Allergic Reaction

A recent patient of mine went camping in Big Sur and returned with swollen arms, body and face – the picture of poison oak misery. So thought I’d post on allergic reactions.

Rash and anaphylaxis lie on opposite ends of the allergy spectrum. My heart weeps for anyone who gets an ER bill for the simple local rash. Topical OTC hydrocortisone or Benadryl +/- oral Benadryl +/- prednisone are cutting edge care, and quite easy to deliver even with telemedicine. For added finesse, add Technu (or Dawn dish soap) to remove the poison oak oils if that’s the problem.

On the other hand, ER’s earn their keep when allergy migrates to anaphylaxis. Such reactions, though infrequent, are life threatening, and are the reason for EpiPen and Auvi-Q autoinjectors. These are two products that help you inject 0.3mg epinephrine, which is remarkably effective. (Simultaneously they suction your cash costing ~$2-300 each… with1-2 year shelf lives!)

Red Flags:

• Rapid onset
• Tongue/lip/neck swelling
• Wheezing
• Shortness of breath
• Dizziness
• Unconsciousness (obviously)
• Past hospitalizations/intubations for the same

Happy Words

• Itchy
• Localized rash
• Improving since onset
• Gradual progression over days
• No past serious allergic reactions

People suffering allergic reactions are everything from mellow to miserable to moribund. But their treatment paths are fairly similar. Depending on urgency, we consider topicals, then orals, then IV meds. For adults unimproved by topicals, 50 mg Benadryl, 60 mg prednisone and 20 mg Pepcid are a common approach. Sometimes we try IV Solumedrol. If your doctor uses epinephrine it means he or she is concerned. Your heart will race, and expect to be observed for a few hours or admitted. Intubation happens in the extremes.

Whether caused by bees, plants, peanuts, shrimp, cat hair or meds, our approaches in the ER really don’t vary. But following up with an allergist to help nail down the culprit makes good sense. In my med kit I carry a $6 1 mg epinephrine vial with syringe as well. Quite a markup for the EpiPen, eh?

911 for the red flags… Pre-R for everything else.

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