Case Study 32

The Answer

Assessment

  • Allergic reaction with unknown cause.
  • Possible non-allergic rash.

The Plan

  • Start the patient on Benadryl® 50 mg every six hours.
  • Keep an instructor with the epinephrine close to the patient.
  • Monitor the rash.
  • We would like to have the patient bathe and wash his clothes but the scarcity of water makes it unlikely we can rinse the soap off, which could make the problem worse.
  • Develop an evacuation plan.

Anticipated Problems

  • The reaction becomes severe and compromises airway or becomes anaphylaxis.

Comments

There are a wide variety of causes of rash ranging from allergies to infections and insect bites, among others. Wilderness First Responders are not trained to identify a rash or its cause, although in this case, and based on a worst case scenario, allergy is on their problem list.

Allergic reactions are caused by an excessive release of histamines and other substances from the body’s immune system in response to the presence of foreign allergens, such as pollens, animal dander, foods, plant oils, insects, and drugs. Allergic reactions range from mild (e.g., hay fever) to severe (e.g., anaphylaxis).

Allergic reactions range from mild to severe, and they can be immediate or delayed. For most people, the allergic response is mild, though often irritating. Hay fever, runny nose, sneezing, swollen eyes, and itching skin is one example of a mild allergic response. An allergic reaction may also be local, red, swollen, and itching, the result of insect stings or contact with a plant.

Signs and Symptoms of a Mild to Moderate Allergic Reaction

  • Local swelling near a sting
  • Runny nose, sneezing, swollen eyes, hay fever
  • Flushed and itchy skin
  • Hives or welts on the skin
  • Mild or no breathing difficulty

Antihistamines treat the underlying reaction, the release of too much histamine. Monitor the patient closely for a developing severe reaction. If you can figure out what may be causing the reaction, such as pollen being shed by the local trees or the dust in an old cabin, get away from the source.

An anaphylactic response is a massive, generalized reaction of the immune system that is potentially harmful to the body. Instead of the mild symptoms of hay fever, anaphylaxis can produce asphyxiating swelling of the larynx, rapid pulse, a fall in blood pressure, rash, itching, hives, flushed skin, swollen and red eyes, tearing of the eyes, swelling of the feet and hands, nausea, vomiting, and abdominal pain. The airway obstruction and shock may be fatal. Onset usually occurs within a few minutes of contact with the triggering substance, although the reaction may be delayed.

Anaphylaxis - Signs and Symptoms

  • Flushed and itchy skin
  • Hives and welts on the skin
  • Swollen face, lips, and tongue
  • Respiratory distress
  • Shock

If you catch the allergic reaction while the patient can still swallow, administer oral anti-histamines. When the reaction becomes severe, the anaphylaxis is treated with administration of epinephrine, a prescription medication, to counteract the effects of the histamine.

The Tale Continues

The Benadryl relieved some, but not all of the itching. The patient was very uncomfortable and unable to sleep. In the morning you update your SOAP note.

Objective

Patient Exam: At 1600 hrs March 6 the patient has a red raised bumpy rash that does not have blisters. He states it began this morning on his belly and has spread through the day to cover his lower back, abdomen, front of his thighs and neck. The rash produces a constant itching.

There is a vague sensation of chest tightness but no shortness of breath and no respiratory involvement.

At 0800 hrs March 7 the rash persists and now covers 40% of his BSA (lower back, abdomen, front of his thighs and neck. Also his face and shoulders/upper arms). There is no respiratory involvement. Patient is able to walk without shortness of breath. The itching rash prevents sleep. The patient is very uncomfortable. He has scratched a few places into abrasions.

Vital Signs

TIME

1615 hrs 3/6/00

0800 hrs 3/7/00

 

LOR

A+Ox4

A+Ox4

 

HR

72, strong, regular

72, strong, regular

 

RR

16, regular, unlabored

16, regular, unlabored

 

SCTM

pink, warm, dry

pink, warm, dry

 

BP

radiul pulses present

radiul pulses present

 

Pupils

PERRL

PERRL

 

Temp

98.9°F (37.1°C) oral

98.0°F (37°C) oral

History

Symptoms: None stated other than the itching rash

Allergies: Seasonal hay fever.

Medications: We have administered Benedryl 50 mg every six hours since 1600 hrs yesterday.

Pertinent Hx: Claritin for seasonal allergies. Not taking the medication at this time.

Last in/out:

Pt has never had a response like this. He had shortness of breath and throat swelling in response to a bee sting several years ago and was prescribed an Epipen®. He has not had a response since and does not know the location of where his EpiPen®.

Events:

Patient has been backpacking for the past four days. No new medications taken. He does not consider the backpacking ration a change in his food types.

Assessment

  • Allergic reaction with unknown cause.
  • Possible non-allergic rash.

Plan

  • Start the patient on Benadryl® 50 mg every six hours.
  • Keep an instructor close to the patient with the epinephrine.
  • Monitor the rash.
  • We would like to have the patient bathe and wash his clothes, but the scarcity of water makes it unlikely we can rinse the soap off, which could make the problem worse.
  • Evacuate the patient by walking. Carry the cell phone in case his conditions worsens. Rendezvous with vehicle at trail head and drive to hospital for physician evaluation. Continue the Benedryl® 50 mg every six hours.

Anticipated Problems

  • The reaction becomes severe and compromises airway or becomes anaphylaxis.

Comments

Concern for an anaphylactic reaction is present. These leaders noted the spreading rash. They also noted that there were no s/s of respiratory problems or shock. They made a sound plan, with options in case the patient's condition worsened.

Both the patient’s discomfort and the reaction continuing are good reasons to evacuate. These allergic responses commonly can take days to resolve and may need treatment with steroid medications.

The End Tale

The patient was able to walk to the trailhead. He remained uncomfortable due to the itching rash and fatigued from lack of sleep. He arrived at the hospital at 1600 hrs and was administered a steroid by the physician. The rash persisted for another 24 hrs, then abated. Its cause was never identified.


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