Hold That Epi!

      Attack One responds to a call for a woman having an allergic reaction. This has been a frequent call this summer, with the bee population increasing and the hot, dry conditions. The lady's 10-year-old daughter meets the crew at the door and guides them to a woman sitting at the kitchen table. They notice she is in mild distress, with beads of sweat on her forehead. She describes being very light-headed and a little short of breath. They apply some oxygen and prepare a small syringe with some epinephrine.

   The lady is 41, and the paramedic finds her perfusing well, with an elevated blood pressure and normal pulse rate. She is speaking clearly, and says she's having no trouble breathing. She relates developing a sore throat that started about an hour ago while she was outside mowing grass. She was sweaty when she came inside, and her throat hurt, so she took a penicillin pill her husband had been given a couple of months earlier for strep throat. She believed the sweating was due to a fever. Getting worse, she felt she must be having a reaction to the penicillin, although she had taken it many times before without problems. She has no other allergies. When asked, she reports no chest pain, palpitations, loss of consciousness, nausea or vomiting. Her past medical history includes only high blood pressure and a tubal ligation; her last menstrual cycle was three weeks ago and normal.

   The paramedic examines the patient and notes she's now diaphoretic only around her head--she'd said it was over her entire body when she first noticed it. She is breathing normally, with no distended neck veins, clear lungs, a regular heartbeat, no rash or signs of trauma, and no edema in her feet. Her blood pressure is up a little, but other vital signs are normal.

   "Ready for the epi?" the other crew member asks the medic.

   "I don't think she needs it," the medic replies. "She's perfusing well and doesn't give any other indication she's having a major allergic reaction. Vitals are stable, no swelling of the mucous membranes, and clear lungs. I don't think she'll benefit from it."

   Instead, the paramedic is now concerned about why the woman got so sweaty, and why her throat hurts. She denies being diabetic, and her fingerstick blood sugar is 92. Her throat is still painful, she says, but when the medic examines her, there is no redness, enlargement of lymph nodes or difficulty swallowing. When pressed to describe the pain, she says it's like a tightness in her throat. It has not changed since taking the penicillin, nor has the sweating.

   The paramedic recalls that diaphoresis is associated with hypoglycemia and acute myocardial ischemia, and he's already ruled out a blood sugar issue. He tells the patient he's concerned that her symptoms could be from something other than an allergic reaction, which is why he checked her blood sugar and now wants to do an EKG. She says she's never had an EKG done, but knows what it is--many of her family members have heart disease. The female crew member assists in placing the 12 leads, and the paramedic is surprised as the machine prints out an EKG that is interpreted as acute MI.

   He quickly reads the EKG himself, finding a normal sinus rhythm and ST segment elevation in the inferior leads, II, III and aVF. The anterior leads have reciprocal changes. The paramedic then turns to the patient. "I'm concerned the problem you're having isn't related to the medicine, but is from your heart," he starts. "Although you have no chest pain, the heart tracing shows you may be having a problem related to an area of your heart not getting enough blood. You're doing well right now, but we need to take you to a hospital that specializes in heart care, and the doctors will read our EKG again and do some other tests to see if there is, in fact, a heart problem. Your vital signs are stable, we're going to keep you on a heart monitor and some oxygen, and give you an aspirin, because you're not allergic to it and it's helpful to patients having heart problems."