EPIPen, ideas on why it's in the kit?

[disassociative]

Here in TN; where the entry level designation is NREMT-B at the national level along with EMT-IV at the state level; the EMT is allowed to adminster epi 1:1000 via SubQ or IM; as well as to do blind insertions and start IV's. I find it strange that most places put such restrictions on EMT-B.

I remember when I got on with my first ambulance service as EMT-IV. It was all good, up until the checkoff. I had to go through all of the kits(jump kit, adult airway, peds airway, drug box, ambulance itself) and document all of it: Laryngoscope blade battery status, write down the expiration dates as well as record the nearest exp on ALL meds, LR, NS, D5W, INT Kits, IV Start Kits, you name it.)

I used to sit and wonder how anyone in ems could abuse drugs. After documenting them all day; the last thing I would want to see when I got home would be a syringe full of morphine, lol.

Anyways, don't get me wrong.. EMT-IV IS NOT EMT-I. We were NREMT-B, EMT-IV; however, we were required to spend a little more time in class focusing on more in depth physiology, etc.

I think epi admin in BLS form of course(not cardiac) should be employed across the span of EMS Personnel.

 

[Ridryder911]

So let me ask you this... what is the basic going to do, when after they adminster the Epi and the patient then goes into SVT or a rate of 160 to 180 (common after Epi administration)?

There is a reason, why medications should only be administered by those that can correct the adverse effect and correctly monitor the patient afterwards.

R/r 911

 

[Flight-LP]

I think epi admin in BLS form of course(not cardiac) should be employed across the span of EMS Personnel.

It is.........its called an Epi pen. Completely EMT proof, no possible way to OD someone. perfect for EMT-B's. SQ/IM epi and EMT-B should NEVER be used in the same sentence. as Rid said, once the dose is secrewed up by an overzealous and under-educated EMT-B, the consequences will be irreversible unless immediate ALS is available. Not much an EMT-B can do about SVT, V-tach, or an acute MI...............

 

[disassociative]

Well; consider the alternative:

Anaphylactic Shock: Throat closes, airway is compromised--patient dies.
I am by no means talking about an ACLS dose of EPI.

Also; most EMT-IV would be riding with a paramedic; and those on BLS--would have the sense to put an ALS unit on stand by in case of such an event.

As an EMT-IV we had epi-pens and the ability to dose and pull up the needed amount of epi.

0.01 mg/kg

Adult: 0.3-0.5 mg SC
Ped: 0.15 mg SC

weight / 2.2(0.01)

As I am sure most will agree; with the skill of medication administration
comes the responsibility.

and with this responsibility; lies the realization that sometimes you simply need ALS or if you are ALS someone who is trained more in depth. There is no shame in it. If someone's throat is closing from anaphylaxis and an EMT-IV administers epi--that buys valuable time.

I, in no way; shape or form advocate witholding ALS reponse simply because you think you can do a skill on your own. I am just saying--it is a handy thing to have around--that's all.

 

[Meursault]

What Flight-LP said. As a basic, all I'm doing with the Epi-Pen is buying 20-30 minutes to hand the patient over to ALS or get them to an ER for definitive care. That's enough for my level.

 

[BossyCow]

An Epi-pen is a tool. Those of us allowed (or mandated as in my state) to carry them have training on how to use it and when it is appropriate. I think since mandating it in our state, it is being over-used.

The type of allergic reaction that will require the intervention of an Epi-pen is pretty rare, affecting less than 3% of the population and most of them carry their own Epi-pens.

The original poster of this thread was an untrained, possibly future EMT-B, who had some rudimentary First Aid Training of a dubious nature. Putting an Epi-pen, of unknown origin (he thinks it might have been put there by an RN who works with him), unknown expiration date, and unknown dosage (adult or jr?) into a first aid kit, that is accessed by the general public, is irresponsible.

The value of this particular tool is irrelevent when you consider how it was being handled. I mean, chain saws are also valuable tools, but I'm not going to encourage 3rd graders to play with them unsupervised.

 

[Flight-LP]

Well; consider the alternative:

Anaphylactic Shock: Throat closes, airway is compromised--patient dies.
I am by no means talking about an ACLS dose of EPI.

Also; most EMT-IV would be riding with a paramedic; and those on BLS--would have the sense to put an ALS unit on stand by in case of such an event.

As an EMT-IV we had epi-pens and the ability to dose and pull up the needed amount of epi.

0.01 mg/kg

Adult: 0.3-0.5 mg SC
Ped: 0.15 mg SC

weight / 2.2(0.01)

As I am sure most will agree; with the skill of medication administration
comes the responsibility.

and with this responsibility; lies the realization that sometimes you simply need ALS or if you are ALS someone who is trained more in depth. There is no shame in it. If someone's throat is closing from anaphylaxis and an EMT-IV administers epi--that buys valuable time.

I, in no way; shape or form advocate witholding ALS reponse simply because you think you can do a skill on your own. I am just saying--it is a handy thing to have around--that's all.

Sorry, but I completely disagree with your written logic. First off, Sub-Q Epi administration is pointless in anaphylaxis / severe allergic reaction, it absorbs too slowly. IM in the lateral thigh is preferred due to its ability to absorb an average of 300% faster than a sub-q administration. Second, Epi is given too many times to too many patients that do not need it. Epi should ONLY be given for true anaphylaxis or a severe reaction i.e. angioedema, wheezing, pharyngeal edema. Not because someone itches or has a rash all over their body. And unless they are knocking on death's door, no one over 40 should get it with a known cardiac history. Many Paramedics have issues differentiating the levels of reaction, much less try to have a basic do it. That aside, there is still the basics of pharmacokinetics, again a topic that many medics don't understand, one that basics certainly won't regardless of the time spent in the "IV" training class. Here is where the problem lies........................

If a pt. is in anaphylactic shock, neither will work. If the central organs are hypoperfused, do you really think the vastus lateralis is getting any level of perfusion. NOPE! You need IV access and IV Epi (amongst other interventions). In other words, you need an ALS responder. BLS response and attempted treatment in the severe allergic reaction or anaphylactic patient is not beneficial to a patient. These patients REQUIRE ALS, there is no reason to afford them anything less.

Sorry to rant, but we must stop trying to justify the less educated being able to perform pseudo-ALS. There is a level of education and certification to address this critical level, it is a PARAMEDIC. Watering down education is one of the major demise's of our industry.................It sickens me to see people just "go with it" falsely believing there is a benefit......................

 

[disassociative]

Well; here is the last thing I am going to say on the topic; as I have run reports to enter in.

in TN Emt-IV is encouraged to look for epi pen on the pt. SubQ/IM epi is what is kept on our ambulances in the BLS drug line. This is how TN has set it forth for us to follow--as to the true logic of the medical directors/committee that implemente this provision into the scope of practice, I have no idea what their logic was. However, I(in my personal opinion) think it is a good thing.

 

[Gbro]

I was going to wait and ask our medical director about EPI/Anaphylaxis/Cardiac arrest. But since there seems to be a great deal of information here, I’ll try here and also bring it up with Doc.

Over labor day weekend, I had 2 bee sting reactions where I used the Epi pen.
Enroute to the 2nd sting, as the call came in "Bee sting and the party thinks he is having a heart attack"

21 miles to scene, and no contact with 1st Responder's for Pt. update.
We were discussing whether there would be any benefit in administering the Epi if the Pt. is in cardiac arrest upon our arrival?

We had ALS enroute, and decided to try and contact Medical control for directions in case of arrest.

 

[Ridryder911]

Did the bee stings present a true anaphylaxis or a reaction? There is a true difference in anaphylaxis (stridor, laryngeal edema, with severe swelling of the periorbital area, tongue, and of course shock symptoms) or reaction: uticaria, swelling, itching.

Epi injected sub-q and muscle is worthless in severe conditions. Actually, ironically it takes sub-q Epi approximately 15-30 minutes to work, which in true anaphylaxis is usually too late. The reason is simple. One has to have good circulation enable to distribute medication sub-q and muscle (shocky or poor circulation, cardiac arrest does NOT have enough circulation). This is the reason analgesics and medications should never be given I.M. or Sub-q for those in shock, burns, etc... because when and if they do begin to perfuse, the medication will then be distributed. i.e. burn patient that recieves Morphine Sulfate IM, with a poor blood pressure only later to be resucitated then the Morphine will be pumped through the body... boom..bottoms out the pressure.

There is much more to treating patients than just adminstering a medication and hoping for the best. One needs to know all the circumstances and methodology of pharmodynamics and pharmokinetics of how they and where they operate. This is the reason for increased education and the opposition of us that believe only in very and very few rare circumstances should untrained (BLS) be allowed to administer medications.

R/r 911

 

[Gbro]

No question on Sept. 2ND Pt.
presented with O2 sat. 78%, Chest pain, Dyspnea, stated feels can't breath.

This pt did seized, 2 min post epi administration. Medics on intercept stated that its not all that unusual. Pt in seizure 1 min(approx). 5 min (post Epi) stated, feel a lot better, feels like its only a moth in throat now.


Question Sept 4Th Pt.
Pt was unresponsive but was breathing. Looked like a lobster just removed from hot water. started to respond 3 min post Epi.
Later in ER pt. stated "funny thing, i never had any trouble breathing"?? did know what was happening, ie. epi stick but couldn't feel the stick.
Just don't know, Looking forward to Review medical director.

 

[Ridryder911]

No question on Sept. 2ND Pt.
presented with O2 sat. 78%, Chest pain, Dyspnea, stated feels can't breath.



Question Sept 4Th Pt.
Pt was unresponsive but was breathing. Looked like a lobster just removed from hot water. started to respond 3 min post Epi.
Later in ER pt. stated "funny thing, i never had any trouble breathing"?? did know what was happening, ie. epi stick but couldn't feel the stick.
Just don't know, Looking forward to Review medical director.

Tell them to stay away from Iodine and any IV dyes. Since the shellfish is high in iodine and usually this is what they are allergic to. There is a specific reaction in the throat with swelling called angio neurotic edema. Usually, H2 blockers such as Benadryl, Pepcid, or Zantac is added as well as steroid(s) such as Decadron or Solu-Medrol, etc.


R/r 911

 

[KEVD18]

...We were discussing whether there would be any benefit in administering the Epi if the Pt. is in cardiac arrest upon our arrival...

im confused. we you discussing the use of epi in general during an arrest, or using an epi pen for a person in arrest?

 

[njcoldone]

epi-pen

New Jersey has given the go ahead to carry epi on bls units with the approval of the medical director-- after proper training . In some obvious cases it very well could save a life . There are parameters that must followed for the storage of and use of same. recently I heard a dispatch for a neighboring squad to respond to a bee sting and pt. administered (pre-arrival) epi even though they did not present with signs or symptons of anaphlaxis . In my opinion that is the downfall of having it available to bls. Of course it is no different than say nitro administration (assist) , you must have proper training and apply your skills. Do the benefits outweigh the risk ? I would have to guess that anyone with an anaphalactic reaction would answer a definite yes are there risks involved of course. Should an R.N. be carrying epi-- I would question how they received the prescription (unless it has been prescribed to them for personal use) and if they administer it without medical approval there certainly could be serious repercussions.

 

[Gbro]

im confused. we you discussing the use of epi in general during an arrest, or using an epi pen for a person in arrest?

Kev;
When we were in transit to the call, 20+ min and the call was for a Bee sting & the Pt. thinks he is having a heart attack.
So we were discussing what to do in the event "this" pt. is in cardiac arrest.


We had ALS enroute, and decided to try and contact Medical control for directions in case this is an arrest.

Sorry if i confused you, Its usually me that suffers from confusion.

 

[Ridryder911]

Kev;
When we were in transit to the call, 20+ min and the call was for a Bee sting & the Pt. thinks he is having a heart attack.
So we were discussing what to do in the event "this" pt. is in cardiac arrest.


We had ALS enroute, and decided to try and contact Medical control for directions in case this is an arrest.

Sorry if i confused you, Its usually me that suffers from confusion.

Now, I am thoroughly confused. It does not matter if the arrest was caused by Anaphylaxis or by having an AMI, Epi sub-q would not be beneficial due to the poor circulation and distribution. IV form would be beneficial due to ability of catecholamine response.

R/r 911

 

[Gbro]

It does not matter if the arrest was caused by Anaphylaxis or by having an AMI, Epi sub-q would not be beneficial due to the poor circulation and distribution.

Define beneficial,
and the Epi-Pen is an IM injection.
I myself would define "beneficial" 2 ways. Beneficial to Pt., and beneficial to our/Us as we did everything we could do.
Wouldn't have to look at that hole being dug and think now if we would have just....., Of course that is why we don't put them up on platforms like some cultures use to do.

Pop used to say,
A carpenter had it worse, every time he drove by that house he built, he could see his mistakes, EMT's and Doc's, mistakes are buried.

 

[njcoldone]

The use of epi or should I say the potential possession and use of by emt's has become controversial . We have been properly trained during emt certification so the use of isn't any different (or assist with ). The problem I see is that it has become more available to UNTRAINED personnel. Because it is now carried by basics some may believe it could do no harm but only good--Wrong Wrong Wrong. The adverse effects could include a fatal reaction (A friend had this happen to pt. who used their brothers epi). Does this give a small percentage an advantage to reverse the effects of anaphlaxis of course, the same as a defib for cardiac , but please be trained .

 

[bstone]

Sorry for coming in late to this conversation. How about using the epi-pen for people having severe asthma attacks (unconscious). Since it dialates the lungs (is a sympathomimetic), might it be used in these cases?

Where I was trained as an Intermediate (New Hampshire) we draw up our own Epi (1:10,000 for IV, 1:1000 for IM/SC) I have protocols for using an abuterol neb for asthma, but I theorized that Epi can be used in addition for severe cases. Obviously I would never just do something and always get MedControl orders for anything outside protocol.

Thoughts?

 

[Ridryder911]

Define beneficial,
and the Epi-Pen is an IM injection.
I myself would define "beneficial" 2 ways. Beneficial to Pt., and beneficial to our/Us as we did everything we could do.
Wouldn't have to look at that hole being dug and think now if we would have just....., Of course that is why we don't put them up on platforms like some cultures use to do.

Pop used to say,
A carpenter had it worse, every time he drove by that house he built, he could see his mistakes, EMT's and Doc's, mistakes are buried.

Okay, nothing personal, but it is apparent you do not understand pharmacodynamics or physiology very well. By administering 1:1,000 Epinephrine into the subcutaneous tissue (fat) it will be stored in such or if it even reaches the muscle (usually epi pens never reach muscle tissue), and until the time peripheral circulation is restored (if ever returns). Just because you have given the medication does not mean it will be circulated at that time. Beneficial is NOT a term for the provider, rather it is a term used for the patient. There is really a reason for them not to make such recommendations for administering in any other conditions, do you not think that has not been considered, by those that truly understand medicine?

Remember, in shock syndromes, and poor circulation that the present conditions in the predominant capillary circulation is immediately shut down. Hence, the reason the skin becomes pale in shock state and the precapillary & post capillary sphincters close and the blood supply is reduced in the circulatory system due to the sympathetic (adrenergic) response. Even if by chance it does so happen reach the muscle area it still will be in poor circulatory area, again since skeletal muscle blood supply is reduced. Ever hear of lactic acid build up in post shock and post cardiac arrest? The epinephrine strength; again is 1:1000 not 1:10,000 (nine thousand times stronger than the IV form) will be in the fat cells and when & if the pressure and peripheral circulation is obtained again the epi will be released.

Can one imagine a patient that responded to resuscitation measures, and the heart (which is already damaged) for someone to give an additional 9 boluses of Epinephrine for no reason? What effect would this have on an already damaged heart? (hint.... tachycardia = increased stress on the heart = increased oxygen demand on the heart = increase AMI size = potential death)

So defining the term beneficial is not that vague in medicine. One sees it often in medical literature. So when one sees such term ..." beneficial".... this means, does it really outweigh the risks or dangers involved? Not, in regards to the provider. Sometimes, the risks does not outweigh the treatment: hence the art of practicing medicine. Is those risks worth it? Hence the need to know the science and all involved in medicine before administering any medication(s). Unless you are educated (NOT trained) in such, one should not be administering medications. Giving the form or admininstering the medication is not difficult part, knowing exactly when, how, and what is really occurring in the body, as well as all potential consequences are.

The same analogy could be true in comparing a pharmacy tech to the pharmacist. Sure it is easy to place pills in the bottle, or to hand the dosage packet to a patient/customer, but wouldn't you rather have the pharmacist review and be sure it is correct knowing that it is exactly the right medication strength, dosage, and does not interact or potentiate with any of your other medications?

If you want the responsibility of making those decisions, then go to school for such. That is why there are licenses, and control ... it is not that "simple".

R/r 911