Nut Allergy – Sneezing

There are certain calls you get that usually turn out to be nothing — baby choking, person slumped over wheel of car, fall with severe bleeding. In fact, just about every call you get, usually turns out to be nothing much. That’s good. Over time it is a great calmer. I usually say to myself, it’s probably nothing.

We get dispatched to a seven year old having an allergic reaction to some medicine he got at church. We are being dispatched to a local supermarket where the patient will be found in a green SUV. I’m sitting in the back of the ambulance as we have a three person crew today, and my EMT partners have been working for the ambulance each for over twenty-five years so they get the front seats. I think about getting the epi out just in case, but I don’t. Whenever I preprepare, it ends up as a wasted effort. I can’t tell you how many packages of defib pads I opened up on the way to “cardiac arrests” when I first started — “cardiac arrests” where we found the patients alert and talking when we arrived.

We pull up and a cop comes over and asks if I have an epi-pen. I have the house bag over my shoulder as I step out — the med bag is in one of the main pouches. He says the boy ate some nuts or something in a brownie or cookie at a church party and he’s allergic to nuts and he started throwing up, and he got hives and his eyes started swelling, so his parents got him in the car, and drove to the supermarket and got him some liquid benadryl. But they don’t have his epi-pen with them.

The mother is holding the boy and I can see the eyes, still open, but swollen, and I can see some hives on his arms. He looks very pale. The mother says the boy was wheezing so they also gave him some puffs from his inhaler. I sit the med bag down on the hood of the car and take out the epi after asking the boy’s age and weight, I draw up .15 mg of epi 1:1000 in a 1cc syringe. The child starts screaming when he sees the needle. The mother has to give the child to the father to hold so I can hit him with the shot. IM, instead of SQ, as our new protocols dictate. I stick the needle in and dodge a fiercesome kick. One of my partners then says to the child, its okay, no more shots. In the back of my mind, I am thinking, don’t make promises you can’t keep. I hope no more shots. I think they did give him some benadryl syrup so I can at least hold off on the benadryl, which would have meant another needle.

I ask the parents which hospital they want to go to, and they ask which one is closest and then they ask for directions, and then I say, no, he needs to go to the hospital in the ambulance, with us, one parent can ride along. He needs to be monitored, I say, just in case. When you ingest an allergen, the reaction can come back.

***

Many years ago I did a call for a large man who had eaten several brownies with peanuts to which he was allergic, but he said that he had been hungry and they were so good, he went ahead and had them, and hoped he wouldn’t have a reaction. He was dripping with sweat and vomiting. I hit him with the epi and he was doing a whole lot better until we got to triage when I turned around to talk to the nurse and then turned back and he was out — his BP went down to 60 and he was pale diaphoretic and mottled, and they had to hit him with more epi. He crashed again on them later in the shift. I never forgot that.

***

We get in the ambulance and the boy stops crying and the swelling around his eyes subsides, although he is still very pale. I put him on the monitor. He is afraid that the stickers will hurt, but I say no, and he lets me put them on. His heart rate of 144 slowly goes down to 116. His lungs are clear. His SAT on ambient air is 100%. We take off to the hospital, non-priority, and mom and I have a nice chat about the dangers of nut allergies, etc, while I write my report up, but still keeping an eye on the child.

I call the hospital and tell them we are just a couple minutes away with a child allergic to nuts, who had a reaction, didn’t have his epi-pen, I gave epi, and the child is better. They like it short and sweet.

I’m looking at the monitor and I see the heart rate start to rise, which I find very odd. It goes to 140, and then 150, and then 160, and then 170. The SAT starts to drop as well, 96, 92, 90, 85, 80. The child looks the same. Equipment failure? I check the sensor. It is on solidly. The boy isn’t shaking his finger. He sneezes. “Bless you,” his mom and I say together. He sneezes again. “Bless you.”

“Are you okay?” I ask.

He doesn’t say anything. I stimulate him and he at least looks at me, then he sneezes again and again. I look at the SAT — it still reads 80. As I reach for an oxygen mask and try to think how I will explain this to the parent, I notice, he is rubbing his legs. I look at where he is rubbing — I don’t see any hives, but the skin almost in front of me starts to turn red. His face is flushed now as well.

“He’s having another reaction,” I say.

Just like that multiplying hives appear like in some sci-fi movie of a human turning into a creature. I touch his red bumpy skin and when I move my hand off I see my finger prints. He’s mottling. We’re in the ER driveway now.

I have the epi out, draw it up quickly and hit him again. No resistance from him this time. For good measure, I give him some benadryl IM also. No messing around worrying about another needle. He doesn’t even flinch.

Wheeling him down the hall, we navigate through a maze of stretchers, patients, staff and other EMS people and visitors. I tell the triage nurse the patient has had another reaction. The boy is crying and scratching himself. The nurse directs us to a treatment room.

The boy is doing better now, the hives have retreated almost magically, but his skin is still somewhat mottled. His Sat is up to 98%, but that’s with the 02. We get him over onto the bed, and I give my report to the nurse.

They put in an IV and give him Solumedrol, and tell the mother they will have to keep him at least 24 hours for observation.

After I’ve written my run form I go back to the room, where the child, a non-rebreather on, the swelling much subsided around the eyes, no hives visible, sleeps under the watchful eyes of his mom, who signs the back of our run form agreeing to let us bill the insurance company, and she smiles, and thanks us for helping them, for all we did, for helping her son.

8 Comments

  • pixie.dust says:

    Nice work! We’ve had patients sign out of the ER AMA because they didn’t want to wait around and be observed for a while … and guess what? They’ve come back (usually via rescue) with symptoms just as bad as before, or worse. Heh.Did that guy with the brownies think if he chewed/swallowed quickly, his body might just not notice the nuts? Ha ha!!

  • Anonymous says:

    I’ll remember that about re-reacting. I enjoy your blog and am reading your 2nd book. :)SVM, EMT

  • Parameddan says:

    Can you guys start IV’s.

  • KT says:

    Wow…. That would really suck for a patient to get worse on ya like that, but it’s nice you just have to shoot up the epi. I’ve had to watch a patient deterioate on me, but at least we were only going from the front entrance to the ED (I work in a hospital), but still, you think, “please, let’s just get to the ED…”

  • Brendan says:

    This is why I like having Solu-Cortef in our protocols (it recently replaced Solu-Medrol. Same difference really). Give the epi, the Benadryl, and the corticosteroid, and chances are there won’t be another reaction. Or at least, not for a good while.

  • PC says:

    Yes, we can start IVs. However, we are somewhat dissuaded from doing pediatric IVs unless really merited. Because the kid reacted so badly –crying, kicking — to the initial shot and because he had already recieved benadryl orally, and then seemed to be responding to treatment, I chose not to put in an IV. I would have done an IV if he was at all receptive, or if he hadn’t gotten the benadryl. Solumedrol for pediatrics requires calling for medical control. We were close to the hospital so I deferred calling(again I would have had to have done an IV before and I didn’t want to agitate the child.) When the second and much more severe reaction came on, we were pulling into the ER. If we were farther out, I would have done an IV at that point and called for the Solumedrol. Allergic ingestions are always tricky, particularly when the allergen is in a brownie or cookie, it becomes almost like a time-release attacker.Thanks for the comments.PC

  • armed_and_christian says:

    Good work keeping an eye on him and staying alert.When I was a new EMT, we went on a run for a pediatric “allergic reaction”. When we got there, the kid was running around the living room and climbing on the couch. His mom swore it was an allergic reaction because he threw up right after she gave him the prescription cough syrup for the respiratory infection he had been fighting (you know, the ongoing wet, productive cough, the endless mucous, etc). I was checking his vitals while my medic for the day (who has never been around kids, apart from working) quizzed mom on the circumstances and details, and checked the bottle of cough syrup, which was really sickeningly sweet stuff.On a hunch, I asked mom what he had been doing before she gave him the medicine. Just eating lunch, she tells us. “Oh, yeah?” I ask. “What did he have for lunch?”Chocolate milk, Salami circles, and cheddar cheese.People should have to take a test before being allowed to raise children.

  • Anonymous says:

    Good cautionary tale. I work in a really busy urban system where it’s not uncommon to run back to back calls for 8-10 hours straight. Last shift I worked we did 10 calls in 10 hours. It can be tempting when someone says they don’t want transport to run through the refusal process, do the assessment, and say sign here and here. But it’s always nice to hear about situations like you’ve described to remind me the danger in this. Everyone has a refusal story from hell, and I know I’ve had my share of near misses even when I did everything by the book and per protocol. Not only does it serve as a reference on what can go wrong, but it helps me have a real life story to tell a patient. I can say, “I know you think everything is fine and dandy now, but let me tell you of a situation just like this when a child went downhill despite our treatment and would have died if the paramedic hadn’t transported that child.”It’s stories like this that make people realize the danger. As far as the insidious onset of baked goods, I wasn’t aware of that. Another teaching point.

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