A 13-year-old girl is brought to the emergency department by paramedics due to difficulty breathing that started 30 minutes ago. She was at an amusement park with her family when she was stung by a bee on her left ear. The patient experienced shortness of breath; itching; and a raised, red rash on her face and neck minutes after the sting. Medical history includes asthma that is well controlled on budesonide. Blood pressure is 80/40 mm Hg, pulse is 144/min, and respirations are 28/min. Pulse oximetry shows 92% on a nonrebreather mask. The patient is in obvious distress. The oropharynx is patent and without swelling. On auscultation of the lungs, severe bilateral wheezing is present. Heart sounds are rapid without murmurs. There are multiple raised erythematous papules on her face, neck, and upper chest. The patient's vital signs normalize, and symptoms resolve completely an hour after a single dose of epinephrine and nebulized albuterol. What is the appropriate disposition for this patient?

Question

A 13-year-old girl is brought to the emergency department by paramedics due to difficulty breathing that started 30 minutes ago.  She was at an amusement park with her family when she was stung by a bee on her left ear.  The patient experienced shortness of breath; itching; and a raised, red rash on her face and neck minutes after the sting.  Medical history includes asthma that is well controlled on budesonide.  Blood pressure is 80/40 mm Hg, pulse is 144/min, and respirations are 28/min.  Pulse oximetry shows 92% on a nonrebreather mask.  The patient is in obvious distress.  The oropharynx is patent and without swelling.  On auscultation of the lungs, severe bilateral wheezing is present.  Heart sounds are rapid without murmurs.  There are multiple raised erythematous papules on her face, neck, and upper chest.  The patient's vital signs normalize, and symptoms resolve completely an hour after a single dose of epinephrine and nebulized albuterol.  What is the appropriate disposition for this patient?

Quizplus · Accepted Answer

Explanation: This patient with a history of asthma developed severe anaphylaxis (eg, hypotension, hypoxia, severe wheezing) after a bee sting. Because of the severity of her initial symptoms and history of asthma (likely the single most important risk factor for fatal anaphylaxis), she should be admitted to the hospital for observation. Although there are no universal guidelines dictating which patients with anaphylaxis require hospital admission, it is generally accepted that those with protracted anaphylaxis (ie, symptoms lasting hours to days despite treatment) should be admitted. In addition, patients who experience complete resolution of symptoms with treatment should be admitted under the following circumstances: Severe symptoms (eg, hypotension, upper airway edema, respiratory distress) occurred at presentation, as in this patient. Multiple doses of epinephrine were required to achieve symptom resolution. These patients are believed to have a higher risk of biphasic anaphylaxis (ie, recurrence of symptoms after an initial period of resolution), which can be fatal. Because both the timing and severity of symptom recurrence are unpredictable, admission for extended observation is recommended. In addition to asthma, other risk factors for fatal anaphylaxis include older age, cardiovascular comorbidities, and delayed administration of epinephrine. (Choice A) Desensitization therapy for bee (and other Hymenoptera) stings takes months to years to achieve and is not performed in an inpatient setting. (Choices C, D, and E) In this patient with severe symptoms (eg, hypotension, hypoxia), biphasic anaphylaxis could be fatal; therefore, hospital admission (vs discharge home) is required. In contrast, those who have milder anaphylactic symptoms (eg, pruritus, rash, nausea) that resolve after a single dose of epinephrine may be considered for discharge. All patients should be discharged with an epinephrine autoinjector. Antihistamines may improve pruritus or hives, and corticosteroids may help suppress a further inflammatory response; however, there is no strong evidence that either medication prevents biphasic anaphylaxis, which is a concern in this patient. Educational objective: Patients with anaphylaxis should be admitted to the hospital when symptoms are protracted or severe (eg, hypotension, upper airway edema, respiratory distress), or require multiple doses of epinephrine to resolve. These patients are at increased risk of biphasic anaphylaxis (ie, recurrence of symptoms after an initial period of resolution), which can be fatal. References: Predictors of hospital admission for food-related allergic reactions that present to the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/21195944) Anaphylaxis risk factors for hospitalization and intensive care: a comparison between adults and children in an upstate New York emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/30582495) Anaphylaxis diagnosis and management in the emergency department of a tertiary hospital in the Philippines. (http://www.ncbi.nlm.nih.gov/pubmed/32099823)

A 13-Year-Old Girl Is Brought to the Emergency Department by Paramedics