arrythmia4 - showman

[ArchivalUser]

A 24-year-old third-year medical student is brought to the emergency department from the operating
room after she began to have trouble breathing after she put on her gown, latex gloves, and mask. This
was going to be her first time "scrubbing in" to a case on the first day of her surgery rotation. Another
medical student who was "scrubbed in" to the case, tells you that the she was grasping at her throat
and attempting to rip off her gown. She is now on a stretcher, gasping for air. She is brought into a
room and all of her clothes are taken off, revealing red hands and an eruption of well-circumscribed,
erythematous, raised lesions covering her entire body. Her blood pressure is 70/50 mm Hg, pulse is
110/min, and respirations are 45/min. She has marked laryngeal edema and audible wheezes. The
other student says that this is the second day of their third year, and that the only other patient contact
that they have had was during the first year when they went as a group to evaluate a patient in
respiratory isolation. At this time the most correct statement about her condition is:


A. Her rash is unrelated to her respiratory symptoms

B. Her symptoms are caused by the anxiety and stress from the first surgical experience

C. Her symptoms are due to an infectious pathogen

D. Her symptoms are the result of bioactive mediators released when exposed to an
antigen

E. She should be given indomethacin immediately to reduce the respiratory symptoms

[ArchivalUser]

dd latex allergy

[ArchivalUser]

Yes Latex allergy DD

[ArchivalUser]

ddd

[ArchivalUser]

d...

[ArchivalUser]

agreed with all !!!dddddddddddddd

[ArchivalUser]

The correct answer is D. This patient is experiencing an anaphylactic reaction, which is a
life-threatening response in a sensitized individual to a specific antigen, most likely the latex in the
gloves, and is associated with the release of lipid mediators, secretory granule preformed mediators,
and cytokines. The manifestations typically occur within seconds to minutes of exposure and include
respiratory distress, vascular collapse, urticaria and angioedema, gastrointestinal symptoms, and
shock. The reaction involves IgE-dependent activation of mast cells, basophils and the release of
mediators such as histamine, cytokines, and lipid mediators. The immediate treatment involves the
ABCs (intubation, oxygen, and intravenous saline), epinephrine, a vasopressor agent such as
dopamine, an antihistamine such as diphenhydramine, and glucocorticoids to alleviate later
recurrence of symptoms.

It is incorrect to say that the rash is unrelated to her respiratory symptoms (choice A) because they
are both associated anaphylactic reactions. Anxiety and stress from the first surgical experience
(choice B) may be associated with vasovagal (vasodepressor) syncope, which is the cause of the
common "faint". It frequently occurs during periods of stress or fear and often occurs in medical
students during new experiences. The symptoms include hypotension, bradycardia, nausea, pallor,
diaphoresis, and a sudden, transient loss of consciousness. Lying down and elevating the legs
reverses the symptoms. This is very different from a life-threatening anaphylactic reaction where
hypotension, tachycardia, respiratory failure, shock, and skin manifestations occur. Assuming a
supine position during an anaphylactic reaction does not reverse the symptoms.

This patient is most likely experiencing an anaphylactic reaction from the latex gloves, not an
infectious pathogen (choice C). Pathogens may cause septic shock by releasing toxins that then
activate cytokines, platelet activating factors, arachidonic acid metabolites, and humoral defense
systems. This manifests as hypotension, tachycardia, changes in mental status, and cold extremities.
The laryngeal edema and specific rash that this patient has are more consistent with an anaphylactic
reaction than septic shock.

She should definitely not be given indomethacin immediately to reduce the respiratory symptoms
(choice E) because it is a nonsteroidal anti-inflammatory drug that may cause similar life-threatening
respiratory reactions in patients with asthma. You do not know her medical history. Also, this is not
part of the management of anaphylaxis, which includes epinephrine, saline, vasopressors, and
intubation.