What if it had happened on board: anaphylactic shock

[kingfisher]

On Friday, my wife woke me up because she was feeling very uncomfortable: she was feeling extremely itchy all over, including her throat and especially in fingers and toes. It quickly became unbearable in such a way that she was crying on the bed. She also was finding it more and more difficult to breathe. By then she was able to tell me that she had woken up with a migraine and had taken a paracetamol painkiller, a brand which she had taken several times before.

Because my brother-in-law is hyper allergic to nuts, and I recognizned the symptoms, I immidiately thought anaphylactic shock.

I grab the phone and call emergency services. They asked whether I have anti-histaminicum at home, which I had (I'm mildly allergic to dust) and they recommended that I gave here on. By the time I found the box (still with ER services on the line) my wife had passed out. I was able to wake her up enough to administer the antihistaminicum. I had also told the lady on the phone that we needed the ambulance, as in NOW!

With the antihistamin administered, things calmed down amazingly quick, given the fact that Claritine isn't the strongest of pills. 5 minutes later, ambulance arrived with 2 emergency guys, a nurse, a nurse trainee and a doc. SWMBO was put on oxygen, given a shot and taken to the hospital. 2 hours later, we were home again, and she was in bed, sleeping off the exhaustion.

Remarks:
1. In five minutes, it went from disagreable to lethal. The speed of deterioration was frankly scary. A quick call to make. The call to emergency services literaly went like:
" Me: I think my wife is suffering an allergic reaction to the pills [SWMB with hands flapping walking around the bedroom]
ER: Do you have an antihistamin
ME: Er yes, hang on [rummage through pill box]...she is really in pain now[SWMBO crying on the bed, hands and face spotted red, trembling]
SWMBO: I can't breathe [SWMBO passes out on bed]
ME: eh: better get the ambulance up here
ER (who probably heard SWMBO): on the way

2. I have antihistamin at home because of my mild allergy. I gues a lot of people don't. Without that very minor dose, it would have been a hell of a lot worse. Stock up on antihistamin

3. What if this had happened on board: I got stung by a wasp this summer (my mum is hyper allergic to wasps), what if fray bentos pies contain traces of nuts (bye bye brother-in-law), what if SWMBO had taken paracetamol on board.

4. Apparently I made some good calls (shows the value of a bit of first aid training we get at the sea-scouts), and I learned that people with difficulty breathing should sit, not lie down. When they lay down, there is more pressure on the chest (especially with SWMBO, who is well formed).

all is well now, SWMBO had to stay of the wine the whole weekend /forums/images/graemlins/grin.gif

 

[Gerry]

All good stuff. we also carry a thing called an 'epipen' which gives an instant dose of straight thru the skin.
You just thump the thing on the patients thigh and it delivers the dose, so even if they are unconscious it is possible to deliver the dose.
I highly recommend it. Prescription only in Europe I believe.

www.gerryantics.blogspot.com

 

[Sans Bateau]

Pleased to hear all is well now, very enlightening first hand account. You are to be praised for being what sounds like a very cool headed person in an extremely challenging situation, especially when a loved one is involved, well done.

 

[CPD]

Did you find out the cause ?

 

[davies]

The Epipen is certainly a life-saver in this situation. I keep an in-dates one permanently accessible

 

[kingfisher]

Cause

SWMBO still needs to take some tests. But given the fact that all she took that morning was the painkiller (Minoset+, a paracetamol based painkiller), it makes for easy deduction that that is the cause.

I made indian food the evening before, but with the speed of the reaction, it had to be caused by something that was taken moments earlier.

Euh hang on, need to make some changes to the original message : "better get the ambulance up her" could do with a correction

 

[Danny Jo]

What if it had happened on board: anaphylactic shock?

If on board Freestyle, Clarityn or its generic equivalent would have been available. (Freestyle's skipper is inclined to blow up like a balloon if stung by a wasp.)

Clarityn is the trade name given by Schering-Plough to their brand of loratadine. Its patent ran out about 5 years ago, and a number of generics versions of the same drug are now available at about a third of the price. The last lot I bought were Tesco's own brand loratadine.

Incidentally, the manufacturer used an interesting strategm in an attempt to maintain its market dominance in spite of the lapse of its patent on loratadine. About 18 months before the patent's expiry, the manufacturer ceased to supply loratadine to the NHS, offering instead desloratadine (marketed as Neoclarityn). The ostensible grounds for this change were that loratadine is metabolised in the body to desloratadine, which accounts for most if not all of its antihistamine activity. It was argued that it makes more sense to give the active ingredient. To ensure that they could patent desloratadine they had of course to argue that for patenting purposes it was a new drug (whereas for sales purposes it was the active component of a tried and tested old favorite). And while Clarityn ceased to be available for prescription by NHS doctors, it remained on sale to the public through pharmacies. Schering-Plough's strategm was not as successful as perhaps the company had hoped, because many hospitals switched to other antihistamines rather than start using the "new" drug desloratadine.

Edited to substitute "manufacturer" for "manufacturers".

 

[Superstrath]

This happened to me once, at 0100 while I was OOW driving a ship along the Cuban coast from Havana. I got itchy, then it felt like burning all over, especially the palms of my hands. Then I fell over. My lookout saw me go, called the Captain.
As I was also responsible for medical issues on board, I studied the books, decided I was not long for this earth, and took to bed.
In the morning, we concluded that it was an allergic reaction. We had been eating a lot of fresh fruit, notably mangos, in Havana, and a lot of fesh sea-food that we were buying for cigarettes on the quayside.
One or both of these was probably the cause. I decided in the end that it was mango, and avoided the things for years afterwards, despite them being the most delicious of fruits.
It was a horrible experience, and could have been disastrous. What a mess our cargo would have made scattered along the Cuban coastline; four thousand tonnes of limes bound for East Germany.
It could have been limes, I suppose, although avoiding them would have been difficult, since all we ate on board seemed to be previous cargo: Lamb, mackarel and limes. Made the Chief Stewards costs look good to head office, I imagine.

Al

 

[johnalison]

I would support the carrying of Epipen, though I don't remember if the shelf life is as short as generic Adrenaline which is only about one year. Clarityn is a perfectly effective drug for many people, but the absorption of a drug from the stomach is very slow, say 20 minutes to work, and only an injection can really be relied upon, especially if the patient is in a collapsed state, when absorption is even slower. Some drugs will work quicker if bitten and retained under the tongue.

 

[MoodySabre]

Scary. Glad it worked out OK and you were there - that's the really scary thing if it happens before they can call for help.

My daughter was diabetic before she had a pancreas transplant. A hypo could come on very quickly even if she had been eating/injecting properly. A sweet fizzy drink and glucose tablets kept to hand. Once found her unconscious on her bedroom floor (she doesn't live with me but I became worried when phones weren't answered and went round). Still worry even though that can't happen now.

 

[davidfox]

I have heard about rubbing the gums with the pill aiding absorbsion. - any comments form anyone?

 

[georgeo]

Hi, a few comments. First I am very pleased that Mrs Kingfisher is fine, and clearly Mr kingfisher handled a difficult situation very well. As regards the precipitant, then the paracetamol is unlikely to be the cause. More likely are the co constituents, particularyl aspirin or an NSAID (brufen or similar). If Kingfisher chooses to PM with the precise details of what she took I will check it out for him through our drug information service.
Secondly, it is worth putting things in perspective. I have been at the sharp end of 'general medicine', hospital based, since 1979. I reckon I have seen about half a dozen cases of genuine true anaphylaxis. This condition, despite the hype, fortunately remains rare. In 3 of the cases I was directly responsible, the reaction occurred on the end of needles as I was injecting penicillin. Now if you want a genuine brown trouser moment, these episodes certainly count, and each one is seared into my memory! (they all recovered, by the way). Genuine anaphylaxis is associated with swelling of the face, mouth lips tongue epiglottis and throat, accompanied by bronchopspasm, a very high pulse rate, a dreadful feeling of impending death ('anguor animi') and then collapse. In my experience the patient goes puce red, pallor following subsequently only if they are about to meet their maker. Treatment is as outlined above, adrenaline, antihistamine, steroids, anti bronchopasm agents and fluids ie a full blown medical emergency. What is relatively recent however, is the rise in the number of people carrying epipens where there is no clear indication that these people are at risk from such a catastrophe. Some of our primary care colleagues seem to hand them out like smarties I am afraid, and we see a succession of people brought in suffering from the side effects of the injected adrenaline with no hint of underlying anaphylaxis. If really faced at sea with severe or life threatening allergy, get anti histamine into the patient by any means available, use an epipen if they have one and you really think they have life threatening allergy (but remember, giving adrenaline to someone who does not really need it is hazardous and can in itself be life threatening! And common or garden hyperventilation, in somebody who is convinced, usually wrongly, that they are prone to anaphylaxis, can mimic many of the symptoms (check their colour, if puce, get worried)) and follow your ABC wilst waiting for help.
Regarding superstraths' post, I suspect he was suffering from ciguatera poisoning rather than side effects from mangos! The symptoms he describes are classic, he says they were eating a lot of fish, fish from that area (barracuda particularly) are notorious for this, and he was lucky to get away with it although from what he says, it sounded pretty awful! And he has denied himself, needlessly, mangoes for all these years!. Hope this helps

 

[jimbaerselman]

Many thanks, rosbif. Very informative.

Please correct the following if I've made an error:

What if it happened on board? If no adrenaline, most vessels carry 'sea-sickness' tablets, and the majority of those are anti-histamines. Chew if they're capable.

 

[georgeo]

good point jimbaerselman. Cinnarizine (stugeron) is indeed an antihistamine, although not often used for these properties. But certainly worth trying, I would double the dose in these circumstances. Very much doubt however that it is absorbed buccally (via the gums) though, you would have to get it into them somehow.

 

[awol]

On the odd occasion that I have suffered mal de mer I have popped Cinnarizine tablets between gums and cheek and have gained relief, so they are either absorbed buccally or I just needed a placebo.

 

[nick1568]

Glad to hear it all turned out ok in the end. It can be really scary, I had a similar experience with my fiancé once.

With a view to what if that happened at sea. There is of course only one thing do, put out a Pan Pan broadcast. Just like you dialed 999 for an ambulance and got quality advice and a swift response, HM Coastguard will provide the marine equivalent. I say all that with my CG cap on of course!
If the situation warranted it I wouldn't hesitate to put out a Mayday either, after all the criteria is grave and imminent danger to life. I really don't expect anyone would come and tell you off if it turned out to have been an over reaction.
HMCG has a standing arrangement with a couple of hospitals to provide Radio Medical Advice for situations like this, and of course the aircrew on SAR helicopters are all trained to paramedic standards. Our colleagues in the RNLI also have paramedics and doctors on the crew's of many life boats. Hopefully between all these people some help would be with you very swiftly indeed.

Anyway I'm very pleased things turned out for you in the end.

Nick

 

[BrendanS]

I've had experience of Coastguard response to Pan Pan Medico (which no longer exists officially as you know) When they had more information the response was immediate, and RNLI and helicopter on the scene swiftly

 

[Superstrath]

[ QUOTE ]
Regarding superstraths' post, I suspect he was suffering from ciguatera poisoning rather than side effects from mangos! The symptoms he describes are classic, he says they were eating a lot of fish, fish from that area (barracuda particularly) are notorious for this, and he was lucky to get away with it although from what he says, it sounded pretty awful! And he has denied himself, needlessly, mangoes for all these years!. Hope this helps

[/ QUOTE ]

Thank you for that insightful response, Rosbif. Ciguatera poisoning? That sure as hell wasn't in the Ship captain's Madical Guide. In fact, this is the first I've ever heard of it. It was horrible, the burning sensation on my palms and soles lasted about a week. This occurred in 1982, and nothing like it has happened since. I allowed the mangos back into my diet years ago.
These days I have to deny myself alcohol much of the time, which is much worse than skipping a bit of fruit occasionally.

Alistair

 

[georgeo]

classic symptoms. Not that ciguatera poisoning crops up this side of the atlantic, but one has to be very careful eating certain fish in tropical waters. I wonder whether this is widely known amongst our fellow sailors about to head for warmer climes with the ARC etc

 

[polantom]

While Stugeron/cinnarizine is indeed an antihistamine, a number of other travel sickness remedies are definitely not antihistamines. Preparations such as Kwells or Joyrides are antmuscarinics and it would not be advisable to take them for an allergic reaction.
It would be better to carry a specific antihistamine on board in addition to travel sickness remedies to avoid any confusion about whether a preparation was appropriate to take for a particular set of circumstances. Antihistamines such as Cetirizine and Loratadine are cheap and effective. Its a case of horses for courses. Cinnarizine is not the best antihistamine for treating allergies and tends not to be used for this purpose.
As for Epipen its a Prescription Only Medicine in the UK.
Also as has been stated genuine anaphylaxis is pretty rare. Unfortunately there is a bit of a panic reaction to allergies, real or otherwise, in certain people so please don't believe all the hype. As a pharmacist I dispense many Epipens every year and I counsel patients on how and when to use them and while some of them may be at risk of allergic reactions of varying severity, most of them have never actually experienced anaphylaxis and have just been given the pen as a just-in-case or occasionally to reassure the worried-well.
Glad to hear Mrs Kingfisher was okay