Down In the Mouth

   The crew of Attack One has just completed a public safety demonstration on a hot summer afternoon when they are dispatched to another metropolitan park for a woman in respiratory distress. On arrival they find a lady in that condition, with a distressed park ranger holding her off to the side. Concerned family members in the picnic area can only watch as the woman labors to breathe. The crew quickly exits the vehicle and moves to her side.

   The patient is unable to speak, and it's immediately apparent that her swollen tongue is sticking out of her mouth in a very unusual manner. She is pale and diaphoretic. A male bystander and the park ranger explain that the woman, at a picnic with a large family group, took a drink from a cola can. She immediately reported she had swallowed something that stung her in the mouth, her tongue began to swell, and she developed tremendous distress. Family members report she is healthy and has no history of reactions to stings, and neither she nor her family members have a self-administration package of epinephrine.

   The crew members take immediate action, supporting the patient on her side and using a tongue depressor to keep her tongue from completely obstructing her mouth. The lady is close to completely losing consciousness and losing her airway. The Attack One crew leader had pulled all the epinephrine out of the drug box as soon as he heard that a sting had caused this severe reaction. As he prepares a dose for the patient, he asks the EMT to pull everything out of the supply bags that might be needed for an airway or a cardiac arrest. "Get out the needle cricothyrotomy kit, the nasal intubation airway, the IV supplies with all sizes of catheters, all the drugs, and a bunch of bags of IV fluids," he instructs. "Get the intraosseous kit out and open it. Have it all ready immediately!"

   The paramedic quickly prepares a syringe of the higher concentration of epinephrine, drawing up 0.3 cc of the 1:1,000 preparation, which is most common for treating allergic reactions. This is almost a reflex action for the crew, but as he pulls the cap off the subcutaneous needle, he and the paramedic holding the patient conduct a rapid discussion about giving the medicine.

   "She's almost unconscious and isn't perfusing her skin at all," the second medic says. "She'll never absorb the epinephrine out of her skin if you give it there. She's also about to completely lose her airway. Her tongue is completely swollen, and I see the spot where she was stung right on the end of her tongue. It would be best to give the epinephrine IV, but I've already checked for veins, and she has none I can find. They have completely collapsed, and she has no pulse except at her carotids. Give her the dose in her muscle."

   The lead paramedic changes out the needle to a longer and larger one. "Does the patient have a spot under her tongue I can give it in?" he asks. "Giving the epinephrine into that big muscle will help both the swelling there and her shock. It's almost as effective as giving the medicine intravenously!"

   "Great idea," the second medic replies. "The whole bottom of her tongue is open, and she needs that epi fast, or she's going to arrest."

   The lead medic grabs the woman's tongue with a 4x4, pulls it up the best he can, and uses the tongue blade to create a space right above the lower teeth. He inserts the longer needle into the muscular area of the lower tongue, and no blood can be drawn back into the syringe. He injects the epi and pulls out the needle. He then asks the other paramedic to prepare for a nasal intubation, and grabs the materials needed for inserting an intraosseous needle.

   "We'll give that dose two minutes to work, then we need to be prepared to give the next dose IO," he says. "Get the endotracheal tube through the nose and into the area above her larynx right now, and that should give her an airway at least temporarily. If it slides right into her trachea, leave it there, but if not, don't worry. We need to get her the medicines and fluids first."

   The tube slips right into the woman's nostril and sits comfortably above her larynx. The patient at this point is unresponsive, but has a rapid pulse at the carotids. The pulse oximeter cannot get a reading.

   The EMT has prepared all the supplies and assumes the role assisting the patient's breathing through the nasal tube, while the paramedics finish inserting an intraosseous needle into the patient's tibia. They prepare a bolus of saline, a first dose of diphenhydramine and the next dose of epinephrine.

   As they near the two-minute mark from the first dose of epinephrine, the EMT is first to notice a change in the patient. "She is breathing a little bit more," he observes, "and it looks like her face is getting a little pink." Then the pulse oximeter captures a heart rate.

   "Let's give her the bolus of saline and the dose of diphenhydramine intraosseously," the lead medic says. "We'll give her a slow dilute injection of the epi into her IO line, so we can keep her moving in the right direction."

   Now the patient's tongue swelling is beginning to decrease, and the crew notices her skin begin to pink up. She starts to stir a little, then gags. The IV epi, 1:10,000, is diluted in another 10 cc of saline, and the paramedics begin administering 1 cc of that mixture about every 30 seconds. "It will be time to pull the nasal tube out when her tongue swelling decreases a little more," the paramedic says, "so we don't make her vomit."

   The next steps come quickly. Her tongue swelling decreases dramatically, and the tube is pulled out. The pulse oximeter captures an oxygen saturation of 95%, and skin perfusion improves. Finally the lady begins to open her eyes. It is only at that point that the crew can stop and appreciate that more than 100 people have gathered around the site and are watching as the crew works. They all cheer as the woman opens her eyes and weakly asks, "What happened?"

   "You had an allergic reaction to a bee sting on your tongue," the lead medic tells her. "You were really sick, and we had to give you some adrenaline and put this needle in your bone to get you better."

   The patient remembers nothing, but notes that her tongue still feels weird, and the site where her IO line was in place hurts. As the crew loads her onto the cot, they simultaneously look for a site for a conventional IV line. They find one and place a saline lock, capping off the intraosseous needle.

   "We don't want you to get real sick again and not have a good line in place," they tell the woman. "We don't know where that bee that stung you went, and we don't know if you will have another reaction. But we will keep a close eye on you."

Emergency Department

   The woman is unchanged on the trip to the hospital, and her pulse rate slows gradually. She arrives in the ED stable. The crew shares the history with staff, and one of the family members who followed along to the hospital offers to provide further history: "I filmed the whole thing," he says. "Do you want to see it? The crew worked for 3 minutes and 30 seconds until she woke up and asked what happened!"

   Thankful that the patient had a good outcome, the crew watches the video with the ED staff and the patient herself. What seemed like a long time to the crew at the scene in fact took place in seconds. The emergency physician congratulates the crew on a livesaving effort.

   The patient is observed in the ED for 12 hours but develops no further problems. She goes home with a sore tongue and sore tibia. New medicines sent with her include a self-administration set for epinephrine and instructions for using it.

Case Discussion

   This case demonstrates the extremely critical nature of allergic reactions. This patient reacted with two of the mechanisms that can occur with such reactions:

• Local swelling, which can be extreme and life-threatening if it occurs in dangerous body areas (e.g., mouth, throat, neck).
• Circulatory collapse and profound shock.

   Allergic reactions can also be fatal by causing severe airway constriction (bronchospasm), cardiac dysrhythmias or a combination of the above.

   Epinephrine is a medication that can be delivered by the widest possible number of routes. It is effective when administered subcutaneously, intramuscularly, in the tongue (intraglossally), intravenously, into the bone marrow or down an endotracheal tube. The key to lifesaving is rapid administration and giving the drug in a site where it can be delivered to key receptors that allow it to work. The paramedics here correctly deferred putting the epinephrine in the woman's skin, because her poor perfusion meant none of it would be picked up into the vascular system and delivered to key organs and blood vessels.

   Giving the medicine into the tongue was a good decision. For more than 50 years, the tongue has been recognized as a site that has the same medicine-delivery characteristics as the intramuscular and intravenous routes. The tongue is a very muscular organ, filled with large veins. The tongue's perfusion is also preserved even in low-flow situations. This patient had medicine administered into the tongue with two clinical effects: It acted locally to reduce swelling, and it was picked up and delivered to receptors in the blood vessels, reversing the shock state.

   In this case, the epinephrine increased vascular tone, reduced swelling and reversed the airway compromise, restored perfusion, and woke the patient up.

Initial Assessment

   A 38-year-old female in respiratory distress and shock due to a bee sting in the mouth.

   Airway: Compromised. The patient's tongue is so swollen, it is protruding out of her mouth.

   Breathing: In distress, unable to speak.

   Circulation: Patient is cool, with very pale skin.

   Disability: No neurologic deficits.

   Exposure of Other Major Problems: Tongue swelling is compromising the airway. Patient may also have swallowed the bee.

Vital Signs

   AMPLE Assessment (obtained after patient woke up)

   Allergies: None.

   Medications: None.

   Past Medical History: Patient unable to give a complete history.

   Last Intake: Eating when sting occurred.

   Event: Local and systemic reaction to a bee sting in the mouth.

   Learning Point: Severe reaction to a bee sting, with administration of epinephrine in an atypical manner to address both elements of the life threat.

Customer Service Opportunity

   There are cases where EMTs must provide immediate lifesaving actions with little time for explanation to the patient or significant others. There are also incidents that occur in front of audiences of intensely impacted bystanders who in these days record the action on cameras and cell phones.

   There are few interventions the EMT needs to know as precisely as the administration of epinephrine to the victim suffering a life-threatening allergic reaction. The medication must be administered before the life threat becomes irreversible. Fortunately, epinephrine can be given in almost every form available to the EMT, and is packaged in a variety of mixtures and rapid-administration tools that facilitate timely delivery. With life-threatened patients, the EMT must take action immediately and then be able to explain the process to the patient and bystanders afterward.

   Similar timely actions are required to control bleeding, open an airway or apply defibrillation. The EMT needs to train on each of these interventions to the point where they virtually can't be done wrong. It is also important that the EMT be prepared to function in front of a camera, and not develop stage fright at a critical time. Some agencies now film providers in training doing critical EMS evolutions, so the members are aware of what an interaction looks like on film. In all cases, timely patient care is the critical priority.

   James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.