I’m writing a story about a person who has an allergic reaction to shellfish while eating in a restaurant, and I had a lot of questions:
1-What would the shock symptoms look like?
2-Would a high end restaurant have an epi-pen available, or would they have to wait for the EMTs to arrive?
3-Where does the epi-pen injection go? Arm, leg, thigh, belly, butt?
4-How long would the victim have to stay in the hospital? Will they be fine immediately, or what would the symptoms be like for the next day or so?
I can only speak from my experiences with anaphylaxis, for me brought on by bee stings.
- I get hives and massive itching, then my throat starts to close and I have trouble breathing.
- Epi-pens are prescription items. Restaurants don’t generally get to administer medicine. If someone is very allergic, they carry their own Epi-pen.
- Thigh
- I stayed in the hospital for a few hours. Once the epi-pen and anti-histamines were on board I recovered very quickly, although I had a headache for a while.
Yup. Itchy throat first, then eyes, then everything swells shut. Blood pressure drops dramatically. Maybe hives. EMTs will have epinephrine, maybe not as an epi-pen. I’ve gotten lax in carrying mine–I know the cause and haven’t had an issue in 30 years (at least not to that extent). The recovery is very quick, although BP goes pretty high for a bit. You get very focussed on breathing…
What they said, plus:
- Wheezing and coughing that might initially be mistaken for a coughing fit or some irritation. Swelling of the face, especially around the eyes and lips; the onset of this may precede breathing difficulties, or may not.
- Thigh, through clothing if necessary - as long as it’s not something that will impede the sharp end (advice my wife was given: Don’t waste time taking off tight jeans - inject through. If the clothing can easily be lifted or pushed aside, then inject into bare skin)
If it helps, based on my experience at a private school:
- all vulnerable pupils carried their own epi-pens
- their classmates were given directions on how to inject (if the pupil themselves couldn’t)
- the school nurse had epi-pens
From the teaching presentation I wrote back in '07 or so:
How do adult food allergies usually present? Signs & Symptoms:
Skin: Urticaria and angioedema
GI Tract: “GI anaphylaxis” and Oral Allergy Syndrome
Respiratory: Bronchospasm and rhinitis
Anaphylaxis: “a bad thing……”
Skin signs & symptoms:
The skin is a common target organ for allergic responses to food. Acute urticaria is characterized by pruritic, transient, erythematous raised lesions, sometimes accompanied by localized swelling (angioedema). AKA hives. Chronic or recurrent eczema may be exacerbated by a food allergy also. Food allergy accounts for up to 20 percent of cases of acute urticaria. Lesions usually occur within one hour after ingestion of or contact with the causal food.
GI tract signs & sx: OAS
The oral allergy syndrome (OAS) is characterized by pruritus and edema of the oral mucosa occurring after the ingestion of certain fresh fruits and vegetables. The symptoms rarely progress beyond the mouth. Gastrointestinal “anaphylaxis” occurs shortly after the ingestion of an implicated food and include nausea, vomiting, abdominal pain and diarrhea.
Respiratory Signs & Symptoms:
Bronchospasm. Food-induced bronchospasm is an IgE-mediated illness that may result from the ingestion of a causative food or from the inhalation of vapors released during cooking or in occupational settings. The prevalence of food-induced wheezing in adults with asthma is less than 2 percent.
Rhinitis: nasal congestion, rhinorrhea, sneezing and pruritus The prevalence of food-induced allergic rhinitis, even among patients referred to allergy clinics, appears to be less than 1 percent. Gustatory rhinitis is rhinorrhea caused by spicy foods. This is not an immunologicreaction; it is mediated by neurologic mechanisms.
Anaphylaxis:
A dramatic multiorgan reaction associated with IgE-mediated hypersensitivity. Fatal food-related anaphylaxis appears to be more common in patients with underlying asthma. The foods most often responsible for food-induced anaphylaxis are peanuts, tree nuts (walnut, almond, pecan, cashew, hazel nut, Brazil nut, etc.) and shellfish. Patients who experienced fatal or nearly fatal food-induced anaphylaxis had almost immediate symptoms
The restaurant would not provide or administer the epi-pen, unless an employee went rogue using her own epi-pen. (If your character didn’t know he was allergic and wouldn’t have his own, this could be a workaround. But the employee would definitely not be acting in accordance with policy. Another possible hero might be a customer at a nearby table.)
Yeah–it would be interesting to explore the liability around this, as I understand that the negative effects of epinephrine are totally eclipsed by the potential positives. However, you could definitely induce a heart attack or stroke in the wrong person. My BP went from about 80/50 to 160/110 (or close–it was a long time ago).
I think from a liability standpoint, it’s pretty straightforward. There’s no duty on the part of the restaurant to attempt a rescue, but once you attempt it, you’re potentially liable for seeing it through. Some places have good Samaritan laws that might protect a failed rescuer, but probably not to the point where it’s safer to try than not to. It’s unfortunate.
That’s the rub–if you’re in anaphlaxis you’re on the edge of death (I certainly was), but if you pop a vessel and stroke out, you’re dead. Probably safer to give the victim some benadryl suppositories!
1-What would the shock symptoms look like?
Mild symptoms would be hives on the skin, itching, sneezing, slight wheezing. More severe symptoms are vomiting, collapse due to low blood pressure, wheezing, swollen face or swollen throat making breathing difficult.
2-Would a high end restaurant have an epi-pen available, or would they have to wait for the EMTs to arrive?
I doubt it. They are pricey and seldom used.
3-Where does the epi-pen injection go? Arm, leg, thigh, belly, butt?
Muscle. Thigh works well. Others more rarely used.
4-How long would the victim have to stay in the hospital? Will they be fine immediately, or what would the symptoms be like for the next day or so?
Often gone in a few minutes to hours. Symptoms might return so it is traditional to observe sicker patients for four hours or more and admit patients with more serious symptoms, other chronic conditions, are very old or young, or (if severe) live alone and have no one to observe them.
Also important to note: Like first aid for many other life-threatening conditions, an epi-pen does not make the victim recover. It buys time until the professionals can arrive.
Interestingly/alarmingly, airlines do not carry epi-pens on flights and may not even stock epinephrine vials, which would likely require a medical professional to administer.
Doctors (Me) been called to assist four times while I was flying. I would respond, and after dealing with the problem would usually be greeted by other doctors less used to dealing with acute problems who did not put up their hands right away.
My recollection is limited, but the kits I saw included (IIRC) Tylenol, Gravol, epinephrine, Ativan, a stethoscope, a blood pressure device, a thermometer and basic blood sugar stuff. This might not be typical and I might be wrong.
Thanks everybody, for the responses.
Since some folks have already spoken of what this is like from the inside I though I’d mention what it looks like from the outside.
I’m told that when I had an anaphylaxis episode my face turned bright red and there was swelling of my lips/mouth/eyes. Then the hives broke out. My speech became slurred and thick due to swelling of my tongue/mouth/throat.
Other symptoms that occur can include vomiting and spontaneous release of urine and feces as the anaphylaxis reaction continues to worsen.
I’m told that it looks quite frightening to observers, not just to friends and relatives but also strangers.
When I had my worst episode I realized the next morning I had some rather nasty scratches on my neck. My spouse told me I’d been clawing at my own throat while struggling to breathe. Also had lots of other scratches because in addition to everything else I had the most hellish itch all over my body. The sort of itch where the pain of clawing strips of your own flesh off feels better than the itch and the pain comes as a relief.
Nope. Restaurants would not stock those. Either hope the EMT’s get there quick (they don’t carry epi-pens, either, but they do have equivalent medications - speaking from experience here) or hope there’s a bystander with one whose willing to use it on a stranger.
Thigh is very much preferred. As noted up thread, don’t wrestle with clothing, you can inject through the clothing. Time is critical here. You want it to go into something “meaty”, a big muscle mass.
An epi-pen (or equivalent) will have an almost immediate effect, but it does take a bit of time for things like swelling to go down. Epi-pens only last about 15 minutes, but allergic reactions can continue for three days, so a second epi-pen might be needed until other medications (generic Benadryl and steroids, usually) take effect. I think I also got something additional by nebulizer for my breathing.
After my worst episode I was held 6 hours in the ER then released to go home with my spouse, who was instructed to keep an eye on me.
How I felt while leaving the hospital was… mixed. Epi-pens and the like are stimulants, Benadryl is the opposite, and steroids in high doses (and 120 mg of solu-medrol is definitely a high dose) can also alter your mood although that usually takes a day or two to really get going. Also, had just had a near death experience. But my breathing was back to normal, I was no longer itching and I felt sort of twitchy and jumpy.
There’s no duty provide an epipen for someone in anaphylaxis who does not have their own. Good Samaritan laws don’t go so far as to say that you must use your own $800 epipen (thus leaving yourself vulnerable) on the chance that this other person needs one, but you don’t actually know for sure.
The only person who could be faulted for not providing an epipen for someone is a parent who did not provide one for their own child, or someone in loco parentis who forgot to bring a child’s pen (or the pen of someone who was not a child, but an adult in need of supervision).
I’m not sure if you meant this as a correction to what I wrote, but to clarify, I’m in agreement the restaurant has no duty to administer an epi-pen. I’m saying if the OP is writing a scene where a character needs an epi-pen and doesn’t have one, it’s plausible that an allergic server or fellow customer might come to the rescue, even though they would be taking a risk in doing so. Good Samaritan laws in the U.S. generally protect those who try and fail to help; contrary to the portrayal in Seinfeld, they don’t impose an obligation to help.
I did not see it mentioned yet, but you don’t really need to be sure that an epi-pen is needed. If you think it might be needed for anaphylactic shock, use it.
Maybe it is just a panic attack, maybe something else, you are not likely to harm someone by using an epi-pen when it isn’t needed.
They are going to get an adrenaline rush, blood pressure will go up temporarily, maybe quite a bit, it may take some time for the person to calm down, etc. If you think that you have used an epi-pen in error the person should seek medical help just in case. The same as if they had needed the pen, they should seek medical help too just to be sure there isn’t something more.
Do not be afraid to use it if you think it is needed. Not using it could have severe consequences. Using it when not needed won’t.
“But dad! I was just high!” Whack him in the thigh with the pen, that’ll wake him up.
Having administered epinephrine thousands of times, the above is generally true. It can often save lives and at the small dose supplied is unlikely to cause harm. However, I would want to see enough symptoms to justify giving it. In the setting of a known history, I would definitely give it for the combination of hives and vomiting, or wheezing or any breathing change, or low blood pressure or faintness, or any swelling in the neck, face or lips. If unsure, give the medicine.
There’s a joke (can’t remember which comedian), apropos but kind of in bad taste (apologies in advance).
“My friend Mock died the other day. Before he did, he kept trying to hand me his Epipen. He must have really wanted me to have it. He was really excited; waving his arms all around. Of course I’ll always treasure it…”