The Attack One crew is eating dinner when the alert tones signal their next call for help. They respond to a “woman who’s swelling” and find the patient in the bathroom of a local restaurant. A friend who is with her provides most of the history, because the patient has difficulty speaking.
“We were eating dinner,” the friend reports, “and suddenly she got very pale, said she didn’t feel well and got up to go to the bathroom. I was so concerned, I followed her in here, and I noticed she began slurring her words. I thought she was having a stroke! Then her tongue and face started swelling.”
The female patient, standing over a sink and drooling, nods her head and confirms her friend’s account. With a rapid set of questions, the paramedic determines this is a healthy 40-year-old with no history of allergies of any type who was eating a salad that had some kind of nuts in it. The patient had never reacted to food or nuts before.
The EMT assisting the patient struggles to get vital signs. She tells the paramedic the pulse oximeter won’t get a reading on the patient’s fingers, and she can’t feel a radial pulse. The patient leans over the restroom sink, drooling because she’s unable to swallow. She occasionally voices a yes or no to the questions the paramedic asks her friend.
“We need to get you lying down,” the paramedic tells the patient. “This appears to be a severe allergic reaction, and you need some medicine right now to keep it from getting even worse. We will let you know everything we do. You have to help us by keeping your airway open, so you tell us when and how you can move.”
The patient is getting very light-headed but wants to stay near the sink because she is also nauseated and feels better with her head over the sink, splashing water on her face. She is being stabilized by the two EMTs, who get a restaurant chair that will fit inside the small restroom for the patient to kneel on.
The paramedic knows the patient will be in trouble within minutes. Either the swelling in her tongue and mouth will obstruct her airway, or her perfusion will keep dropping and she will be unconscious soon—or both.
“We have to get you some medicine, so we are going to put some adrenaline in a shot in your arm right away,” the paramedic tells the woman. “Then we have to get you into the ambulance and give you some more medicine.”
Epinephrine from the 1:1,000 vial is drawn up and administered into the patient’s upper arm. She doesn’t react at all to the shot, and the paramedic knows her perfusion is worsening.
The EMTs move the woman in the chair out to the lobby area, where the ambulance stretcher waits. They place her on her side on the cart, with a basin to drool in, but at this point she responds minimally. The crew moves the stretcher rapidly to the ambulance.
The paramedic advises the restaurant manager and patient’s friend that the patient needs to be moved quickly to the hospital. He asks them to contact the patient’s family and have them meet her at the emergency department, and to gather a list of the ingredients in the salad the patient was eating, so the patient can be aware of what appears to be a severe allergy. The friend will get the information and then come to the hospital.
The paramedic is preparing the entire range of equipment in the back of the ambulance. The airway and needle cricothyrotomy kits and medication box are opened, and the intraosseous tools are prepared. “We might need everything in the book for this patient,” the paramedic quietly tells the EMT.
As the stretcher is locked into the bracket, the paramedic looks over the patient again. She is unresponsive and in shock. She has cool skin and is diaphoretic. Where the epinephrine was placed in the skin of her upper arm, none appears to have been absorbed.
In the lateral position, the patient is maintaining her airway. She has reactive pupils but does not attempt to speak. It appears her tongue is beginning to protrude from her mouth.
Oxygen is applied, and the paramedic instructs the EMTs to put a nasopharyngeal airway in, lubing it well. He wants the nose to be well lubricated in case he needs to intubate. Around a very swollen mouth and tongue, an airway through the nose will be much easier. The needle cricothyrotomy kit is ready if that fails.
The paramedic looks for an IV site and finds one small vein still present at the elbow. “Get two liters of saline ready and open the intraosseous kit in case I need it,” he directs the EMT.
The paramedic wants to administer another dose of epinephrine because the first subcutaneous dose does not appear to be absorbing and the patient is sinking into shock. He thinks through the ways epi can be given: into a vein; into a bone; into muscle; into the tongue; into the skin; onto a mucus membrane. At this point he would prefer to give it into the vein but knows that may take a few minutes to secure, and even more minutes to secure an intraosseous site. He recalls that the tongue has characteristics of both muscle and vein, and this very critical patient has a grossly swollen tongue that would benefit from some epinephrine. It also might be the place in her body that is perfusing the best right now.
He draws up into a syringe of about 0.3 cc of the 1:1,000 epinephrine, grabs the patient’s tongue with a piece of gauze and injects the medicine into the lower surface. The medication goes in like it’s being pushed into a vein.
With the patient’s airway still patent, he tries to get an intravenous line. The vein will only tolerate a small catheter, and as he inserts it through the skin, there is still no response from the patient.
He starts a bolus of a liter of normal saline. As he prepares to draw up an IV bolus of epinephrine 1:10,000, the patient gives her first sign of improvement: She coughs and opens her eyes.
“Ma’am, how you doing? You were getting pretty sick there, and we had to give you some medicine to get this allergic reaction turning around. Are you breathing OK? Can you talk to me?”
She looks at the paramedic and seems to be trying to see if she can speak. The paramedic notices that her tongue is not sticking out of her mouth anymore. “I feel like I swallowed a bee,” she says.
The paramedic tells her to keep on her side and that he will give her some more fluids and a dose of diphenhydramine, and she should keep feeling better. He asks the EMT to give the patient the Yankauer suction and instructs the patient to use that to suction herself if she still doesn’t want to swallow.
The IV diphenhydramine is given, the crew administers a liter of saline, and the patient asks if she can sit up.
“You sure can—do whatever you are comfortable doing,” a very relieved paramedic tells her.
“What happened to me?”
“A very severe allergic reaction,” the medic explains. “Your voice is much better, so the swelling in your mouth must be getting better. You have received some Benadryl, which may make you a little sleepy, and two doses of adrenaline. One of them we gave you when we were still at the restaurant. You are probably getting enough blood flow to your arm now that the medicine will get picked up and start to work. You may get a little jittery. But the second dose went into your tongue and was the one that really worked well for you.”
By arrival at the ED, the patient feels much better. She reports she’s still a little nauseated, but the swelling in her mouth is going away and she can swallow. Her vital signs are improving, although the subcutaneous dose of epinephrine is likely keeping her pulse rate a little high.
As they enter the ED, the patient appears much improved. She is assessed by the emergency nurses and physician, and the paramedic reports the story of the initial collapse. She receives some medication for nausea, and the bolus of fluids is completed. She is observed in the ED for several hours to make sure she has no recurrence of reaction, since some of the nuts that caused the reaction are still in her stomach and soon to make their way through her intestines. No further reaction occurs.
The restaurant manager and patient’s friend identified the nuts in the salad as pine nuts and share that information with the patient. Like many persons who have had severe allergic reactions, she says that from now on, “No nuts of any kind will be in my diet.”
She sees a dietician, who helps her identify what products might contain nuts; educates her on reading food labels; assists her in obtaining an allergy alert bracelet; and ensures she fills her prescription for an epinephrine injector and knows how to self-administer it.
Allergic reactions can come in a variety of forms. Minor allergic reactions cause skin rashes, mild swelling and itching. Those reactions are typically treated with an antihistamine (diphenhydramine) and sometimes with steroids. More severe reactions occur when a person is exposed to an allergen and it releases a flood of inflammatory chemicals into circulation, which can cause swelling in a very sensitive site (the airway), airway constriction (wheezing) or loss of circulatory tone (shock). A complete description of anaphylaxis and comparison to other forms of shock was presented in a prior column (“Driver Down!,” www.emsworld.com/10322851).
In North America the most common cause of anaphylaxis is penicillin. Foods that cause anaphylactic reactions include fish, especially shellfish (lobster, crab, oyster, shrimp, scallops), seeds, fruits, vegetables, cow or goat milk and eggs. But the most common food allergies, especially in children, are to nuts. These are most notable with peanuts (a legume) and tree nuts, which include pine nuts, almonds, walnuts, hazelnuts, pistachio nuts, cashews, filberts and Brazil nuts. People who are sensitive to nuts often know of their allergy, but some are not aware until a major reaction occurs.
Epinephrine is a lifesaving medication that can be administered by a wide number of routes. It is effective when administered intravenously, intramuscularly, in the tongue, into the bone marrow or down the endotracheal tube. In this case administration by the subcutaneous route did not match the patient’s need to have the medication in the bloodstream, because circulation to the skin where the medicine was placed was deteriorating too quickly.
A clinical state of poor perfusion means the medicine must be given in an area where it will move quickly into circulation, which makes the intravenous route the one of choice. Intraosseous delivery or delivery in the muscle (where an auto-injector will deliver epinephrine) or the tongue (which is largely muscle with a few large veins in it) are also methods to rapidly get epinephrine to the bloodstream. Epinephrine is an extremely potent intravenous medication, and one that would produce profound skin damage if it accidentally leaked from the vein, so small doses must be used. Diluting the standard intravenous preparation of 1:10,000 by mixing one milliliter with 10 milliliters of saline is an appropriate IV dose for administration of one or two milliliters at a time through a good intravenous line.
James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at email@example.com.