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You are working on a hot June day in a BLS unit. You would rather be camping with the kids at Writing-on-Stone Park. You're trying to stay cool and the tones go off, calling you to work. The address is a legal land description in a rural area. You have no trouble finding the patient. He is sitting on the ground beside his tractor, which is connected to an anhydrous ammonia applicator. His wife is there with him and she is frantic. She identifies herself as a nurse and keeps saying that her husband has a heart condition, but this could be an allergic reaction. She is crying and keeps repeating herself.

The patient's skin is flushed. There is no history of trauma. The patient appears conscious but is not actively moving. You have parked your ambulance upwind from the tractor.

Your partner obtains the following information from the patient's wife. This 75-kg 68-year-old man has no allergies. Medications are ASA, NTG and Inderal. He suffers from angina and suffered a myocardial infarction last year. He has been otherwise healthy and active and doesn't smoke or use alcohol. He has a family history of CAD as his father and two brothers suffered fatal myocardial infarctions while in their 60s. He had his lunch on the tractor about a half an hour ago. After taking his lunch to him his wife noticed that he stopped going around the field and climbed out of the tractor. She went to check on him and found that his tongue was “all swollen” and he had trouble speaking.
Your patient is lethargic but responds to voice. He is unable to speak in comprehensible words and you notice his tongue is significantly swollen.

Primary Exam and Initial VS

He is breathing 24 times a minute and has wheezing in both lungs. His breathing is laboured. His heart rate is regular 96 beats per minute and weak at both the radius and at the carotid. His blood pressure is 160/74. His O2 sat is 95 per cent. His temperature is 37.0 ºC. His BGL is 7.5 mmol/l. His skin is flushed with no insect stingers found, no pacemaker or surgical scars and no needle marks. His abdomen is soft. He is continent and you notice tearing of the eyes. Pupils are equal and reactive.

1. What is your next course of action?
2. What kind of back up would you most like for this call?
3. How will you assess this patient?
4. How will you move him to the ambulance?
5. This patient is a load and go
6. Your initial assessment indicates either an allergic reaction or exposure to anhydrous ammonia. Your first treatment would be:
7. You have performed a primary examination. While providing the initial care you recognize certain care that can assist this patient’s current condition. In addition to the treatment already provided, you would also:
8. The only EpiPen in the ambulance has expired but you have some 1 ml ampoules of 1:1000 epinephrine that aren’t yet expired. How will you draw it up?
9. What size needle would you use for the injection?
10. You have an IV established with 18-gauge in the left AC, 1000 ml NS and a 10 drop set. What rate do you want to run the IV at this time?
11. What is the most appropriate dose for a second dose of epinephrine in anaphylaxis if the first dose is not effective?
12. Despite your appropriate treatment of this patient his LOC has deteriorated and his BP is now 80/52. You have been en route for approximately 15 minutes and have twice that time left to reach the hospital. He tolerates the airway management that you have chosen and is being adequately oxygenated and ventilated. What is your next course of action?
13. As an EMT-A you might want to try what other intervention on this patient?
14. You are an EMT-A practitioner and despite your efforts this patient goes into cardiac arrest. The cardiac monitor shows a slow PEA. You then:
15. You meet with the ALS unit and they jump into your unit to assist you. After a quick report everyone goes to work. The paramedic elects to initiate an epinephrine low dose infusion to try to counteract the anaphylaxis or toxic effect causing the cardiac arrest. How would you prepare an epinephrine infusion?
16. The patient’s Sp02 is low and your partner is having difficulty ventilating as they state the chest is tight. What do you think this patient needs most right now?
17. Other than the epinephrine infusion, what infusion would you consider for refractory hypotension with anaphylaxis?
18. As a paramedic, you might try , as an alternative to additional doses of IM injection of epinephrine.
19. This patient has arrested and is still in a bradycardic PEA. Next you might want to:
20. This patient could receive a variety of medications at this time. What medications are most helpful in this situation?
21. One of the possibilities in this situation is acute MI. The most likely reason for this patient to be a cardiac arrest is the fact he has stressed his body enough to then stress his heart into suffering a cardiac arrest.
22. This patient responds to the initial ALS treatment and now is in ventricular fibrillation. The next treatment would be to:
23. The patient remains in ventricular fibrillation. You can also administer a second dose of:
24. This patient has been in a persistent pulseless rhythm for a long period of time. You might elect to administer:
25. The differential diagnosis in this patient’s cardiac arrest could be: