Acute Onset, Pruritic Rash


• Scene – vitals

• En route – refusal

• Hospital – refusal


• Response to treatment – Refusal.

• Disposition – Spoke with Online Medical Control (OLMC), who advised that the best thing for patient was Benadryl and to follow up with PCP for allergy testing. Dr. ordered 12.5mg Benadryl PO for patient every 4 hours, call back if any shortness of breath develops.


Elliot Williams, Paramedic Woodburn Ambulance

David Sheridan, MD Associate Professor Oregon Health and Science University

Vladamir Novikov, Paramedic Woodburn Ambulance


David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center


• Rash
• Urticaria (hives)
• Food allergy

Differential Diagnosis

• Allergic reaction

• R/o anaphylaxis

• Stevens-Johnson syndrome (target lesions)

Patient Workup History:

• Caregiver states – Ongoing food allergy problems cause a full body rash. Unknown what the allergy is and having a hard time following up with primary care due to insurance push-back. Patient rashes are worse today and very itchy; patient is scratching, screaming and not able to sleep.

• Parents state that patient consumed quail eggs today but they were mixed into meatballs; don’t know if she is allergic.

• No shortness of breath, patient is irritable but otherwise acting normal.

Physical Exam:

• Rash all over, slightly raised

• GCS – 15

• EKG – stach

Editor’s Notes

This looks like urticaria – raised, erythematous lesions that can be anywhere on the body. This is a common rash with exposure to allergens; possibly food, in this case. The presence of wheezing may be difficult to detect due to the crying. However, the airway seems quite intact!

-David Spiro, MD

Standard Approach Notes

• Rashes are very common occurrences in the pediatric population and can be due to multiple etiologies

• Food allergies are a spectrum and can be very severe, such as anaphylaxis, due to the systemic exposure of the allergen in the gastrointestinal tract. Signs of anaphylaxis include full body rash, difficulty breathing (stridor, wheezing, etc), emesis, abdominal pain, facial swelling or hypotension.

• If signs of anaphylaxis are present, the immediate treatment is an EpiPen, if available. Use Epinephrine 1:1000 (.01mg/kg IM) if an EpiPen is not available.

• Children without anaphylaxis benefit from an antihistamine, as ordered in this case. EMS personnel should also provide caregivers with a description of what anaphylaxis looks like, in case there is a delayed presentation. At the hospital, depending on the extent of exposure and symptoms, a child may also receive steroids.

The prehospital suggested approach is:

• Ensure airway protection without difficulty breathing.

• If wheezing (expiratory usually), patient benefits from albuterol. Severe respiratory distress needs IM epinephrine.

• If stridor (inspiratory usually), patient benefits from racemic (or regular) epinephrine.

• Any signs of anaphylaxis in a child indicate need for an EpiPen (or 1:1000 epinephrine 0.01 mg/kg IM)

• Children <30kg receive EpiPen Jr (0.15 mg); Children >30kg receive the standard EpiPen (0.3 mg)

• An IV may only be required if significant vital sign changes are noted; e.g., hypotension that need fluid resuscitation

Suggested references

The Immune System and Immunologic Complications

Food Allergies


• Gender: Female

• Age: 2 years

• Height: Not Available

• Weight: Not Available


• Temperature: Not Available

• Blood Pressure: Not Available

• Heart Rate: 185

• Respiratory Rate: 30

• Pulse Oximetry: 100% RA Signs and Symptoms Red, slightly raised, full-body rash; irritable

History Medical

• Allergies: Eggs, dairy, grain

• Dispatch info: Possible allergic reaction.


• Lives with both parents


• OTC non-drowsy antihistamine

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