Case: 65 yo man presents after being stung by a bee. Complains of wheezing, shortness of breath and tightness in his throat. SBP 95, O2 sat 97%, tachypneic and tachycardic. PMHx HTN treated with atenolol. Management?
Initial Considerations/Tapas:
-ABCs- pts prone to rapid airway compromise, sensation of "lump" or "fullness" in throat is omnious sign, consider definitive airway mgmt
-Epi is mainstay of treatment- 0.3mg of IM epi (1:1000 concentration) q15 minutes as needed for mgmt of hypotension, edema (DO NOT give IV epi unless you are coding the pt(i.e. they are not "alive")- if IV dosing required, 1mg of 1:10,000 epi IV)
-pt's on B-blockers may have blunted response to epi- administer 1g IV glucagon
-antihistamines (H1 and H2 blockers) 50mg IV push of diphenhydramine (H1) and raniditine (H2); use cimetidine with caution, as can increase 1/2 life of B-blockers)
-steroids (onset 4-6 hours after administration); methylpred 125mg
-pt should be observed 4-6 hours (can rarely have phenomenon of relapse 4-6 hours after initial event)
General Anaphalyxis Pearls:
-Anaphalyxis caused by IgE mediated type I hypersensitivity rxn. Preformed antibodies cross-linked by exposure to antigen, results in massive mast-cell degranulation, release of histamine and leukotrienes.
-Common precipitants of anaphalyxis include bee/insect stings, food allergies (particularly nuts), drug allergies (PCN, sulfa drugs), radiocontrast agents (anaphalactoid rxn- not IgE mediated)
For IV Epinephrine I have heard that either 1:1000 or 1:10,000 can be used as long as it is 1 mg and titrated to 1 cc / minute. (1 cc of 1:1000 = 10 cc of 1:10,000)
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