History:

 

• Onset and location
• Insect sting/bite
• Food allergy/exposure
• Medication allergy/exposure
• New clothing, soap, detergent
• Past history/reactions
• Medication history
  • Antipsychotics
  • Antiemetics

 

Significant Findings:

 

• Itching/hives
• Coughing/wheezing/respiratory distress
• Chest/throat constriction
• Difficulty swallowing
• Hypotension/shock
• Edema
• Dystonic/extrapyramidal reaction
• Involuntary muscle contractions of the face, chest, neck, back, and pelvis
• Deviated pupils
• Swollen tongue

 

Differential:

 

• Urticaria (rash only)
• Anaphylaxis (systemic effect)
• Shock (vascular effect)
• Angioedema (drug induced)
• Aspiration/airway obstruction
• Vasovagal event
• Asthma
• Congenital heart disease
• Infection
  • Pneumonia
  • Croup
  • Epiglottitis

 

 TREATMENT

 

• Oxygen

 

• 12-Lead EKG

 

• Initiate IV/IO

 

• Benadryl 1 mg/kg IV/IM max 30 mg

 

Hives/rash only; No respiratory component ?

 

• • Notify receiving facility or contact Medical Control

 

Wheezing/airway involvement/ hypotension/difficulty swallowing/ swollen tongue or lips ?

 

• • Epinephrine 1:1,000 0.01 mg/kg IM; max 0.5 mg; may be repeated every 15 min; max 4 doses

 

• • Normal Saline 20 mL/kg IV; max 60 mL/kg or 1,000 mL to reduce signs of hypotension

 

• • Methylprednisolone (Solumedrol) 2 mg/kg IV; max 125 mg

 

Respiratory distress ?

 

• Yes

 

• • Albuterol (Ventolin) 2.5 mg via nebulizer

 

• • Notify receiving facility or contact Medical Control

 

PEARLS:

 

• Common medication groups that cause dystonic reactions include:

 

• •  Antipsychotics:

 

• • • Zyprexa (Olanzapine),
    • Haloperidol (Haldol),
    • Alprazolam (Xanax),
    • Fluphenazine (Prolixin),
    • Thorazine (Chlorpromazine),
    • Ziprasidone (Geodon)

 

• • Antiemetics:

 

• • • Compazine (Prochlorperazine),
    • Promethazine (Phenergan),
    • Hydroxyzine (Vistaril),
    • Metoclopramide (Reglan)

 

• If the patient is hemodynamically unstable, request an order of OLMC: Epinephrine 1:10,000 0.01 mg/kg IV/IO; max 0.3 mg