Airway & Respiratory, Patient Care

The Lion’s Bite: Anaphylaxis protocols prompt quick treatment & recovery

Issue 2 and Volume 33.

Radio silence is a rare occurrence in the New York City EMS System. With an average volume of more than 3,100 calls a day, EMTs and paramedics are exposed to the gamut of call types, both ordinary and unusual.

EMS personnel in the NYC 9-1-1 system, like many other systems, are highly knowledgeable and skilled to deal with such a diversity of assignments. But being at the center of the post-9/11 world, FDNY EMS crews are always prepared for what will come next.

Such was the case for FDNY paramedic unit 49 Rescue when dispatched to a call for a possible ˙anaphylactic shockÓ a few hours into their tour. The dispatch information provided to the paramedics indicated that their patient was a 56-year-old male who was stung by a poisonous barb while cleaning his aquarium.

The crew arrived on scene in just a little more than two minutes. During their short response, the crew thought about their anaphylaxis protocols, wondering what type of situation they were about to encounter and what actions they would need to take upon arrival.

The crew arrived and, to their surprise, found the patient in front of the call location, ambulating toward their vehicle. He was immediately placed on a stretcher, and the crew began their evaluation.

One member of the crew reviewed the history of the complaint while the other began to perform a physical examination, collect vital signs and obtain an ECG.

The patient said his lionfish stung him while he was cleaning his saltwater aquarium. The physical exam revealed significant localized swelling and pain to his right middle finger. There were no signs of respiratory distress, wheezing, facial edema, or signs and symptoms of vasodilatation.

Consistent with protocols, the crew immediately placed the patient on high-flow O via a non-rebreather mask, and established a large-bore IV of 0.9% normal saline (KVO). The ECG showed a normal sinus rhythm. The patient’s vital signs were: pulse 74 regular, respiratory rate of 18 and blood pressure 170/140.

Skin color, temperature and moisture were normal. Lungs were clear bilaterally, pupils equal and reactive, and the patient’s mental status was alert and oriented. Despite a slightly elevated BP due to pain and anxiety, the patient’s vitals appeared normal.

Typically, a patient presenting as in this case, would be transported to the nearest hospital under transport policy. However, the crew, aware of the seriousness of anaphylaxis and unsure of the dangers associated with a sting from the highly poisonous lionfish, called on-line medical control to discuss additional treatment and a transportation decision.

The patient was transported to the„Venomous„Bite„Center at„Jacobi„Hospital„Center in the„Bronx. During the 15-minute trip to the hospital, the patient’s condition remained unchanged. The crew also applied ice packs and elevated the extremity to minimize swelling and reduce circulation.

The patient was evaluated and treated at the hospital and was subsequently discharged without further compromise.

A lionfish is a venomous marine fish that’s known to be a voracious predator. They have extremely long and separated spines, and typically have a striped appearance with red, brown, orange, yellow, black or white coloring. Although the hardiness and disease resistance of the lionfish make their care relatively simple, the venom from the spines is extremely painful, so they’re recommended only for the careful aquarist. Stings from their spines are deadly to their normal prey, and humans will suffer severe pain, and possible headache and vomiting.

Anaphylaxis is an acute systemic and severe allergic reaction. Anaphylactic shock is the most severe type of anaphylaxis, occurring when an allergic response triggers a quick release from mast cells of large quantities of immunological mediators (i.e., histamines, prostaglandins, leukotrienes) and leads to systemic vasodilation (associated with a sudden drop in blood pressure) and edema of bronchial mucosa (resulting in bronchoconstriction and difficulty breathing). If left untreated, anaphylactic shock can lead to death in a matter of minutes.

The symptoms of anaphylaxis include respiratory distress, hypotension, urticaria, flushed skin, angioedema (facial swelling of the lips, face, neck and throat), itching, anxiety, fainting and/or unconsciousness.

In„New York City, protocols exist for poisonings, venomous bites and anaphylaxis. BLS protocol for poisonings includes airway monitoring, oxygen administration and possible ALS intervention. The ALS protocol allows for a variety of treatment modalities to be administered under standing orders for patients exhibiting signs and symptoms of an anaphylactic reaction.

Lessons Learned

  • Dispatch information is sometimes accurate.
  • Even a possible anaphylactic patient may walk to the ambulance.
  • EMTs and paramedics must always be prepared for the unusual.
  • Prompt treatment and care result in prompt recovery.
  • When in doubt, a medical control physician is only a phone call or radio contact away.
  • The lion’s bite may be worse than its roar!

For airway compromise, ALS providers can administer oxygen, albuterol sulfate and epinephrine, and intubate. A large-bore IV of normal saline or Ringer’s lactate is required, and rapid infusion of fluid is permissible if signs of decompensated shock occur. Administration of diphenhydramine is also permissible under the poisoning protocol.

Although mortality from anaphylaxis is estimated to be less than 1%, approximately 15% of the„U.S. population is considered at risk.(1)„Although anaphylaxis is rare, prehospital personnel must remember that it’s life threatening and can occur at any time. Quick recognition, aggressive treatment and transport will make a difference in the most severe situations of anaphylaxis.

1. Neugut AI, Ghatak AT, Miller RL. ˙Anaphylaxis in the„United States: An investigation into its epidemiology.Ó. Archives of Internal Medicine 2001;161:15-21.