Question: This question is based around a call that has had some interesting discussion and I am curious to get your input on. The call was initially for an allergic reaction, updated while en route to say that the patient was seizing.

Upon arrival, you find a 28 year old male lying on the ground. A family member states that the patient was stung by a wasp on the back of the neck approximately 15 minutes ago. They immediately gave him Benadryl orally and he self-administered his EpiPen (the family seems reliable and as far as you can ascertain both of these medications were administered appropriately and were not expired).

They continue on to tell you that about five minutes ago, the patient had a seizure that just ended as you arrived. The patient has never had a seizure before. There was no trauma suffered from the seizure. The patient has a history of anaphylaxis to wasp stings but no other past medical history.

On examination, there are no signs of trauma and the patient denies any pain. The patient is conscious, but agitated and confused to place and time (GCS 14). He has slight swelling of the lip but no urticaria anywhere on his body and no other facial swelling. His breath sounds are clear on auscultation. He appears to have been incontinent of urine. There has been no vomiting or diarrhea.

Initial vitals are a heart rate of 102 regular and full, respirations 24 regular and full, pupils PEARL 4mm. Blood sugar is 6.7 mmol/L. BP is unobtainable as the patient continues to become more agitated and will not remain still. Oxygen saturation is also unobtainable as the probe keeps coming off his finger while he moves around.

Specific points that came up in our discussion that we would love to hear your thoughts on are:

1. Based on the information available here, should this patient receive epinephrine (epi)? It is easy for us to second guess the inability to obtain a blood pressure (BP) on this patient, but for the purposes of discussion, I think we should accept that none of us were on the call and it was not possible for this medic to obtain a BP even by palp.

2. Are we held strictly to the traditional “two systems involvement” view of the diagnosis of anaphylaxis or are we permitted to consider a broader definition such as that published by Sampson et al. in the summary report of the Symposium on the Definition and Management of Anaphylaxis?