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Allergic reaction?

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Tiered in with EMT squad. Enroute information is female with complaint of throat swelling closed.

Get on scene and enter their ambulance and see female sitting upright on cot, respiratory rate 40, accessory muscle use. Pt. awake, color pink, skin warm/dry. No adventagious sounds heard. Pt. on oxygen per NRB, sats 97%, BP 170/100, HR 120 per machine.

Initial contact shows scared look from patient, 1-2 sentance wording. Best info from squad is possible allergic history to flowers where patient was helping setting up for funeral. Onset of slight symptoms 1 hr prior.

Listen to breath sounds which are clear. Auscultate trachea, no stridor heard. With the lung sounds, no evidence of uticaria anywhere on torso, no evidence of swelling/edema. Only complaint is throat swelling. Oral cavity normal.

Monitor placed sinus tach without ectopics. Patient very anxious and moving around on cot. Epi 0.3mg given IM. IV then established by partner. 25mg Diphenhydramine given IV. Pateint states a little better approximately 2 mins later. Reassessed lungs, etc. without change. Vitals BP 150/100, HR 110, RR 34, sats 99%. Pt. is exhibiting beginning s/s of hyperventilation. Pt. breathing pattern coaxed with some success.

Calling in radio report and patient start again to become very scared as gestures throat again swelling up. 0.1mg Epi 1:10000 given IV. 10 seconds later patient begins screaming and shows Levine sign. No changes in monitor, ST. Episode lasts 10-15 seconds. Pucker factor is 15 on 1-10 scale. No time or conditions available for 12-Lead as patient very unsettled. Pt. verbally calmed for remainder of 2 minute transport.

Arrive hospital and off load to ER. ER doc meets you at door, report given. Upon doc assessment, ativan given to calm pt. but then pt. again has throat swelling sensations and doc administers Epi with same screaming/Levine sign gesture.

You leave to go back in service. Find out later pt. goes to cath lab with suspected MI.

Later in evening, Cath reveals all vessels open.

Hummmm....allergic reaction or atypical MI????

Thoughts.

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Posted · Report post

The fail ... it is so strong.

You state yourself this patient showed no signs of anaphylaxis and yet you jack her up with adrenaline, worse yet, IV adrenaline?

Please don't use eponymous; I had to look up what Levine's sign was ... and if she is clutching her chest do you think it might have had something with that IV adrenaline you put into her?

Sounds to me like a little bit of pseudo anaphylaxis and certainly not something that is a candidate for IV adrenaline or DPH; if the patient actually had angioedema with stridor but without systemic involvement (which is not unheard of) then some nebulised adrenaline is appropriate.

There is good empirical evidence that adrenaline is overused in patients with asthma and anaphylaxis. Yes, early administration of adrenaline is critically important in patients with anaphylaxis but if you're giving this sort of patient adrenaline then I would very seriously hope you are not teaching this same clinical approach to your students.

There was a case here a few years ago of a Doctor giving a patient adrenaline for "anaphylaxis", the patient ended up suffering myocardial damage and the case was referred to the Health and Disability Commissioner as a breach of the patient's right to receive care with appropriate care and skill.

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Posted · Report post

Reference scenario. Case of trying to understand the problem at hand and assessing the patient. Limited classical signs/symptoms yet presents with potential laryngeal closure due to allergen per history. You may not have availability due to geography, but would be case to bounce off on-line medical control. There was some relief of symptoms with initial EPI as well as subsequent Benadryl. Combination of the respiratory alkalosis with EPI probably did cause the cardiac symptom. Sorry for the 'Levine sign' blurb. No, don't teach just do, but assess and analyze what you have (differetial diagnosis) and treat to do no harm.

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Posted · Report post

The epi was overboard and several doses even worse. What was it that made them suspect an MI (EKG changes, troponin)?

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Posted · Report post

Case of trying to understand the problem at hand and assessing the patient.

Which is no different than any other patient

Limited classical signs/symptoms yet presents with potential laryngeal closure due to allergen per history.

The history is piss poor; did you ask for further information?

but would be case to bounce off on-line medical control.

No it's not, that is the bitches way out ... do you know that in South Africa, New Zealand, Australia and the UK there is no medical control?. What do you think we do? We use our brains

There was some relief of symptoms with initial EPI as well as subsequent Benadryl. Combination of the respiratory alkalosis with EPI probably did cause the cardiac symptom. Sorry for the 'Levine sign' blurb. No, don't teach just do, but assess and analyze what you have (differetial diagnosis) and treat to do no harm.

Remind me again how adrenaline causes respiratory alkalosis? or how respiratory alkalosis causes cardiac symptoms?

If you want to do no harm perhaps you need to seriously invest in a greatly expanded education of pathophysiology and pharmacology; in a very similar case the treating clinician was found to have acted without reasonable care and skill having inappropriately administered adrenaline to a patient he thought was having "anaphylaxis".

Of all the drugs in the ambo bag of tricks adrenaline is one of the most dangerous but also the most life saving. You must use it wisely. .

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Posted · Report post

Slow down all.. remember hind sight is 20/20.

I agree that epi was a little much, but I also recall that up to 40 + % present with no external skin signs or swelling. Anaphylaxis can be very difficult to Dx due to its huge variability in presentations and causes among patients, yet life threatening when severe.

If the medic withheld epi and she dies would we be singing the same tune?

Instead of slamming, lets break this down piece by piece with pro's and cons and learn from it.

Now...I want to state this respectfully...its always tough to arm chair quarterback....here are my thoughts:

The subjective history you presented (I cant speak to what you actually obtained) is a bit thin. A detailed subjective assessment would be useful to you figuring out what is/isn't going on, including AMPLE history. This would give insight into the ongoing medical conditions the patient has and what (if any) impact they had on your call. A patient on B-blockers, ACE inhibitors (which have their own Anaphylaxis mimic properties) and statins would imply a pre-existing CAD, and therefore a more cautions approach in regards to the EPI. By contrast, a patient with anti-depressants, benzo's/anti-anxiety meds, and SSRI's would imply an anxiety component, and therefore perhaps administering some Benzo's of your own. Finally, a more detailed PMhx, especially regarding her allergy to flowers would be useful. If she simply has hay fever, this is one thing. If she has been intubated before..that is another.

Her physical assessment is essential too. I will take you at face value when you say lungs are clear, although I will state I have seen numerous providers tell me that when the lung sounds were not clear, merely silent. You paint a clear clinical picture of a patient who is either quite ill, or quite anxious, or both....presenting in severe respiratory distress, yet shows no signs of actual anaphylactic/anaphylactoid reaction. An ETCO2 waveform would be very useful...and impartial/objective assessment, of her respiratory distress as well. Looking for ETCO2 levels and waveform morphology would be useful to rule out some things. Given the vitals, combined with your physical exam, and the presentation in congruent with an anaphylactic/ioid reaction... I am leaning toward a very dramatic and convincing anxious reaction. But I wasn't there and a more detailed AMPLE history would be useful in looking for pitfalls. I cant rule our chemical exposure (cleaning compunds, floral agents, something unaccounted for), stress, etc.

In this case, Obviously all the basic VOMIT medicine is called for ( VOMIT as in Vitals, O2, Monitor, IV and Transport) I cant speak for the practice in your area, but without convergent validity indicating other more serious pathology...more targeted treatment is not advised.

I would be very tempted to try a low dose of ativan or valium to clear up the anxiety / drama, and see what symptoms (if any) the anxiety was masking. In our service, we can medicate severe anxiety (refractory to other interventions) , especially when it is becoming an obstacle to the care of the same patient.

NOW, with that said, I want to state that there are too many unknowns. I think this stresses the importance of a good environmental, physical, and subjective assessment.. and that how we all..all of us...some times can have a call run us instead of us running a call.

And with that, I think this brings a scene from a movie to mind.

http://www.youtube.com/watch?v=gJXYrx0kEow

I think you got caught up in quicksand. We all can sympathize, even if we dont admit it.

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Posted · Report post

Doing an adequate exam is essential in a case like this. You have a pt that is presenting in extremis from what is presumed to be anaphylaxis. Someone that is truly as sick as this woman presents is going to have abnormal lung sounds. You are going to hear wheezing or stridor, you are going to see some drooling. You are not going to have a pt who has clear lungs and can tolerate an exam of her pharynx. This sounds like a case of provider anxiety due to lack of experience.

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Posted · Report post

Please don't use eponymous; I had to look up what Levine's sign was ... and if she is clutching her chest do you think it might have had something with that IV adrenaline you put into her?

Actually Kiwi, Levine's sign is something that used to be quite common in the texts over here in the US, not so much anymore...unfortunately.... I can't speak for elsewhere. One of those things instructors like to torment their students with. Kinda like Grey-turner's and Cullen's sign. So I don't think he was pretentious, just using the common vernacular of the area.

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Actually Kiwi, Levine's sign is something that used to be quite common in the texts over here in the US, not so much anymore...unfortunately.... I can't speak for elsewhere. One of those things instructors like to torment their students with. Kinda like Grey-turner's and Cullen's sign. So I don't think he was pretentious, just using the common vernacular of the area.

Good point croaker. Let's just hope she didn't have a positive Throckmorton.

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From what I obtained from the providers, ER EKG was suspicious with T-wave abnormalities suggestive of MI. I don't know the particulars of labs, etc....

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Good point croaker. Let's just hope she didn't have a positive Throckmorton.

I had to look that one up (its been a LOOOOOOONG time...pun intended). GROOOOAAAAN!

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Posted · Report post

The history is piss poor; did you ask for further information?

This is the information that was given to me for review.

No it's not, that is the bitches way out ... do you know that in South Africa, New Zealand, Australia and the UK there is no medical control?. What do you think we do? We use our brains

I bow to your knowledge not taking into consideration how this post would be disseminated nationally. I was speaking about the US where that availability of on-line medical control can and is very beneficial in difficulty cases. That is why I mentioned the prior geography memo. The purpose of this review is to have the provider think about what is happening and what to or not to do. By utilizing medical control, if available, uses the adage of 'two brains can be better than one'. Don't use this as a crutch, but don't 'harm' the patient when there are resources available to assist in 'thinking it out'.

Remind me again how adrenaline causes respiratory alkalosis? or how respiratory alkalosis causes cardiac symptoms?

You are over analyzing the post. Adrenaline causing alkalosis? The point is that the patient was very anxious with signs of hyperventilation, where the EPI may have exacerbated the symptoms and potentially cause coronary spasm leading to the cardiac symptoms described.

If you want to do no harm perhaps you need to seriously invest in a greatly expanded education of pathophysiology and pharmacology.

This is what is being done with the review of this case in class, to discuss the differential diagnosis of presenting problems and how to properly assess and treat.

Of all the drugs in the ambo bag of tricks adrenaline is one of the most dangerous but also the most life saving. You must use it wisely. .

I do fully agree with you on this.

The subjective history you presented (I cant speak to what you actually obtained) is a bit thin. I cant rule our chemical exposure (cleaning compunds, floral agents, something unaccounted for), stress, etc.

Sorry, remembered some other items told to me. No medical history other than the possible floral allergy. No other past medical history. On no medications or allergic to medication. Remember being told onset of symptoms 30 minutes prior to meeting tier.

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Posted · Report post

From what I obtained from the providers, ER EKG was suspicious with T-wave abnormalities suggestive of MI. I don't know the particulars of labs, etc....

Was this after the multiple doses of epi?

I would like to say thanks for posting this. As has been pointed out, hindsight is 20/20. While that's not necessarily great for you in the moment, it's great for many here in that they can learn from it.

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I would like to say thanks for posting this. As has been pointed out, hindsight is 20/20. While that's not necessarily great for you in the moment, it's great for many here in that they can learn from it.

That's the intent of presenting this to the class, to learn from it. I think there is a misconception I was on call. This was presented to me second hand to I tried to get as much information as possible. Just looking for other opinions with the post. Thanks.

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I don't think that the fail is huge at all...I think it's a great scenario for everyone to learn from...

The fail is taking someone that had the balls and commitment necessary to post a scenario, which most often ends with being called an idiot, and jumping on them so fucking hard that they are longer willing to post scenarious, something desperately lacking at the City.

I'm trying to think of the last Kiwi scenario, but none are coming easily to mind...

And I think that it was you, if not, one of our other Aussies, that said that there are senior medics or some such that you can call if you have questions? The equivalent of med control? When did you become the holier than thou, "I know everything, I never fucking ask for help, that's for bitches! If you ever don't know an answer get you stupid ass back to school and get super smart like me!" guy?

I'm sure that many, like me, are often impressed by your knowledge, but lately it seems that you've just gone off of the deep end.

Anyway, I'm thinking laryngo/bronchospasm. It would explain the previous symptoms, respiratory anxiety/tachypnea, anxiety driven tachycardia, the rebound from the initial treatment (initial response placebo driven) and the chest pain/pressure as well.

Without trouble shooting it, but instead going on just what is given, I'm saying moderate laryngo/broncho spasm, then a bystander noticed her anxiety and said, "She's having an allergic reaction and her throats closing!", most likely one of the first responders, causing the elevated pulse/resps, but unresponsiveness to treatment, as the majority of the symptoms were not anatomical.

Can you run back and give her a half cc of Glucagon realy quick, to see what happens? :-)

And was Epi appropriate? Nah, I don't think so, but .1 of Epi causing screaming and chest pounding? I just don't see it....the Epi increased the already present relatively psychosomatic symptoms maybe.

Good case man....

And if this turns out to be a reasonable diagnosis? Fuck the 'bitches' way out, as it sounds as if our superior, "I don't need to ask shit!" Aussie provider would have done nothing I guess..., or, what is the proper treatment for pseudo anaphylaxis?

Dwayne

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Posted (edited) · Report post

Tiered in with EMT squad. Enroute information is female with complaint of throat swelling closed.

Get on scene and enter their ambulance and see female sitting upright on cot, respiratory rate 40, accessory muscle use. Pt. awake, color pink, skin warm/dry. No adventagious sounds heard. Pt. on oxygen per NRB, sats 97%, BP 170/100, HR 120 per machine.

Initial contact shows scared look from patient, 1-2 sentance wording. Best info from squad is possible allergic history to flowers where patient was helping setting up for funeral. Onset of slight symptoms 1 hr prior.

This is a convincing enough history for me to give IM epinephrine. With the benefit of hindsight, it sounds like there may have been an element of anxiety to the presentation. It would be interesting to know more about previous hx of allergy / anaphylaxis, but the reality is the patient's first presentation can be life-threatening, so such information is rarely useful.

Calling in radio report and patient start again to become very scared as gestures throat again swelling up. 0.1mg Epi 1:10000 given IV.

I'm surprised that you got this order. I would assume the physician was concerned about impending airway compromise, and trying to save you from a cricothyroidotomy. Was the patient really young? Was the physician aware they were hypertensive?

IV epinephrine is for life-threatening symptoms, in the presence of circulatory compromise, when you're concerned that IM epinephrine is going to be absorbed too slowly to be effective.

I had a guy who was apneic, cyanotic, no radials, terrible compliance with BVM ventilation, sat probe picking up 68% *for what it's worth. He gets 0.5 epi IM, his ECG shows sinus tach at 180 bpm with runs of VT, and he starts throwing hypoxic seizures. 2 x 0.1 mg 1:10,000 IV, his saturation comes up to 82% (now maybe an accurate reading), he has radials, and his BP cycles at 182/110. So we give 2.5 midazolam / 250ug fentanyl, piss ourselves in fear, intubate, give another 0.3 mg epinephrine IM, 600 ug ventolin MDI via the ETT, and things get a little less crazy, with something approaching a reasonable BP, saturations in the mid 90's. And so we drive to the ER, and give some benadryl, now we've got time. This is a cool war story... but the point is, this is the sort of patient IV epinephrine is made for.

[At the time we didn't have steroids, we considered mag, but didn't want to upset the apple cart. Epi drip was also considered, but seemed unnecessary at that point, with a decent pressure and compliance].

10 seconds later patient begins screaming and shows Levine sign. No changes in monitor, ST. Episode lasts 10-15 seconds. Pucker factor is 15 on 1-10 scale. No time or conditions available for 12-Lead as patient very unsettled. Pt. verbally calmed for remainder of 2 minute transport.

This is probably coronary vasospasm from the IV epinephrine.

Doing an adequate exam is essential in a case like this. You have a pt that is presenting in extremis from what is presumed to be anaphylaxis. Someone that is truly as sick as this woman presents is going to have abnormal lung sounds. You are going to hear wheezing or stridor, you are going to see some drooling. You are not going to have a pt who has clear lungs and can tolerate an exam of her pharynx. This sounds like a case of provider anxiety due to lack of experience.

With respect to the large amount of education and experience you bring to the discussion, would it not be possible that the patient has some developing laryngedema that has not caused enough closure to cause stridor? Couldn't early and judicious (i.e. IM) epinephrine, prevent this patient from worsening?

I don't think that the fail is huge at all...I think it's a great scenario for everyone to learn from...

The fail is taking someone that had the balls and commitment necessary to post a scenario, which most often ends with being called an idiot, and jumping on them so fucking hard that they are longer willing to post scenarious, something desperately lacking at the City.

This is an awesome point. Thanks for posting OP.

All of us have made mistakes. And none of us were there on your call. I don't think the treatment was optimal, but I applaud the fact that you went out and looked for more input.

Edited by systemet
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Posted · Report post

...but the reality is the patient's first presentation can be life-threatening...

Which part did you see that might be life threatening? I'm assuming that as the lung sounds were found to be 'clear' that the pt is moving enough air to determine such a thing, no stridor, oral pharynx unremarkable, tachy, but a catecholamine dump from the anxiety can easily explain the minor/moderate tachycardia as well as the relative hypertension it seems.

Not to mention that this is a funeral, so not only is this person probably wound a little bit tightly assuming that the funeral is for a relative, but I'm guessing that I'm not the only one that had pts in such situations that have dramatic illness when they tire of not being the center of attention.

Not sure, but I still think that anxiety, or laryngo/broncho spasm is still a better fit...

Dwayne

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Ok I slept on this all night and I remembered something that may fit the s/s. VCD .. Vocal cord dysfunction can present with many of the s/s and often has a strong anxiety component.

Of course the history is still pretty thin, we don't even have an age or a complete history... Which is the real lesson/issue

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Which part did you see that might be life threatening?

Perhaps I wasn't clear. What I meant was that, in general, it would be nice to know if the patient has a prior history of anaphylaxis, and how serious previous cases were. But that this wasn't particularly important, because while a history of prior serious reactions suggests the current situation may deteroirate rapidly, the absence of that history doesn't tell us much.

In this patient, if they are developing laryngeal edema, that could become life-threatening. If the patient says they feel their throat is closing, I'd be tempted to give the epinephrine. I agree that the narrative doesn't give the impression that they're getting ready to check out right now.

I'm assuming that as the lung sounds were found to be 'clear' that the pt is moving enough air to determine such a thing, no stridor, oral pharynx unremarkable, tachy, but a catecholamine dump from the anxiety can easily explain the minor/moderate tachycardia as well as the relative hypertension it seems.

Absolutely. Could be anxiety, could be a psychiatric issue. It's difficult to know without being there. My understanding (which might be incorrect), is that stridor is a very late sign of laryngeal edema.

Not to mention that this is a funeral, so not only is this person probably wound a little bit tightly assuming that the funeral is for a relative, but I'm guessing that I'm not the only one that had pts in such situations that have dramatic illness when they tire of not being the center of attention.

Sure. But, then again, people sometimes get sick at funerals as well. This is a really hard judgment to make without actually being there. Obviously if you feel this is something psychogenic, then you're not going to give the epinephrine.

Not sure, but I still think that anxiety, or laryngo/broncho spasm is still a better fit...

You may be right. The trouble with these case presentations is that everyone gets a slightly different impression of the patient in their minds, and it becomes tempting to interpret the patient's condition in terms of your own past experiences, that may not relate to this particular case.

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Wish I could jump on these posts faster. Seems like when I spot them they've already been busted wide open and not much more can be contributed without re-iterating another post. With the vitals and pts presentation would opiates or benzos considered to reduce the pts anxiety?

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Mm, if you've already got a POTENTIAL allergy issue, with histamine release and all that, wouldn't giving an opiate not necessarily be a good idea? (Am I off in the ditch with my understanding that opiates can cause histamine release?) Plus, don't you only administer opiates to help with anxiety when they also have concurrent pain (AKA chest pain) and you're treating the pain to diminish the anxiety? Unless she's got a pain source, you'd have to come up with a really good reason for having given a narc, right?

I might consider a benzo... very low dose, not wanting to increase sedation too much in case this really is a zebra monster getting ready to pounce on us... hm. Never thought of that angle before.

Wendy

CO EMT-B

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Mm, if you've already got a POTENTIAL allergy issue, with histamine release and all that, wouldn't giving an opiate not necessarily be a good idea? (Am I off in the ditch with my understanding that opiates can cause histamine release?)

Outside of a theorectical effect on coronary arteries (important in ACS/MIs) , and of course allergic reaction to opioids, the opioid's histamine release tends to be realtively benign. Additionbally, certain opioids have this effect more than others. Codiene and heroin tend to have it more often, whereas Fentanyl have it very little at all.

Plus, don't you only administer opiates to help with anxiety when they also have concurrent pain (AKA chest pain) and you're treating the pain to diminish the anxiety? Unless she's got a pain source, you'd have to come up with a really good reason for having given a narc, right?

Well, the answer is "Adult Diapers". (in otherwords...depends. Get it. Depends lol)

It depends on your service protocols. It depends on your medical director as well, who may or may not have much influence on your protocols depending on your state.

Here locally giving opioids strictly for sedation (outside of RSI/mai/intubation, wich is assumed to be painful anyway ) is definitly not a common occurance, but we have a process called a SWO Diviation that you would do this if you had good justification, you would just have to justify yourself later.

Personally, I understand that opioids have anxiolytic effects, but given the risk vs benifit and the general pharmacological profile I would go with a benzo instead. Valium most likely, though ativan could be useful in this role. I like valium for this better though, just not impressed with Vit A.

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There can be some histamine release with morphine, it's not uncommon but is not allergy. There is less with fentanyl.

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...You may be right. The trouble with these case presentations is that everyone gets a slightly different impression of the patient in their minds, and it becomes tempting to interpret the patient's condition in terms of your own past experiences, that may not relate to this particular case...

Yeah, I'd thought about that, but then immediately discounted the possibility based on the fact that I really, really wanted to pull this out of left field and be right about it. You and your, "Let's always try and be objective" bullshit....grrrrrr

There can be some histamine release with morphine, it's not uncommon but is not allergy. There is less with fentanyl...

This is interesting...I've never really thought about it. So a hystamine cascade reaction (Unsure if that would be an approprate description) due to an allergic response would not be aggrevated by a secondary cause of hystamine release not allergen initiated?

And no, I'm not even going to pretend that I remember the cascade involved, nor if there are a bunch of hystamines types that bind to different receptors so as not to create comorbidities if released at the same time...Etc. Just answer the God damned question...

Just sayin'... :-)

Dwayne

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This is a great case to present, and I'll tell you right now, I have been on both sides of the fence.

One time I had a atypical anaphylaxis (to latex..... a church girl) It was one of the first scenario's I ever posted here, and if I was smart enough I would dig it up. But I cannot find it (would be laughable by now I am sure).

I have also had a severe anxiety after taking an inhaled steroid for the first time, that I thought was anaphylaxis.

So here is my thoughts;

A) Don't trust your ears when there is a hummingbird between them.

B) A Patient can kill themselves, and sewer you're career with fear/drama. Don't let them do it!

C) Learn to love you're EtC02. If you don't have it... Get it!. If you have a high Sp02, and low EtC02, you are probably looking at anxiety.

D) Never, ever, ever, ever, let anyone ever distract you when you are trying to critique you're calls to improve patient care. Stick to you're own agenda, and those with integrity and common goals in this profession will surround you with support.

Casual reading:

http://www.ncbi.nlm.nih.gov/pubmed/11801981

http://www.ncemi.org/cse/cse0412.htm

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