Down In the Mouth

   The crew of Attack One has just completed a public safety demonstration on a hot summer afternoon when they are dispatched to another metropolitan park for a woman in respiratory distress. On arrival they find a lady in that condition, with a distressed park ranger holding her off to the side. Concerned family members in the picnic area can only watch as the woman labors to breathe. The crew quickly exits the vehicle and moves to her side.

   The patient is unable to speak, and it's immediately apparent that her swollen tongue is sticking out of her mouth in a very unusual manner. She is pale and diaphoretic. A male bystander and the park ranger explain that the woman, at a picnic with a large family group, took a drink from a cola can. She immediately reported she had swallowed something that stung her in the mouth, her tongue began to swell, and she developed tremendous distress. Family members report she is healthy and has no history of reactions to stings, and neither she nor her family members have a self-administration package of epinephrine.

   The crew members take immediate action, supporting the patient on her side and using a tongue depressor to keep her tongue from completely obstructing her mouth. The lady is close to completely losing consciousness and losing her airway. The Attack One crew leader had pulled all the epinephrine out of the drug box as soon as he heard that a sting had caused this severe reaction. As he prepares a dose for the patient, he asks the EMT to pull everything out of the supply bags that might be needed for an airway or a cardiac arrest. "Get out the needle cricothyrotomy kit, the nasal intubation airway, the IV supplies with all sizes of catheters, all the drugs, and a bunch of bags of IV fluids," he instructs. "Get the intraosseous kit out and open it. Have it all ready immediately!"

   The paramedic quickly prepares a syringe of the higher concentration of epinephrine, drawing up 0.3 cc of the 1:1,000 preparation, which is most common for treating allergic reactions. This is almost a reflex action for the crew, but as he pulls the cap off the subcutaneous needle, he and the paramedic holding the patient conduct a rapid discussion about giving the medicine.

   "She's almost unconscious and isn't perfusing her skin at all," the second medic says. "She'll never absorb the epinephrine out of her skin if you give it there. She's also about to completely lose her airway. Her tongue is completely swollen, and I see the spot where she was stung right on the end of her tongue. It would be best to give the epinephrine IV, but I've already checked for veins, and she has none I can find. They have completely collapsed, and she has no pulse except at her carotids. Give her the dose in her muscle."

   The lead paramedic changes out the needle to a longer and larger one. "Does the patient have a spot under her tongue I can give it in?" he asks. "Giving the epinephrine into that big muscle will help both the swelling there and her shock. It's almost as effective as giving the medicine intravenously!"

   "Great idea," the second medic replies. "The whole bottom of her tongue is open, and she needs that epi fast, or she's going to arrest."

   The lead medic grabs the woman's tongue with a 4x4, pulls it up the best he can, and uses the tongue blade to create a space right above the lower teeth. He inserts the longer needle into the muscular area of the lower tongue, and no blood can be drawn back into the syringe. He injects the epi and pulls out the needle. He then asks the other paramedic to prepare for a nasal intubation, and grabs the materials needed for inserting an intraosseous needle.

   "We'll give that dose two minutes to work, then we need to be prepared to give the next dose IO," he says. "Get the endotracheal tube through the nose and into the area above her larynx right now, and that should give her an airway at least temporarily. If it slides right into her trachea, leave it there, but if not, don't worry. We need to get her the medicines and fluids first."