Case Study

[Guest guest]

You are dispatched to a local walk-in care clinic for a patient in respiratory

distress. En route to the call dispatch notifies you that you are responding to

a 47 year old male with a possible allergic reaction.

Upon arrival the attending physician tells you the patient ate lunch at a local

restaurant and may have come into contact with something containing peanuts. The

patient had a minor reaction to peanut butter two years ago, and has avoided

peanut products since. The physician gives you the following information:

When the patient presented to the clinic he was in respiratory distress, had

petechiae to the eyes and face, and had the following vital signs: BP 92/44, HR

114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He had loud

expiratory wheezing that could be heard from across the room.

The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST with

occasional PVC, and an IV of NS was started. While beginning treatment the

patient's SPO2 decreased to 82 percent and his respiratory distress worsened. He

was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the IV was started, he

received Solu-Medrol 125mg IV. He was started on a double DuoNeb treatment, and

the IV was open for a 1 liter bolus. Within minutes the patient became worse,

with the following vital signs: BP 82/30, HR 144, RR 40, and SPO2 66%. The

patient was given another SQ dose of Epi 1:1 0.3mg, IV Epi 1:10,000 0.5mg, and

the staff began ventilations with a BVM. When the patient became obtunded he was

intubated with a 7.0 ETT with O2 wide open, given an inline DuoNeb treatment,

and was given Benadryl 25mg IV.

Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by BVM, SPO2

84%. The patient is very difficult to ventilate and has loud expiratory

wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, and

chest wall. He is responsive to painful stimuli and occasionally reaches for the

ETT.

The physician asks you to give the patient a paralytic, a second dose of

Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if needed.

Your turn: You are transporting to an emergency room 18 miles away. Would you

follow the physician request, call for other orders, or follow your protocols?

What part of the physician orders would you consider detrimental to the patient?

Bonus question: What part of the previous treatment may have made the patient

worse?