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Why Minutes Matter During Treatment of Anaphylaxis

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“This seems a little dramatic.”

My head snapped back toward the mother carrying the registration clipboard, and I couldn’t help but swallow my frustration at her glib remark. I was leading the way from my urgent care lobby into the procedure room, my eyes never leaving the 13-year-old struggling to breath.

“All I’m saying is that the last time I brought my other kid here for an allergic reaction, there wasn’t that much fuss.”

My focus was on the child in front of me, snot now pouring down her face in two shining rivulets, her hands trembling as the pulse oximeter registered a jackrabbit’s heart rate of 115 and climbing. Her face was round, shiny, and stretched; her lips were trembling, swollen beyond a normal pressure. My own blood pressure started to rise as I initiated an anaphylaxis code while the mom continued to complain about my approach.

“Don’t you think you’re being a little dramatic?” She paused walking, looking at my staff as they flurried around us prepping the procedure room, using a word that had me bristling silently.

“Ma’am, this daughter is in anaphylaxis and we need to administer epinephrine immediately.”

The girl’s face turned a deeper shade of pink and hives continue to blotch her neck. “I’m scared,” she choked.

“I know you are,” I patted her hand, the other holding the autoinjector ready to go. “But you’re in a safe place and we’re going to get you to where you need to be.”

“Where’s that?” Mom asked.

“After we administer the epinephrine your daughter will be monitored for a biphasic allergic reaction. She needs an IV placed, a saline flush, and to be in an emergency department for monitoring for the next four hours.”

“Why can’t you do that here?” Mom asked.

I look around, for the first time, wondering if this woman is in the same urgent care as I am. I wondered if she had any idea her daughter was dying in front of us as she continued to debate my supposedly dramatic bedside manner.

“No, ma’am, we’re in the middle of a COVID surge and we’re not an emergency room. We’re here to stabilize her and get her where she needs to be.”

“I don’t wanna …” The child’s voice wafted up from the exam table, and she looked at me and her mother pleadingly, fearful of the injector in my right hand.

“You don’t have to, honey.” Mom interjected. “Let me go find your dad.”

I watched as the mother left the scene, heading out to the lobby, and out into the parking lot to find her husband waiting between the fast food restaurant and the cell phone provider. We were, after all, in a strip mall urgent care setting. No one outside would imagine the scene we were holding.

Seconds ticked by and her pulse continued to trend upward.

We hit 130.

Her blood pressure continued to climb.

Cresting past 200/100, a level that would concern me for an adult stroking out, I knew I couldn’t wait any longer.

Uncapping the safety, both parents popped back into my sight line and I waved to them urgently. The father seemed to be more aware of the gravity of the situation; he took his daughter’s hand and asked me what I was doing. Again, as calmly as possible, I explained to him that his daughter’s condition was an emergency. Not an urgency. This was real and this was really happening right now.

Almost anticlimactically, the family consented to epinephrine administration and with a single click and three seconds of holding our collective breaths, the child finally got the medication she desperately needed. The snot stopped running down her nose. Her face seemed a little less pink. She started to swallow her saliva instead of letting it run out of the corners of her stretched lips.

She sat up a little bit.

“There, she’s OK isn’t she? She doesn’t need to go anywhere else. She’s better.” The mother said triumphantly, crossing her arms in defiance.

Before I had a chance to argue further, the paramedics arrived and I turned the case over to them. As they ushered the family out, I overheard the lead paramedic saying to the mother, “Epinephrine is a Band-Aid and while your daughter is stable right now, she can get much, much worse so she will be safest under observation.”

So, what should you do if you find yourself concerned that you or a loved one may be experiencing anaphylaxis or a severe allergic reaction? Read on to get the clinical scoop:

This diagnosis of anaphylaxis is made clinically and it is one of the true emergencies that can kill you in minutes. While the most common signs of a severe allergic reaction are skin manifestations (hives), up to 20% of patients experiencing anaphylaxis do not show skin signs. Rather, they may present with a rapid progression of the following symptoms:

  • Evidence of respiratory distress (stridor, wheezing, dyspnea, or retractions)
  • Signs of poor perfusion
  • Abdominal pain and vomiting
  • Finally, an individual might experience an abnormal heart rhythm that leads to collapse and then death.

Clinically speaking, there are NO absolute contraindications to administering epinephrine in the setting of anaphylaxis. Children under 50 kg may be treated with epinephrine 0.01 mg/kg injected intramuscularly into the mediolateral thigh whereas for children with a weight greater than 50 kg, the maximum dose of epinephrine is 0.5 mg per dose. Injections may be repeated every five to 15 minutes if no response is seen clinically, though most patients respond within three injections if anaphylaxis is promptly recognized and addressed.

Epinephrine is one of the tools in the clinicians box to stabilize anaphylaxis but once that’s been implemented, oxygen, albuterol, glucocorticoid steroids, saline, and vasopressors may be utilized if clinically indicated.

Children that have signs of poor perfusion, or who have persistent symptoms not responding to injections, need IV access for infusion and should be in a setting where their airway can be monitored and maintained.

In true emergencies, minutes matter. If you suspect you or your child is experiencing signs of a severe allergic reaction or anaphylaxis, call 911.

Then, please listen to us.

Getty image by Kameleon007

Originally published: February 22, 2022
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