# SQ Epi for asthma



## rhan101277 (Jun 8, 2009)

I was talking to someone who had done this today.  It really helped the patient.  I also wonder about it causing increased oxygen demand on the heart in a already hypoxic patient.

Airway and breathing come before circulation though and if it works as intended everything should come back to normal before to demand goes up, especially in small doses.

Anyone ever use this for asthmatics, where the patients respirations are so bad that they couldn't talk and albuterol wasn't a option?


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## 46Young (Jun 8, 2009)

Yes. Our protocols allow for epi SQ if all else fails, including albuterol/atrovent, solu-medrol, and a mag drip. Epi will increase myocardial oxygen demand for several reasons, and should be used with extreme caution for any pt with a cardiac Hx(I'm generalizing). That being said, I'm prepared to admin epi if nothing else will work, and be prepared to deal with the consequences. I'll give it, if the pt will likely die otherwise. As far as increasing the myocardial oxygen demand for the hypoxic pt, the demand will be (hopefully)rectified by an increase in oxygenation, by dilating the bronchioles. If the pt is really tight, then nebulized meds may not be delivered properly. Epi has worked great for me, although I'm vigilant for any untoward reactions. I'm trying to keep the explanation purposefully simple. There's much more to it than what I've touched on.


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## vquintessence (Jun 8, 2009)

I personally do not and wouldn't recommend it.  Epi is a very potent, non-selective sympathomimetic (alpha and beta1&2).  You're subjecting your pt to quite a physiological workout; the heart, kidneys, pancrease, GI and immune system will all take a beating.  Sending a younger pt without prior cardiac hx into runs of Vtach isn't unheard of.  PM me if you want the "generalized specifics" (love using that phrase!).

What other options does your medic have?


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## drdique (Jun 8, 2009)

*Racemic?*



vquintessence said:


> I personally do not and wouldn't recommend it.  Epi is a very potent, non-selective sympathomimetic (alpha and beta1&2).  You're subjecting your pt to quite a physiological workout; the heart, kidneys, pancrease, GI and immune system will all take a beating.  Sending a younger pt without prior cardiac hx into runs of Vtach isn't unheard of.  PM me if you want the "generalized specifics" (love using that phrase!).
> 
> What other options does your medic have?



Just wondering if anyone in the states is using racemic epi nebs in cases of status asthmaticus?

Also the initial post mentioned the albuterol, is atrovent (ipratropium bromide) used frequently in conjunction with the albuterol neb in the United States?

As for my opinion of epi with severe asthma, i agree with both 46young and vquint.  epi should ONLY be considered if all else has failed and the patient is toiletting. I'd rather give Epi than have to tube them when they drop. Compared to treating anaphylaxis, asthmatics are far more susceptible to the systemic effects of the epi and must be diligently monitored. For asthmatics we usually start at half the 0.01mg/kg dosage used for anaphylaxis and go SC instead of IM to give a slower onset allowing the other body systems to compensate


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## VentMedic (Jun 8, 2009)

drdique said:


> Just wondering if anyone in the states is using racemic epi nebs in cases of status asthmaticus?
> 
> Also the initial post mentioned the albuterol, is atrovent (ipratropium bromide) used frequently in conjunction with the albuterol neb in the United States?
> 
> As for my opinion of epi with severe asthma, i agree with both 46young and vquint. epi should ONLY be considered if all else has failed and the patient is toiletting. I'd rather give Epi than have to tube them when they drop. Compared to treating anaphylaxis, asthmatics are far more susceptible to the systemic effects of the epi and must be diligently monitored. For asthmatics we usually start at half the 0.01mg/kg dosage used for anaphylaxis and go SC instead of IM to give a slower onset allowing the other body systems to compensate


 
A Canadian! Do you in the North still have IV albuterol in your protocols?

As mentioned already, SQ Epi is still used in for severe asthma by some protocols. 

Racemic Epinephrine (a combination of D and L isomers) is used sometimes for bronchiolitis. Also as mentioned before, if airways are tight, alternative methods of delivery may need to be found. Prehospital usually do not have access to some of the different nebulizers that have a better delivery of med particles other than the usual 10%. EDs also have HeliOx to improve deposition of med particles.

In the U.S. national Asthma guidelines, EPR-3, Atrovent is not a standard for asthma especially with children. It is for those that have another COPD component. If there is air trapping it can have some effect but again delivery of particles is an issue as is its onset. Atrovent by itself is not be be considered as a rescue medication. It should be with Albuterol or Xopenex if it is used. 

There have been Paramedics who have mentioned they have Alupent (Metaproterenol Sulfate) on their trucks. I have also heard of some EDs still using Theophylline. The different protocols depend upon the medical director and how up to date he/she stays with the latest and greatest. 

Our EPR guidelines usually are in collaboration with the European Respiratory Society. I have only skimmed the Canadian guidelines to see what new meds you have. BTW, thank you for that HFA thing from the Montreal Protocol. It has been a miserable year learning about 30 new inhalers and teaching thousands of patients how to use them. :glare: Yeah I know it is a global thing but it has a Canadian name associated with it. Gotta blame somebody or some country.


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## TransportJockey (Jun 8, 2009)

NM protocols allow SQ/IM epi 0.3mg for adults for status. We can also neb in Epi (racemic). The main point of the Epi is to allow a little broncodilation so the Albuterol can actually make it down to where it needs to work.


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## daedalus (Jun 9, 2009)

rhan101277 said:


> I was talking to someone who had done this today.  It really helped the patient.  I also wonder about it causing increased oxygen demand on the heart in a already hypoxic patient.
> 
> Airway and breathing come before circulation though and if it works as intended everything should come back to normal before to demand goes up, especially in small doses.
> 
> Anyone ever use this for asthmatics, where the patients respirations are so bad that they couldn't talk and albuterol wasn't a option?



If an asthmatic is such difficulty breathing that they cannot speak, you of course can and will give SC epinephrine in addition to albuterol. Some also allow solu-medrol. 

The patient will be placed on a cardiac monitor because both drugs are sympathomimetic and will place strain on the heart.


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## mycrofft (Jun 9, 2009)

*SQ Epi...AKA "EpiPen"...self administered without a monitor.*

When Alupent MDI was brand new and Primatene Mist (epi MDI) was still Rx, subcutaneous epi was not only a first line treatment for acute status asthmaticus, it was frequently followed by "Susphrine", a long-acting epi. Used to lose patients back then. Now with steroid tx's ongoing, and Albuteral rescue MDI's, we have not lost a pt to asthma in over ten years.


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## akflightmedic (Jun 9, 2009)

daedalus said:


> If an asthmatic is such difficulty breathing that they cannot speak, you of course can and will give SC epinephrine in addition to albuterol. Some also allow solu-medrol.
> 
> The patient will be placed on a cardiac monitor because both drugs are sympathomimetic and will place strain on the heart.



How is South Carolina (SC) epi different from the other states?


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## mycrofft (Jun 9, 2009)

*It has an accent?*

B)..............


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## VentMedic (Jun 9, 2009)

mycrofft said:


> When Alupent MDI was brand new and Primatene Mist (epi MDI) was still Rx, subcutaneous epi was not only a first line treatment for acute status asthmaticus, it was frequently followed by "Susphrine", a long-acting epi. Used to lose patients back then. Now with steroid tx's ongoing, and Albuteral rescue MDI's, we have not lost a pt to asthma in over ten years.


 
Don't forget the IV Theophylline that went along with that treatment.  

Hopefully Primatene Mist will be just a memory soon.

It is good to hear you have a good maintenance track record for asthma at your facility.

Unfortunately asthma still kills too many children and adults each year.


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## drdique (Jun 9, 2009)

*A Canadian Perspective*



VentMedic said:


> A Canadian! Do you in the North still have IV albuterol in your protocols?
> 
> As mentioned already, SQ Epi is still used in for severe asthma by some protocols.
> 
> ...



No, no more IV Salbutamol (that's what we call it) LOL
And as for the Atrovent, we only use it in conjunction with the Salbutamol.
SQ Epi is still our first-line, followed with Mag and 'roids

As an RRT, what are your thoughts on using PEEP, based on starling's law principles, to hyper-inflate the lungs in hopes of creating some rebound to expel trapped air?  I heard a Crit Care Nurse talking about it during some con-ed scenarios......


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## VentMedic (Jun 9, 2009)

drdique said:


> As an RRT, what are your thoughts on using PEEP, based on starling's law principles, to hyper-inflate the lungs in hopes of creating some rebound to expel trapped air? I heard a Crit Care Nurse talking about it during some con-ed scenarios......


 
You DO NOT want to hyperinflate the lungs more since the air trapping has already hyperinflated them.

However, if PEEP is used with caution, you can splint the airways open in some patients. A good graphics program should be used with whatever device you are using the PEEP to ensure you are not creating more problems. If the hyperinflation increases, you risk losing the hemodynamic status and that can be fatal if you have no way to decrease the hyperinflation.  

Often, it takes HeliOx to get through the initial crisis until the inflammation reduces. We have had some people sedated, ventilated and on HeliOx for a long as a week waiting out the inflammation.


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## VentMedic (Jun 9, 2009)

Here's a good article for PEEP, auto-PEEP and the difference between asthma and COPD.

http://www.rcjournal.com/contents/01.05/01.05.0110.pdf


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## TransportJockey (Jun 9, 2009)

So CPAP might be a tool to try if nothing else seems to be working? From waht I understand CPAP might be able to splint the A/W open a little


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## VentMedic (Jun 9, 2009)

jtpaintball70 said:


> So CPAP might be a tool to try if nothing else seems to be working? From waht I understand CPAP might be able to splint the A/W open a little


 
CPAP utilizes PEEP. Too much without the ability to rapidly decompress the chest or add pressors quickly, and you can get a dead patient. Most prehospital devices do not allow for graphics to tell you how to titrate the PEEP. If the patient already presents with hyperinflation or very little air flow or silent chest, I would be very, very cautious with the use of CPAP.

Remember, asthma usually consists of inflammation so you will not always see instant results from any of your therapies in prehospital or even in the ED or ICU.


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## mycrofft (Jun 9, 2009)

*Theophylline! Theodur! Oral alupent tabs!  Shake the rattles and dance.*

We have a terriffic asthma problem here, downwind from the California Delta, swamp cooler A/C in some buildings, many crack smokers and a large proportion of previously untreated or poorly treated African American's with hx of asthma, smoking, etc etc.

We would lose one, two or maybe three a year to asthma. We lost a couple to overdoses who managed to steal their alupent MDI's, actually took the4 MDI's out of their cold dead hands.
_There_ is one underlying trouble with asthmatic label. Those OD's were probably undiagnosed cardiac patients as well. I also wonder about all these mysterious basketball court deaths when I know for a fact many young people use Albuterol, perhaps in vain, as a performance-enhancing drug.


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## VentMedic (Jun 9, 2009)

mycrofft said:


> We have a terriffic asthma problem here, downwind from the California Delta, swamp cooler A/C in some buildings, many crack smokers and a large proportion of previously untreated or poorly treated African American's with hx of asthma, smoking, etc etc.
> 
> We would lose one, two or maybe three a year to asthma. We lost a couple to overdoses who managed to steal their alupent MDI's, actually took the4 MDI's out of their cold dead hands.
> _There_ is one underlying trouble with asthmatic label. Those OD's were probably undiagnosed cardiac patients as well. I also wonder about all these mysterious basketball court deaths when I know for a fact many young people use Albuterol, perhaps in vain, as a performance-enhancing drug.


 
I have actually been considering a travel assignment in the valley. I just don't know if I want to work that hard with all the asthmatics in that area even for just 13 weeks. 

Our latest problem has been with Symbicort which looks like a rescue inhaler. Too many are OD'ing on the LABAs which is why they are under scrutiny. The meds are great but the education given to the patients is very inadequate. 

Albuterol, as well as other asthma meds, has always been controversial in competitive sports. What I have found in the Pulmonary Function Labs is many who have their "performance enhanced" also have some varying degree of exercise induced asthma that had not be diagnosed. Those whose lungs don't react during exercise do not vary in their VO2 max with or without albuterol.

We have had a problem with a few deaths by Primatene Mist being used for performance enhancement as well as a diet aide since it is easy to get OTC.

It doesn't help when you have idiots in the headlines like this:
*Britney Spears Using Asthma Inhaler to Lose Weight*
http://www.rte.ie/arts/2007/1017/spearsb.html

This was a famous case in South Florida with Nikki Taylor's sister and we may never know how she was using her asthma inhalers.

http://www.nydailynews.com/archives/news/1995/07/04/1995-07-04_model_dies_at_17__did_asthma.html


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## ResTech (Jun 10, 2009)

Im surprised that no one has mentioned terbutaline (Brethine). If a pt. is in extremis from Asthma and moving little to no air, obviously an inhaled medication isnt going to be all that effective and an injection is gonna have to prevail as the primary initial treatment. 

Terbutaline is a selective, beta-2 agonist so you should only see some residual side effects unlike Epinephrine.

What are the thoughts on the efficacy of terbutaline versus epinephrine for Asthma?


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## boingo (Jun 10, 2009)

http://www.chestjournal.org/content/71/2/129.abstract


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## VentMedic (Jun 10, 2009)

http://scholar.google.com/scholar?hl=en&lr=&q=epinephrine+terbutaline+asthma


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## ResTech (Jun 10, 2009)

That was an interesting study to read. I noticed they were using a 1mg dose of terbutaline in the study which Im sure contributed to the increase in marked tachycardia. 

Pre-hospital, I know my local protocols and all drug reference materials recommend 0.25mg SQ so I'm interested in any anecdotal observation of terbutaline over epinephrine or comparisons of normal pre-hospital doses.. the 0.25mg of terbutaline compared to 0.3mg of epinephrine.


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## VentMedic (Jun 10, 2009)

ResTech said:


> Pre-hospital, I know my local protocols and all drug reference materials recommend 0.25mg SQ so I'm interested in any anecdotal observation of terbutaline over epinephrine or comparisons of normal pre-hospital doses.. the 0.25mg of terbutaline compared to 0.3mg of epinephrine.


 
Check out the various studies on the link I just posted.


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## ResTech (Jun 10, 2009)

Vent, 
Thanks for posting those links to the studies... I am reading them now.


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