Age: 10.0
Sex: M
Vaccine: VARCEL
Symptoms: Pruritus, Rhinorrhoea, Secretion discharge, Throat clearing, Tryptase
Clinical narrative: Called to evaluate patient about 3-5 minutes after he received the Varicella vaccine. He was in his post-vaccination waiting period when the clinical staff recognized that he was becoming uncomfortable. He had been very anxious about receiving this vaccine, especially given his transplant status -  he had always been told that he shouldn't receive a live vaccine.   On initial survey, he complained that he throat was bothering him. He was sweating and felt like he had some difficulty breathing. His sclera were injected. He was able to talk, alert, and sitting up on his own. His vitals showed BP 110/64, HR 110, RR 28, SpO2 initially was 93-94%. I asked to keep the continuous vitals monitoring on, and had the clinical staff get diphenhydramine 20 mL/50mg orally (taken very slowly from 1525-1540 - honesty I'm unsure if he was able to receive the full dosage - he certainly drank at least 75% of it). We had some difficulty getting him to take it due to the taste, but he was drinking water. He did spit out his oral secretions a few times, no emesis occurred. He said that he needed to blow his nose 2-3 times.   When he coughed to clear his throat, mom and I noticed that he sounded like he had increase mucous and wheezing, which I confirmed by listening to him. I ordered 4 puffs of albuterol at 1530. He does not have a history of asthma or wheezing. We used a spacer and he easily took 4 puffs of an albuterol HFA. He responded positively to the albuterol, sitting up better and his coughing resolved. On exam, his respiratory rate and wheezing improved. However, his pulse oximetry dipped to 92-93% and he developed some increased itchiness and urticaria along the back of the neck and scalp. His pulse oximetry at one time briefly dropped to 89-90%ile post-albuterol administration, but returned to 92-93% and stabilized. When asked multiple times throughout the event, he never felt dizzy or light-headed like he was going to faint. He remained oriented. I reviewed our situation with the mother.   After reviewing and obtaining permission from the mother, we decided to administer epinephrine 0.3 mg IM using an Epipen in the right outer thigh (quadriceps). I administered this at 1540 with MA confirming the dosage and mother present. He significantly improved within a minute, talking more, and felt better able to swallow. His breathing and oxygenation improved to 97-98% and maintained. His BP continued to stay in the 100-110s/60s. His heart rate initially increased to 120,  then went down to the mid 90s. His respiratory rate was in the 20s without more wheezing or retractions. He felt better, but still looked uncomfortable. When asked, he complained some about his stomach hurting - on exam, he was non-tender to palpation and non-distended. Since he was more alert, maintaining good vitals, his perception of throat discomfort was improved, and he was no longer wheezing, I decided to hold off on a second dose of Epinephrine.    I discussed disposition with mom and we felt more comfortable having him transported to hospital via ambulance. We contacted EMS, who arrived within 10 minutes. I was at the bedside for the whole event monitoring his vitals and reassessing him. I personally gave report to the ambulance team upon arrival. He was able to stand easily and walk on his own to the ambulance stretcher to lie down. They left clinic at 1625 to transport him to hospital Main Campus.