockers may help resolve urticaria faster, the true clinical significance of this is unknown. C-collar and long board. Administration: IV Bloods taken. Epinephrine should be administered as soon as the diagnosis of anaphylaxis is made intramuscularly in the anterolateral thigh. Angioedema, urticaria, peripheral cyanosis and laryngospasm fully resolved post 2nd Epinephrine administration. 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. Admitted to high-dependency unit on medical ward for observation overnight. Q12: How would you administer epinephrine in this scenario of a patient in presumed anaphylactic shock who’s had 2 intramuscular doses of epinephrine that haven’t improved his blood pressure? He’s otherwise healthy except for a history of hypertension. }, PMID: 15733315. Epinephrine 1:1,000 0.5mg IM administered. Lieberman P, Simons FE. Scenario 2 . She became diaphoretic and dyspnoeic as a result. bodyHandler: function() { Pitfall: Assuming the patient does not have anaphylaxis just because they don’t have a rash. Doctor called to house, and administered 40mg diclofenac (Difene) IM at 1720. BMC Cardiovasc Disord. Obvious urticaria, cyanosis of lips and nostrils and angioedema present. He saw his Family Physician the day prior, complaining of urinary frequency, and was started on Septra – sulphamethoxazole-trimethoprim. J Allergy Clin Immunol 2001; 108:871‐6. further studies are required to abandon steroids for the treatment anaphylaxis. 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. jQuery(document).ready(function() { It is used to prevent deterioration post-anaphylaxis treatment. 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. Anaphylaxis is a potentially life-threatening medical emergency and a challenge for emergency healthcare providers. PMID: 8498731. A 41-year-old-man without previous ischemic heart disease, developed a severe anaphylactic reaction. Subcutaneous injections should be avoided. A 180 lb man should NOT be getting only 0.3mg IM. Choo KJ, Simons FE, Sheikh A. Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review. }); Saff R1, Nahhas A, Fink JN. What route, what location, what dose? Symposium on the definition and management of anaphylaxis: summary report. The scenario will reflect either a pediatric, geriatric or adult patient. This resource will walk your providers through a scenario containing vital signs, pertinent patient and call information, graphics, return jQuery("#cit11580784 .abstr").text(); Prognostic value of symptoms during a normal or nonspecific electrocardiogram in emergency department patients with potential acute coronary syndrome. Angioedema and peripheral cyanosis remained resolved. Family doctor advised of same. or not administering it properly. Current 4th year medical student in the States and listened to the episode on the way to my shift. 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. 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. 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. Free access: Resuscitation Today Vol 3 Issue 2, Care at the Scene – Research for Ambulance Services, Canadian Paramedicine Feb/Mar 2016 – Open Access Issue, Eat, sleep and be healthy – a paramedic’s guide to healthier shift work, Free access: Resuscitation Today Volume 3 Issue 1, Introducing the Irish Journal of Paramedicine, Understanding diagnostic tests 2: likelihood ratios, pre- and post-test probabilities and their use in clinical practice, Understanding diagnostic tests 1: sensitivity, specificity and predictive values, GRADE guidelines – best practices using the GRADE framework, How to get started with EMS research – JEMS. These rare side effects can be experienced by patients who have previously taken diclofenac PO or PR with no adverse side effects or reaction. bodyHandler: function() { }, They found that the 7-day bounce back rate was 5.8% in the steroid group vs 6.7% in the no steroid group. Simons FER, Gu X, Simons KJ. 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. He was given epinephrine 0.5mg IM, and soon after started complaining of chest pain. Administering epinephrine IM in the deltoid muscle is not recommended. that your teaching aides need to run the scenario from start to finish. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. You arrive to find a 24-year-old woman lying in bed. Transferred to ambulance. }); bodyHandler: function() { How effective are steroids at preventing biphasic reactions in anaphylaxis? jQuery("#cit16973638").tooltip({ showURL: false 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.