Case Study

[ruby_jane, BSN, RN]

This happened in real time this AM....I will post my nursing dx later but am curious to see what you all think of this.

Student with no reported history of asthma or allergies presents stating "I'm having an allergy attack or asthma." Student is a frequent enough visitor that I know her face but has had no unusual occurrences.

Initial VS BP 137/94, HR 116 RR 15, PSO2 98%. Breath sounds diminished at the tops of lung fields bilaterally, nothing adventitious at the bases of lungs. Lips pink, arms flushed, conjunctiva reddened, student stating throat is swelling and tongue is swelling. She reports chest tightness but is able to make 10-word sentences and is not tripod positioning for comfort. She denies nausea.

I am armed with two EpiPens for "unknown allergens." I have no standing orders for Benadryl or albuterol.

Reassessment 12 minutes later after calming her down, calling dad (on the way) and cold water to drink: BP 141/81, HR 113, RR 12, PSO2 98%, diminishment of itching sensation on tongue, throat is itching but reduction in the sensation of swelling. Bilateral breath sounds WNL on the left upper and lower lung fields. Right upper lung fields diminished sounds, front and back, no diminishment on the lower right fields. She is reporting that "it's easier to breathe." No nausea.

Reassessment as dad arrived to take her away (10 minutes after second reassessment) BP 134/84, HR 116, more profound flushing of face, and conjunctiva are pronouncedly reddened, but reduced sensation of swelling tongue. Throat is "itching," skin on her arms is flushed. Dad left to take her to the doctor.

What do you think? Asthma, panic attack, or something else?

[kidzcare]

My initial thought is panic. But that is based on no information of what the student ate in the few hours before incident and no info on activity level before incident.

Continued elevated BP and HR also indicative of panic to me and there was no mention of labored breathing (and indicated that the student was not demonstrating difficulty).

I am interested in the outcome. I will be following. I'm also curious to the age/grade level of the student (I would lean more towards anxiety for a student age 10+)

[ruby_jane, BSN, RN]

High school student; nothing unusual to eat prior to the events. They were getting ready to make ice cream in science. The student never did have labored breathing.

[kidzcare]

High school student; nothing unusual to eat prior to the events. They were getting ready to make ice cream in science. The student never did have labored breathing.

Then I feel more confident in the anxiety theory.

[OldDude]

I'm assuming this isn't an elementary school kid so based on her initial statement, with no history of that stuff, and the absence of "signs" of an acute allergic reaction I'm going with anxiety/panic episode.

[tining, BSN, RN]

Cold have reacted to an odor. I have a teacher that reacts with bleach odor. Perfume makes me have those feeling, although I've never had my blood pressure taken at the time.

[grammy1]

I'm thinking anxiety too. The only thing is the itching of throat and tongue. I've seen quite a few panic attacks here, but never with itching of tongue and/or throat. I would have had the epi-pen out and ready, for sure. As I type this out, and read what I'm typing, I may have to lean more toward allergic reaction.

[Flare, ASN, BSN]

i agree with panic attack / anxiety theory

[ruby_jane, BSN, RN]

Initial VS BP 137/94, HR 116 RR 15, PSO2 98%. Breath sounds diminished at the tops of lung fields bilaterally, nothing adventitious at the bases of lungs. Lips pink, arms flushed, conjunctiva reddened, student stating throat is swelling and tongue is swelling. She reports chest tightness but is able to make 10-word sentences and is not tripod positioning for comfort. She denies nausea.

At this point I was sure I was going to get to test out my EpiPens. I would have sworn it was anaphylaxis.

Reassessment 12 minutes later after calming her down, calling dad (on the way) and cold water to drink: BP 141/81, HR 113, RR 12, PSO2 98%, diminishment of itching sensation on tongue, throat is itching but reduction in the sensation of swelling. Bilateral breath sounds WNL on the left upper and lower lung fields. Right upper lung fields diminished sounds, front and back, no diminishment on the lower right fields. She is reporting that "it's easier to breathe." No nausea.

OK, backing away from the EpiPens here. But thinking to myself...why are those breath sounds diminished?

Reassessment as dad arrived to take her away (10 minutes after second reassessment) BP 134/84, HR 116, more profound flushing of face, and conjunctiva are pronouncedly reddened, but reduced sensation of swelling tongue. Throat is "itching," skin on her arms is flushed. Dad left to take her to the doctor.

Pretty confident now this is panic attack of unknown origin at this point....except I can't shake the weird feeling that it was triggered by an allergen. The anxious kids usually have elevated BP/heart rate resolving with rest in the clinic x 20 minutes. Could have been an odor.... I guess I'll see tomorrow!

[JenTheSchoolRN, BSN, RN]

Oddly enough, I was talking today about oral allergy syndrome. And this may fit here. Does the student have a history of seasonal allergies?

Oral Allergy Syndrome | Symptoms & Treatment | ACAAI Public Website

[KKEGS, MSN, RN]

I would go with anxiety attack except for the itching. That's a perplexing symptom.

[GdBSN, RN]

Oddly enough, I was talking today about oral allergy syndrome. And this may fit here. Does the student have a history of seasonal allergies?

Oral Allergy Syndrome | Symptoms & Treatment | ACAAI Public Website

I just read that article and thought the same thing. I have two teachers at my school who have these weird reaction to fruits and veggies. Neither carry an EpiPen.