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You are with the triage nurse when a 60 year old lady,
Mrs. Graham, presents with her husband who rushed
her to hospital from home where she developed
sudden onset of breathing difficulties after she
initially complained about tingling around her mouth
whilst eating a take-away meal. She looks quite
unwell, is in obvious respiratory distress, she has an
audible wheeze and stridor. She can not speak and
points to her large tongue and then promptly
collapses.
WHAT IS THE MOST LIKELY DIAGNOSIS
AND YOUR IMMEDIATE MANAGEMENT?
DIAGNOSIS:
ANAPHYLAXIS!!!
The patient has facial and tongue swelling, probably swelling of her airway and she could
get into severe trouble in a very short time.
Mild to moderate allergic reaction
Tingling of the mouth
Hives, welts or body redness
Swelling of the face, lips, eyes
Vomiting, abdominal pain
Severe allergic reaction- ANAPHYLAXIS
Difficulty and/or noisy breathing
Swelling of the tongue
Swelling or tightness in the throat
Difficulty talking or hoarse voice
Wheeze or persistent cough
Loss of consciousness and/or collapse
Pale and floppy (young children)
MANAGEMENT:
DRABC:
Danger:
none
Response:
patient drowsy, call for immediate help, resuscitation team
Airway:
Guedel airway difficult to place, prepare for intubation, anticipate
difficult airway - ?cricothyroidotomy / tracheostomy
Breathing:
Give 100% O2, add beta agonist or adrenaline via nebuliser,
prepare for intubation!
Circulation:
BP now 80/55, Pulse 130, give immediately 0.5 mg adrenaline im!
Insert i.v. line and start fluids, give steroids, ie 8 mg
dexamethasone iv or 50 mg prednisolone iv.
Consider antihistamines and H2 antagonists
PROGRESS:
The patient responds well to your treatment and does not require intubation. She is now
stable.
WHAT IS YOUR FURTHER MANAGEMENT?
1. HISTORY:
The patient tells you that she has had eczema, allergic
rhinitis as a child and lots of allergies all her life, including
against nuts, although this was her worst reaction and
presumably the meal must have contained some traces of
nuts.
2. EXAMINATION:
Now it is time to perform a complete physical examination
3. ADMIT:
The patient had a life-threatening episode and could easily
develop a biphasic / multiphasic (delayed degranulation
of mast cells) reaction with recurrence of broncho spasm or
shock, usually (90%) within 4 hours.