Chief complaint: sent from Urgent Care for sternal fracture

HPI

• 79 yo female sent from Urgent Care due to further workup of a sternal fracture
• The patient was in an MVC 2 weeks prior, did not seek medical attention at that time 
• Chest x-ray at UC showed possible sternal fracture, sent to ED for CT of the chest

ED course

• CT scan of the chest abdomen and pelvis with IV contrast, ECG, analgesics, labs including troponins ordered
• After CTs, pt became very anxious, diaphoretic, tachypneic, repeating “I…can’t…breathe”

Exam

• Airway:Patent, no tongue, lip or uvular swelling, patient unable to speak
• Breathing: Minimal air movement b/l, +stridor audible when stethoscope placed over trachea
• Circulation: BP: 145/91, HR: 114 02 sat: 96% RR: 32

Differential:

• anaphylactic reaction, severe bronchospasm, undiagnosed cardio-pulmonary traumatic injury, ACS

Management

• IV access X2, 02 by facemask, cardiac/pulse oximeter monitor, 12 lead ECG, point of care glucose
• Medications: 0.3 mg 1:1,000 IM epinephrine, 50 mg IV diphenhydramine, 40 mg IV famotidine
• Noi improvement after initial medications 
• Epinephine dose repeated, placed on Duoneb by nebulization
• Repeat vitals: BP: 190/110 HR: 122 RR: 34 O2 sat: 95%
• 2 minutes later, patient becomes somnolent
• Decision made to immediately intubate patient with concern for ongoing anaphylaxis with impending airway compromise
• Patient was intubated on first pass, noted mild airway edema 

Case Resolution 

• Pt was admitted to the ICU and extubated the next day
• Of note, the patient had no other traumatic injuries and was ultimately discharged home
• IV contrast was added to her allergy list

Teaching Points

• Anaphylaxis to IV contrast is rare, but is still a possibility!
• Remember to re-dose epinephrine every 3-5 minutes, or start a continuous infusion for severe reactions
• Special considerations for intubation: run a  pre-intubation checklist!
• Have the entire plan for intubation verbalized including cricothyrotomy
• Perform a "double set-up" with one provider attempting orotracheal intubation while the second prepares for cricothyrotomy
• Make cricothyrotomy "part of the plan" to remove the barrier of making the decision in the moment
• If iniital measures including repeated doses of ephinephrine fail, intubate early before edema causes complete occlusion of the airway