# Epipen when Pt is child



## PeteBlair (Mar 28, 2014)

What would you do if you took a "bee sting call" and found a child (50 lbs) with obvious signs of severe anaphylaxis and all you carry on the truck are adult epi-pens?


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## Handsome Robb (Mar 28, 2014)

Per the manufacturer any child over 30 kg (66 lbs) should be prescribed an adult EpiPen. 

You're kid is smaller than that but not by much, if they're peri-arrest I'd give it personally.

Look at it this way, the dosage for epi in anaphylaxis for pedis is 0.01mg/kg so at 50 lbs that's approximately 22.5kg so 0.23mg. that's right in between pedi and adult epi pens (0.15 and 0.30 respectively).


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## teedubbyaw (Mar 28, 2014)

Robb said:


> Look at it this way, the dosage for epi in anaphylaxis for pedis is 0.01mg/kg so at 50 lbs that's approximately 22.5kg so 0.23mg. that's right in between pedi and adult epi pens (0.15 and 0.30 respectively).



I just typed this out and you edited in h34r:

What he said.


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## PeteBlair (Mar 28, 2014)

What if the child weighed approx. 30 lbs (per mother of child)?


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## teedubbyaw (Mar 28, 2014)

PeteBlair said:


> What if the child weighed approx. 30 lbs (per mother of child)?




What does epinephrine do, and what can happen when too much is given (especially in pediatrics)?


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## TheLocalMedic (Mar 28, 2014)

Anaphylaxis is deadly if untreated…  

For the BLS provider:  boogie out of there, call for an ALS rendezvous if possible, make base contact to get permission to use the epi pen, give O2 and treat for shock.  

Bigest thing to be mindful of in kids is the increased workload on the heart due to tachycardia.  Make sure you support their breathing and try to calm them.


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## Handsome Robb (Mar 28, 2014)

PeteBlair said:


> What if the child weighed approx. 30 lbs (per mother of child)?




Well I would never be stuck in this situation because we draw our meds.

But without congenital defects or a known history of cardiac problems id give it more often then not.


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## Milla3P (Mar 28, 2014)

I'd probably freak out and call for the Paramedics!


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## mycrofft (Mar 28, 2014)

Hmmmmmm. Got pediatric bendaryl orders?

Sidebar: while it is usually a bad idea to try to titrate antidotes without advanced life support or at least white tile and plenty of nurses around, is there something which could be given to soften the cardiac effects of epi? IS it worth the risk versus time for transport?


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## Medic Tim (Mar 28, 2014)

I would give it. With my transport times ( min 2 hours on a very good day)waiting would not be an option. Then again this would not happen to me as I draw meds and can also do iv/io epi if needed.

As for the 30 lb that would make me hesitate and administering it (adult epi pen)would depend on a number of variables . Distance to hospital , severity of reaction, progression, pts past hx. Is there a way to break into the pen and draw up the epi from there. 

I can see this being a very difficult call for a BLS crew. Especially if you have a long transport an no ALS backup.


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## mycrofft (Mar 28, 2014)

Dishcharge the epipen into a red top blood tube (no additives) then draw it up with a syringe? Ask your medical controller.


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## Handsome Robb (Mar 29, 2014)

mycrofft said:


> Hmmmmmm. Got pediatric bendaryl orders?
> 
> Sidebar: while it is usually a bad idea to try to titrate antidotes without advanced life support or at least white tile and plenty of nurses around, is there something which could be given to soften the cardiac effects of epi? IS it worth the risk versus time for transport?



While yea benedryl needs to be administered if it truly is an anaphylactic reaction mediated by igE then benedryl isn't going to cut it. It will block further histamine release but doesn't do anything for the massive systemic vasodilation that's already happening along with bronchoconstriction. The Epi is needed not only for it's pretty profound bronchodilatory effects but also the vasoconstriction. Once they're vasoconstricted they need fluids as well since they've third spaced so much already but you already know all of that. 



Medic Tim said:


> I would give it. With my transport times ( min 2 hours on a very good day)waiting would not be an option. Then again this would not happen to me as I draw meds and can also do iv/io epi if needed.
> 
> As for the 30 lb that would make me hesitate and administering it (adult epi pen)would depend on a number of variables . Distance to hospital , severity of reaction, progression, pts past hx. Is there a way to break into the pen and draw up the epi from there.
> 
> I can see this being a very difficult call for a BLS crew. Especially if you have a long transport an no ALS backup.



At 30 kg they'd have to be peri-arrest for me to give an adult dose but at that point it's either do nothing and watch them die or do something and deal with the side effects. Definitely something OLMD needs to be involved in. Risk vs benefit. Yea there's risks but there's a massive benefit and on the other side of the coin, well we know where it's headed. 

Another thought I had is there's multiple documented cases of pediatrics receiving multiple doses of IM and IV epinephrine and surviving or the reaction being refractory and still dying. Those doses are generally given close together albeit epi has a short half life at ~2 minutes. 



mycrofft said:


> Dishcharge the epipen into a red top blood tube (no additives) then draw it up with a syringe? Ask your medical controller.



That's a good idea, didn't even think of that. It would keep the medication as sterile as you're going to be able to. I'd bet if you were really proactive about aseptic technique you could keep it sterile. With that said, I have doubts as to if a BLS crew would have the supplies available to them for this. 

You would think that pediatric epipens would be standard equipment if your agency allows administration of them....


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## mycrofft (Mar 29, 2014)

*Thanks Robb*

"While yes benedryl needs to be administered if it truly is an anaphylactic reaction mediated by igE then benedryl isn't going to cut it. It will block further histamine release but doesn't do anything for the massive systemic vasodilation that's already happening along with bronchoconstriction. The Epi is needed not only for it's pretty profound bronchodilatory effects but also the vasoconstriction. Once they're vasoconstricted they need fluids as well since they've third spaced so much already but you already know all of that. "

No, actually I was so drilled into "epi then benedryl" I had forgotten the "why" behind it. My workplace was a strange mix of "prehospital" and "definitive care". Thanks!

Then due to short half-life we need to make sure we have enough epi to keep things on an even keel if transport is long way. Keep in mind how long the trip is and how much epi is on hand.

Re the plain red top blood tube thing, I'll bet it is sterile if you leave the top in place, but I cannot be absolutely sure that all sterile debris are removed. (Even IV bags and tubing sets are found to have debris in them). Since this, if approved by control, is really "off label", I'd use a filter needle to draw up if available and if going IV. Sub-Q or IM, not so big a concern, just get a small sterile abscess.


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## Smash (Mar 31, 2014)

PeteBlair said:


> What would you do if you took a "bee sting call" and found a child (50 lbs) with obvious signs of severe anaphylaxis and all you carry on the truck are adult epi-pens?



Give it.  Pt is smaller?  Give it.


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## usalsfyre (Mar 31, 2014)

The main problem with adult epi pens is not dose, but rather needle size. The adults tend to be long enough to reach bone in pediatric patients. 

As far as dose. An overdose of epi _might_ (very small chance) kill a pedi. True anaphylaxis that's left untreated WILL kill your patient.


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## mycrofft (Mar 31, 2014)

Posterior hipshot?

We popped an expired one into an orange once. 3/4:censored:inch long fine needle.

The style they show in some videos is a little alarming, backfisting on a sitting pt same as self-admin on a standing pt. There are nerves and vessels and bone you don't want to be risking like that. I'd want to use a syringe if possible.


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## TrojanEMT70 (Mar 31, 2014)

*epi pen*

Just give it to them


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## Smash (Mar 31, 2014)

usalsfyre said:


> As far as dose. An overdose of epi _might_ (very small chance) kill a pedi. True anaphylaxis that's left untreated WILL kill your patient.



Damn right.  The single biggest failure in the treatment of anaphylaxis is not giving epi.  Irrational fear of epi must surely contribute.


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## mycrofft (Apr 1, 2014)

But creating an iatrogenic death is a valid concern. Especially in a child where you are starting out with certain knowledge that you are overdosing the patient. This is in combination with other potentially lethal  contraindications (hyperthyroid, cardiac issues being two). 

I think if your pants are long enough to give a drug, it ought to be given properly then; draw up the proper dose and give it, instead of relying on an automated and invariable-dose, expensive device. Either the protocol writers are lazy, or impressed by the convenience of the pen, or don't trust their practitioners. (If you consider it, the device wasn't invented for _professiona_l use but for use by a layperson in an emergency situation; I bet that comes out when someone tries to sue the manufacturer as well as the practitioner if someone gets the wrong dose).

So, this thread unearths two prime issues: how far do you trust your techs in the field, and how do you act when to do so may be as harmful as the condition you are reading? (The answer to #2 is…..)


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## mycrofft (Apr 1, 2014)

…same as in a hospital. Titrate to effects and monitor, and have either a countermeasure or an alternative treatment in your armamentarium.

The ED docs might have a good perspective on this. What condition patients would they rather receive?


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## Carlos Danger (Apr 1, 2014)

mycrofft said:


> I think if your pants are long enough to give a drug, it ought to be given properly then; draw up the proper dose and give it, instead of relying on an automated and invariable-dose, expensive device.



If you have the tools and training, I agree 100%. 

But assuming this is BLS, and/or for some reason "all you have" is the epi-pen (i.e. no syringes), as the OP stated, then you do in fact lack either the tools or the training to give it "properly". That changes the equation.

In that case, in true anaphylaxis, the risk of NOT giving the epi is probably far higher than giving it. The chances of 1mg of epi permanently harming a healthy child is very slim. Anaphylaxis, however, is one of the top non-traumatic causes of death in otherwise healthy peds.

I would imagine most OLMD's would tell you to give it. I'd like to hear Dr. Walsh weigh in on this.


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## jzero652 (Apr 1, 2014)

Call Med Com


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## Medic Tim (Apr 1, 2014)

jzero652 said:


> Call Med Com




Ok you can't get ahold of them... What do YOU do?


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## jzero652 (Apr 1, 2014)

Medic Tim said:


> Ok you can't get ahold of them... What do YOU do?



For me that would not be an issue. I run in Nassau County NY. If I cannot get them on the Radio then we have a cell phone on the bus. I also have their # and Suffolk County Med Com's # on my personal cell, as well as our Company Chief's (who is an MD) #. If I am at someones home then they have a land line. Or call a hosp direct which I have all the local ones on my cell. Worst comes to worst call dispatcher and have them chase it down. Meanwhile Rapid transport and treat for shock. There is always a way, everything cannot be down at the same time.


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## Medic Tim (Apr 1, 2014)

jzero652 said:


> For me that would not be an issue. I run in Nassau County NY. If I cannot get them on the Radio then we have a cell phone on the bus. I also have their # and Suffolk County Med Com's # on my personal cell, as well as our Company Chief's (who is an MD) #. If I am at someones home then they have a land line. Or call a hosp direct which I have all the local ones on my cell. Worst comes to worst call dispatcher and have them chase it down. Meanwhile Rapid transport and treat for shock. There is always a way, everything cannot be down at the same time.




That's all fine and dandy . Not everyone is that lucky. 
The question is how would you or should you treat this pt. what are the pros and cons? A good critical thinking question. What would you do.

So.... Would you give the epi.


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## NomadicMedic (Apr 1, 2014)

Yes. I would give the Epi. As stated before, WITHOUT Epi, anaphylaxis is lethal.


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## jzero652 (Apr 1, 2014)

http://web.unife.it/utenti/giampaolo.garani/Anafilassi/05053023251210125.pdf

I would give it.


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## Handsome Robb (Apr 1, 2014)

I want to hear your own reasoning.

Not something that was backpedaled for and found on Google.

In other news, my better half just texted me and apparently we'll be dynamic station posting out of the fire stations here...this could be a huge step into making this system an actual awesome place to work...


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## mycrofft (Apr 1, 2014)

*Can't help but agree. However….*



Halothane said:


> If you have the tools and training, I agree 100%.
> 
> But assuming this is BLS, and/or for some reason "all you have" is the epi-pen (i.e. no syringes), as the OP stated, then you do in fact lack either the tools or the training to give it "properly". That changes the equation.
> 
> ...









(I was unpleasantly surprised to see homicide so prominent in kids).

But I have to admit, if it was MY grandkid, I'd be running up and grabbing that epi and using it myself if you hesitated,_ if thats all you had_ (a condition of the scenario) and whether or not it was the right thing to do.

Epi is a cheap and well known drug, the big deal is to prevent its exposure to light and ensure it is not getting old or cloudy before use.

The point is to work NOW so techs and parents etc are not put in that position later.  Get rid of epipens, or make it MANDATORY to stock multiple  dosages of  devices, or have a variable dose device if they invent one. Dumbing down medication administration isn not a good idea and opens the door to excesses (like glucagon pre fills and narcan pre fills and insulin pre fills…).


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## jzero652 (Apr 1, 2014)

Robb said:


> I want to hear your own reasoning.
> 
> Not something that was backpedaled for and found on Google.
> 
> In other news, my better half just texted me and apparently we'll be dynamic station posting out of the fire stations here...this could be a huge step into making this system an actual awesome place to work...



So without Epi good chance child will die, with it odds are better for survival. Give it.

But now posed with the question we use our resources to come up with the best way to react. So that if we are ever faced with the scenario suggested we will be prepared to act. You know I will speak to friends at Med Com, Dr.'s, and medic's to get there opinions on the subject. The more informed you are the better provider you can be.


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## Handsome Robb (Apr 1, 2014)

redacted


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## Carlos Danger (Apr 1, 2014)

mycrofft said:


> (I was unpleasantly surprised to see homicide so prominent in kids).
> 
> But I have to admit, if it was MY grandkid, I'd be running up and grabbing that epi and using it myself if you hesitated,_ if thats all you had_ (a condition of the scenario) and whether or not it was the right thing to do.
> 
> ...



Non-traumatic cause of death, in otherwise healthy peds (i.e no cardiac anomalies).


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## Chewy20 (Apr 1, 2014)

As BLS we carry multiple pedi and adult epi pens. BUT if I was in that situation I would give  the adult one. As stated by others a little bit more medicine may not be ideal, but more than likely the PT would be better off having a little more medicine in them rather than trying to fight off anaphylaxis shock with simple o2.

With that being said, I would try to get in touch with my medical director if I had time.


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## Brandon O (Apr 1, 2014)

Medic Tim said:


> Ok you can't get ahold of them... What do YOU do?



Give it every day of the week and twice on Sunday.

There's an analogy here to pediatric versus adult AED pads. Worrying about injury from the extra electricity (or extra epi) when there's a cardiac arrest (or lifethreatening anaphylaxis) is like worrying about a water allergy when somebody's on fire.


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## Handsome Robb (Apr 1, 2014)

Brandon O said:


> Give it every day of the week and twice on Sunday.
> 
> There's an analogy here to pediatric versus adult AED pads. Worrying about injury from the extra electricity (or extra epi) when there's a cardiac arrest (or lifethreatening anaphylaxis) is like worrying about a water allergy when somebody's on fire.



:rofl:


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## Medic Tim (Apr 1, 2014)

Brandon O said:


> Give it every day of the week and twice on Sunday.
> 
> There's an analogy here to pediatric versus adult AED pads. Worrying about injury from the extra electricity (or extra epi) when there's a cardiac arrest (or lifethreatening anaphylaxis) is like worrying about a water allergy when somebody's on fire.



Agreed.

I like that.


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## mycrofft (Apr 2, 2014)

*Talking outside the thread's desert island framework ("If you only had XYZ to use…"..*

I wrote and edited and timed out and rewrote one of my polemics.

Distilled:

1. The stated willingness to use a drug against the manufacturers instructions and against protocols by a technician proves to her or his superiors they are unprofessional and not to be trusted.* Even if it works sometimes, that's hipshot cowboy medicine.

2. Practitioners need to refuse to take out only EpiPEns and insist upon training and tools to use vials and syringes so the pharmacist's prinicples of "right drug, right dose, right patient" are not violated.

3. "If I didn't try they might have died" is analogous to "They'd have died anyway so I did it" as an excuse. That gate has to remain closed.  


PS: I just read the NY State law allowing EpiPens to be purchased, carried and used at and by summer camps. Some lawyer is going to make his client very rich one day by ripping open how the State tried to edge around the simple procedure: if the kid doesn't bring his or her prescribed EpiPens, the kid has to stay home.

*  PPS:Here is the company's info to professionals about EpiPens (from Epipen.com):

"Frequently Asked Questions

Who is EpiPen® (epinephrine) Auto-Injector indicated for?

EpiPen Auto-Injector is indicated _for patient_s with a history of anaphylaxis as well as _for patients_ at risk for anaphylaxis (see “Identifying At-Risk Patients” section)." (Italics mine). They indicate why they should be prescribed. But nowhere does it say for use by professionals.


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## mycrofft (Apr 2, 2014)

*EpiPen as pacifier.*

And, the EpiPen needs to be given within five to ten minutes of exposure. How often do you get there that fast anyway?


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## Brandon O (Apr 2, 2014)

Not sure what you're getting at, mycrofft. Do you think epi autoinjectors work or not?


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## Carlos Danger (Apr 2, 2014)

mycrofft said:


> And, the EpiPen needs to be given within five to ten minutes of exposure. How often do you get there that fast anyway?



Does the epi in the auto injectors work differently than the epi that we draw up into a syringe?

I doubt I'd get there any quicker whether I carried ampules or auto injectors.

Are you suggesting that we shouldn't give epi at all?


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## chaz90 (Apr 2, 2014)

mycrofft said:


> And, the EpiPen needs to be given within five to ten minutes of exposure. How often do you get there that fast anyway?



What about the cases of anaphylaxis where primary symptoms don't even begin that soon? Clearly the earlier during the anaphylactic episode Epi can be given the better, but I don't know where this argument really comes into play.


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## Tigger (Apr 2, 2014)

mycrofft said:


> And, the EpiPen needs to be given within five to ten minutes of exposure. How often do you get there that fast anyway?


Go ahead and cite that then. 

Seriously I'm not sure how you expect every patient presentation to fall neatly little into perfectly outlined protocol boxes. That's just not how it works and I have no idea where you come up with this stuff. If you can't use a little clinical judgement you have no business as a healthcare provider period. I


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## Handsome Robb (Apr 2, 2014)

I'm going to agree, there is no reason epinephrine cannot be effective in the presence of anaphylaxis after 10 minutes. At 10 minutes the pathophysiology doesn't suddenly change. It's still an IgE mediated reaction.

Anaphylaxis occurs in minutes to hours after exposure to the allergen, it's not always instant.


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## samiam (Apr 3, 2014)

> Is there a way to break into the pen and draw up the epi from there.



 Though I cannont "officially" recomend this there are a good 3 extra doses u can squeeze out in a 
time/wilderness scenario. I will look for a video. They teach it unofficially in wilderness survival/medicine.
http://www.youtube.com/watch?v=Ug6FcA0d-30 


Go about 3 min in unless u want to see some pretty pictures for 2 minuites. Again I am not "officially" recommending this.


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## mycrofft (Apr 3, 2014)

Tigger said:


> Go ahead and cite that then.
> 
> Seriously I'm not sure how you expect every patient presentation to fall neatly little into perfectly outlined protocol boxes. That's just not how it works and I have no idea where you come up with this stuff. If you can't use a little clinical judgement you have no business as a healthcare provider period. I



http://www.medscape.com/viewarticle/726456_4

AND I QUOTE:
" Fatality studies suggest that in some patients, there is only a brief window of time during which the low first-aid dose of epinephrine is effective.[17,29–31]"...

	17.	Pumphrey RSH. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30:1144–1150.
    27. Sheikh A, Ten Broek V, Brown SGA, Simons FER. H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2007; 62: 830–837.
	28.	Choo KJL, Simons FER, Sheikh A. Glucocorticoids for the treatment of anaphylaxis (review). Cochrane Database Syst Rev 2010;3:CD007596.
	29.	Bock SA, Munoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001–2006. J Allergy Clin Immunol 2007; 119:1016–1018.
	30.	Pumphrey RSH, Gowland MH. Further fatal allergic reactions to food in the United Kingdom, 1999–2006. J Allergy Clin Immunol 2007; 119:1018–1019.
	31.	Greenberger PA, Rotskoff BD, Lifschultz B. Fatal anaphylaxis: postmortem findings and associated comorbid diseases. Ann Allergy Asthma Immunol 2007; 98:252–257.
	32.	Smith PL, Kagey-Sobotka A, Bleecker ER, et al. Physiologic manifestations of human anaphylaxis. J Clin Invest 1980; 66:1072–1080.
	33.	Brown SGA, Blackman KE, Stenlake V, Heddle RJ. Insect sting anaphylaxis: prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. Emerg Med J 2004; 21:149–154.
===========================
A long article in a journal for and by allergists etc cites a W.H.O. statement that the risks of giving the medicine are outweighed by the risks of not giving it, and I quote again:

http://www.aaaai.org/ask-the-expert/when-administer-epinephrine.aspx

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666145/

" The committee strongly believes that epinephrine is currently underused and often dosed suboptimally to treat anaphylaxis, is underprescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate intramuscular doses."


Epi doesn't reverse anything that's occurred, it only temporarily staves off what's happening. It won't restore lost third-spaced volume from tissues  to vessels. It will try to raise pressure to vital levels,  but once things progress past a certain point, and that can be a short time, epi becomes less and less effective.

Professional discretion to me means using epi and a syringe where the practitioner judges the appropriate dose, draws it up, and administers it. As the article states and the manufacturer claims, Epipens are a first aid device.

I've obviously sidetracked this thread and I apologize.:blush:

PS: As of this past week, California, jogged by the mother of the young girl who died last year at Camp Sacramento of delayed treatment for a peanut allergy, is about to pass a law enabling schools and camps etc. to get and stock Epipens. It is unclear but apparently the law does not (yet) protect paid individuals from suit if THEY administer the injection.


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## mycrofft (Apr 3, 2014)

Robb said:


> 1. I'm going to agree, there is no reason epinephrine cannot be effective in the presence of anaphylaxis after 10 minutes. At 10 minutes the pathophysiology doesn't suddenly change. It's still an IgE mediated reaction.
> 
> 2. Anaphylaxis occurs in minutes to hours after exposure to the allergen, it's not always instant.



1. Pt size and immunological characteristics (recent exposure?) plus dose and route of allergen introduction affect speed of onset and rate  of reaction progress. 

2. Agreed.


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## mycrofft (Apr 3, 2014)

chaz90 said:


> What about the cases of anaphylaxis where primary symptoms don't even begin that soon? Clearly the earlier during the anaphylactic episode Epi can be given the better, but I don't know where this argument really comes into play.



It's a good argument and a quandary, since the first aid dose in an EpiPen is directed for only after s/s are perceived. If the young lady near Sacramento had been injected, instead of oral benedryl being given, and then promptly transported or at least 911 being called, she might likely have survived.


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## mycrofft (Apr 3, 2014)

I'll stop hogging this. Press on.


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## chaz90 (Apr 3, 2014)

mycrofft said:


> It's a good argument and a quandary, since the first aid dose in an EpiPen is directed for only after s/s are perceived. If the young lady near Sacramento had been injected, instead of oral benedryl being given, and then promptly transported or at least 911 being called, she might likely have survived.



My point was that earlier you appeared to imply that if epinephrine couldn't be given within 5-10 minutes it wouldn't be useful. I might have misunderstood your post, but it seemed like you didn't think epinephrine would still be useful further into the progression of symptoms. I understand your post discussing how epinephrine doesn't fix all problems from anaphylaxis (IE, fluid shift), but it certainly goes a long way.


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## Brandon O (Apr 4, 2014)

mycrofft said:


> Epi doesn't reverse anything that's occurred, it only temporarily staves off what's happening. It won't restore lost third-spaced volume from tissues  to vessels. It will try to raise pressure to vital levels,  but once things progress past a certain point, and that can be a short time, epi becomes less and less effective.
> 
> Professional discretion to me means using epi and a syringe where the practitioner judges the appropriate dose, draws it up, and administers it. As the article states and the manufacturer claims, Epipens are a first aid device.



So if I understand your argument, you're saying: since epi is not always effective, and may be less so the longer it's delayed; and since it has some potential for adverse effects which does not decrease with delay; when administered by professionals after a significant delay, it should be administered in a dose-titrated manner in order to minimize the adverse effects?


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## KellyBracket (Apr 4, 2014)

Halothane said:


> If you have the tools and training, I agree 100%.
> ...
> 
> I would imagine most OLMD's would tell you to give it. I'd like to hear Dr. Walsh weigh in on this.



I like the idea of pre-loaded epinephrine syringes, and I bet that however often weird scenarios like this come up will be far out-weighed by the reduction in med errors. This forum has a good number of people who have pediatric epi doses "hardwired" in their noggins, but this ain't a typical crowd!

If I were alone with *my* kid in a wilderness setting (he's about 12 kilos), and he started getting hives and SOB after a bee sting, and all I had was an adult Epi-Pen... Sorry Alden, that needle is going _in_! Probably IM in the thigh, maybe IO, but it's going in! 

I'm not sure about a 4.5 kg preemie. (What's she doing in the wilderness anyway?)

The literature is pretty clear on a few points. Kids die of untreated anaphylaxis, and treatment delay is _muy mal_. There is no hard and fast rule about "10 minutes," since there are few absolute physiologic rules in medicine (golden hour, anyone?), but the principle is the same: Delayed treatment is deadly.

OTOH, I'm not to worried about giving a 50% epi overdose. The real problems are when medics or doctors are giving 10-fold ODs. (See Pediatric Anaphylaxis: Medication errors by EMS )


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