A 50-year-old female with a history of bipolar disorder, ADHD, anxiety, depression, and alcoholism presented to the ED after her family found her at home agitated, restless, and with a “large black burn” on her face. Her husband reported that she had been “picking” at this area of her face earlier in the day; at that time it appeared only slightly red. Per her husband, the patient had also felt “bugs crawling on her legs” and had been picking at and grabbing her legs on the day of presentation.
Chief Complaint: Flu-like symptoms, lip pain/swelling, mouth pain, eye redness, and rash
History of Present Illness: Patient is a 35-year-old transgender male with a history of bipolar disorder (taking seroquel/lamotrigine) who presents with 2 days of:
- Flu-like symptoms
- Progressive lip pain/swelling
- Mouth pain
- Oral ulcers
- Eye redness
- New erythematous rash involving the palms/soles and lower extremities
The patient initially noted myalgias, fever, and malaise 2 days ago. Yesterday, the patient woke up with bilateral eye redness and itching, and he developed lip swelling/discoloration and mouth pain throughout the day. He presented to an outside emergency department (ED) 12 hours prior, where he was told that he had a viral infection, given pain medication, and discharged home. He has not taken any other medications. The patient presents to this ED due to progression of symptoms, including the development of a pruritic rash on his palms, soles, and lower extremities. Upon further questioning, the patient also reports vaginal itching and a fishy odor. He has a history of bacterial vaginosis and states that these symptoms feel similar. The patient denies genital sores, vaginal discharge, and vaginal bleeding. He is currently sexually active with men and women, and does not regularly use barrier protection.
It’s time for another installment of 60 Second Soapbox! Each episode, 1 lucky individual gets exactly 1 minute to present their rant-of-choice to the world. Any topic is on the table – clinical, academic, economic, or whatever else may interest an EM-centric audience. We carefully remix your audio to add an extra splash of drama and excitement. Even more exciting, participants get to challenge 3 of their peers to stand on a soapbox of their own!
Welcome to the Immunology Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online immunology content. Below we have listed our selection of the 4 highest quality blog posts within the past 12 months (as of July 2017) related to immunology emergencies. These are curated and approved for residency training by the AIR Series Board. We have identified 0 AIRs and 4 Honorable Mentions. We recommend programs give 1 hour (about 15 minutes per article) of III credit for this module.
Case: A 24 year old male presents with right sided lip swelling that began several hours ago. This is the second time he has had this type of swelling. His mother has also had this before. He currently has no urticaria, dyspnea, wheezing, or stridor. What is the cause of this patient’s symptoms?
You’re a recent graduate picking up an extra shift in a small ED somewhere north of here. At 3 AM an obese 47 year-old woman presents with shortness of breath and difficulty speaking after eating a Snickers bar an hour earlier. She admits to history of hypertension, peanut allergy, and a prior intubation for a similar presentation. She is becoming more obtunded in the resuscitation room as you are collecting your history. A glance at the monitor shows:
- HR 130
- BP 68/40
- O2 saturation 89% on room air
Anaphylaxis is one of the most under-appreciated and under-treated conditions in the Emergency Department. A common misperception is that you need hypotension to diagnose it. Below is a brief summary of the diagnostic criteria and ED treatment protocol. Immediate administration of IM epinephrine is critical.
A major challenge is deciding which patients can go home and which need to be admitted, because of the risk of “rebound” or a biphasic anaphylactic response. This may occur as late as 72 hours later, but typically occur within the first 24 hours. There isn’t a good answer for this.
What’s your practice in dispositioning these patients? Personally, I admit at least those patients who present with severe hypotension, require more than 1 epinephrine dose, or have poor social support.
NOTE: Unlike the photo on the top, warn patients NOT to rest their thumb on the device because of the risk inadvertent needle puncture.
PV Card: Anaphylaxis
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.