By Chris Kovaleski, Inova Children’s

18-year-old previously healthy girl is being brought into your ED by EMS. Per bystander report, the patient was running around a track and felt her throat “was weird,” so she took 25 mg PO diphenhydramine. By the time EMS arrived, patient was found to be unresponsive with facial swelling and pallor, but with a pulse and spontaneously breathing. EMS administered a total of 0.6 mg IM epinephrine (EpiPen x2), 25 mg diphenhydramine IV and 125 mg methylprednisolone IV. Patient was still minimally responsive, HR 80’s BP 50’s systolic and arrives to your ED shortly after.

ROS: UTA due to patient condition

Exam: VS 93.6, HR 79, RR 18, BP 67/43; weight 52 kg

Pale, eyes opening spontaneously, responds to commands Pupils 3-2

Shallow breaths, clear breath sounds, no tongue swelling or signs of upper airway obstruction

Pale, mottled extremities

Abdomen soft, non-tender

Diffuse hives with facial edema

Labs/Rad:

Glucose: 143

VBG: 7.26/47.6/21.4

Electrolytes off of VBG: Na 145, Potassium 2.6, H/H 13.9/41

Additional 0.3 mg of IM epinephrine given. 1L NS bolus given push-pull. Working on a 2nd PIV. Warm blankets applied. Legs are elevated. Repeat vitals notable for HR 79, BP 71/42, RR 18.

Additional PIV access obtained. Additional 1L bolus given push-pull.

Ingestion labs sent. Additional dose of 0.3 IM epi given. Repeat vitals 86/54, HR 69. Mentation slightly improved but pallor remained. Additional 1L NS bolus administered via push-pull.

Parents arrive at bedside. State that she has been hospitalized in past for anaphylaxis to unknown agent, but otherwise denies previous cardiac conditions, thyroid conditions, etc. Denies any current medications (specifically denies beta-blocker use). ROS otherwise unremarkable.

Epinephrine is started at 0.5 mcg/kg/minute. Repeat HR of 58 and BP 117/55. Patient is now able to answer questions and confirms previously obtained history. Denies any ingestion or known trigger. Repeat vitals in 5 minutes notable for HR 48 and BP 120/62. EKG notable for sinus bradycardia. Repeat vitals 2 minutes later: HR 39 with BP 117/58.

0.5 mg atropine administered. Repeat vitals notable for HR 133 and BP 171/114. Epinephrine drip discontinued with vitals remaining with HR in the 100’s, bp of 100’s/50’s and with normal mental status. Transported to PICU without issue.