Question: This question is based around a call that has had some interesting discussion and I am curious to get your input on. The call was initially for an allergic reaction, updated while en route to say that the patient was seizing.

Upon arrival, you find a 28 year old male lying on the ground. A family member states that the patient was stung by a wasp on the back of the neck approximately 15 minutes ago. They immediately gave him Benadryl orally and he self-administered his EpiPen (the family seems reliable and as far as you can ascertain both of these medications were administered appropriately and were not expired).

They continue on to tell you that about five minutes ago, the patient had a seizure that just ended as you arrived. The patient has never had a seizure before. There was no trauma suffered from the seizure. The patient has a history of anaphylaxis to wasp stings but no other past medical history.

On examination, there are no signs of trauma and the patient denies any pain. The patient is conscious, but agitated and confused to place and time (GCS 14). He has slight swelling of the lip but no urticaria anywhere on his body and no other facial swelling. His breath sounds are clear on auscultation. He appears to have been incontinent of urine. There has been no vomiting or diarrhea.

Initial vitals are a heart rate of 102 regular and full, respirations 24 regular and full, pupils PEARL 4mm. Blood sugar is 6.7 mmol/L. BP is unobtainable as the patient continues to become more agitated and will not remain still. Oxygen saturation is also unobtainable as the probe keeps coming off his finger while he moves around.

Specific points that came up in our discussion that we would love to hear your thoughts on are:

1. Based on the information available here, should this patient receive epinephrine (epi)? It is easy for us to second guess the inability to obtain a blood pressure (BP) on this patient, but for the purposes of discussion, I think we should accept that none of us were on the call and it was not possible for this medic to obtain a BP even by palp.

2. Are we held strictly to the traditional "two systems involvement" view of the diagnosis of anaphylaxis or are we permitted to consider a broader definition such as that published by Sampson et al. in the summary report of the Symposium on the Definition and Management of Anaphylaxis?

 What a difficult case! This is definitely a case which nicely describes some of the grey areas in medicine!

The short answer would be that if you ask multiple physicians for direction on this, you would most likely get multiple answers. Judgment and experience here are the key.

You describe limited evidence of anaphylaxis apart from a history of same and a new possible exposure. The patient has no rash, no significant swelling, no wheezes, no vomiting or diarrhea. It is possible that the patient was having anaphylaxis and did require epinephrine however it is difficult to know.

Seizure would be an uncommon presentation for anaphylaxis unless the patient was profoundly hypotensive or hypoxic as to the underlying cause (which may have been the case here given the lack of a seizure history and the non-obtainable BP: so maybe it was anaphylaxis€¦or was that lack of an obtainable BP on the basis of agitation€¦).

The other consideration would be that perhaps the patient did not have anaphylaxis and was given epinephrine and then seized because of a hypertensive reaction and is now agitated and post-ictal. Those would be our thoughts.

In terms of action, we probably are not going to be able to determine on scene the underlying pathophysiology, and the patient has no obtainable BP and needs transport.

Our direction would be to load and go, patch to BHP en-route for consideration of epinephrine and other interventions and therapies. Our bet is that different BHP would each suggest something slightly different: such is the essence of medicine.

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