# EPI-pen on code with ALS unavailible?



## njemtbvol (Nov 30, 2011)

A discussion I was having down at the squad building- If you were on a code and ALS was unavalible (a virtual impossibility but even so) would you use an epi pen to get epi flowing while performing CPR and AED? would there be a downside do it?


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## rescue1 (Nov 30, 2011)

The short answer is no, you wouldn't. Performing ACLS is beyond the scope of practice for basics in most (all?) states.


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## JPINFV (Nov 30, 2011)

Intermuscular injections, like the Epipen, have a much slower increase in blood concentration than IV or IO, and that's not counting the fact that the patient isn't circulating blood, which will slow down IM absorption even more.


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## JPINFV (Nov 30, 2011)

rescue1 said:


> The short answer is no, you wouldn't. Performing ACLS is beyond the scope of practice for basics in most (all?) states.




Medical reasoning >>> legal reasoning.

The legal aspects can be much easier changed than the pharmacodynamics.


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## medicdan (Nov 30, 2011)

Also, the dosage (concentration) of epi used for allergic reactions is different than that used for anaphylaxis (1:1,0000 v 1:10,000). In fact, some states (and many services) have removed 1:1,000 ampules and replaced them with Epi-Pens to reduce confusion among medics between the two concentrations.


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## JPINFV (Nov 30, 2011)

Just to note, dosage and concentration isn't the same thing.


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## rescue1 (Nov 30, 2011)

JPINFV said:


> Medical reasoning >>> legal reasoning.
> 
> The legal aspects can be much easier changed than the pharmacodynamics.



Well, yes, and I agree. But at this stage, given the way protocols are, I'm not sacrificing my EMT card and risking a lawsuit for going so beyond protocol, and I wouldn't recommend anyone else try either.

But from a strictly medical standpoint, I can't imagine it would be very effective anyway, for the reasons you stated.


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## nwhitney (Nov 30, 2011)

emt.dan said:


> Also, the dosage (concentration) of epi used for allergic reactions is different than that used for anaphylaxis .



Isn't anaphylaxis an allergic reaction?


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## rescue1 (Nov 30, 2011)

nwhitney said:


> Isn't anaphylaxis an allergic reaction?



A minor detail


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## medicdan (Nov 30, 2011)

FAIL... my brain wasn't working this morning. I meant to say "allergic reactions and and cardiac arrest (ACLS)"


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## mycrofft (Nov 30, 2011)

*Anaphylaxis is a hyper-immune reaction*

Sneezing, tearing eyes and urticaria are allergic reactions. (Pass the histamine please).


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## Tigger (Nov 30, 2011)

njemtbvol said:


> A discussion I was having down at the squad building- If you were on a code and ALS was unavalible (a virtual impossibility but even so) would you use an epi pen to get epi flowing while performing CPR and AED? would there be a downside do it?



There might not be a downside per say, but it is not going to have any positive effect on the patient. 

Epi is supposed to be given every three to five minutes during an arrest, that one shot from the EpiPen is not going to have any sort of lasting effect, not to mention that Epi is general given (in an arrest) at 1mg 1:10,000 instead of the EpiPen's .3mg 1:1000.


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## systemet (Nov 30, 2011)

* Not proven to improve cardiac arrest survival in humans versus placebo = probably not worth risking your licence for.

* Plus the pharmacokinetics will suck in a low CO state.


Olasveengen TM, Wik L, Sunde K, Steen PA.Outcome when adrenaline (epinephrine) was actually given vs. not given - post hoc analysis of a randomized clinical trial. Resuscitation. 2011 Nov 22. [Epub ahead of print]

Arrich J, Sterz F, Herkner H, Testori C, Behringer W.Total epinephrine dose during asystole and pulseless electrical activity cardiac arrests is associated with unfavourable functional outcome and increased in-hospital mortality.Resuscitation. 2011 Nov 11. [Epub ahead of print]

Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial.  Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.

Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.  Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.JAMA. 2009 Nov 25;302(20):2222-9.


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## WuLabsWuTecH (Dec 3, 2011)

Legally speaking, I believe there are basics that can do ACLS in texas.  Of course, you can pretty much do anything in texas under the law if your MD ok's it...  Seriously!


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## Handsome Robb (Dec 3, 2011)

WuLabsWuTecH said:


> Legally speaking, I believe there are basics that can do ACLS in texas.  Of course, you can pretty much do anything in texas under the law if your MD ok's it...  Seriously!



The MD has to prove that you have adequate training if I remember correctly. But in the case of ACLS that really doesn't seem to difficult.


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## DV_EMT (Dec 3, 2011)

wait wait wait.... is the person just a code blue or is it due to anaphalaxis... and they're coding?


If you follow ACLS - all dead people get epi
If you follow EMT-Basic scope - May assist with administration of patients own epi-pen

....so if the patient was coding *due to* anaphalaxis, in theory couldn't the EMT administer the medication?


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## Handsome Robb (Dec 3, 2011)

DV_EMT said:


> wait wait wait.... is the person just a code blue or is it due to anaphalaxis... and they're coding?
> 
> 
> If you follow ACLS - all dead people get epi
> ...



Not once they are pulseless and apneic. I'm sure you could argue it but in the end I'd suspect it'd end with your certification being yanked or some other sort of nastiness I wouldn't like to experience. 

I think this thread is talking about a code with an epi pen present btw.

The effectiveness in Epi during arrest and survival to discharge is pretty widely disputed. ROSC is another thing all together but there's a running joke that you could give a rock a pulse if you gave it enough epi.

Other folks have presented the medical reasons on why there's no point with an IM injection anyways so I wont be repetitive.


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## DV_EMT (Dec 3, 2011)

NVRob said:


> I'm sure you could argue it but in the end I'd suspect it'd end with your certification being yanked or some other sort of nastiness I wouldn't like to experience.



Yeah, already been there for stupid county BS here. :glare: PM if you'd like more on that rant lol


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## WolfmanHarris (Dec 3, 2011)

Use an epi-pen to replace IV epi during an arrest? No.
However, we did just get a directive in Ontario for IM epi during cardiac arrest when anaphylaxis is the likely cause of the arrest (0.01mg/kg rounded to 0.05mg to a max of 0.5mg.) and the PCP is not authorized for IV starts.


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## usalsfyre (Dec 3, 2011)

NVRob said:


> The MD has to prove that you have adequate training if I remember correctly. But in the case of ACLS that really doesn't seem to difficult.



Exactly. 

The reason this is done (not that I agree with it) is the vast swaths of west and north Texas with minuscule populations (there's a county in west Texas with 60 people living in it). Your not likely to attract paramedics to those locations, similarly, there often 3-4 hours from a paramedic program. 

Many other states with similar population densities have expanded scopes for Basics and Intermediates as well.


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## Fish (Dec 4, 2011)

njemtbvol said:


> A discussion I was having down at the squad building- If you were on a code and ALS was unavalible (a virtual impossibility but even so) would you use an epi pen to get epi flowing while performing CPR and AED? would there be a downside do it?



I don't see this working, there is no perfusion to the tissue layer during a code that the IM injection will reach.

Plus, Epi pens only contain 0.3mg, we give 1mg

Plus, Epi hasn't been shown to work all that great. Do your BLS stuff, and do it good!


Negative effects? No, its just not gonna work though.


Good question, I like the thinking outside the box.


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## JPINFV (Dec 4, 2011)

Well... obviously the key is to use 3 pens... and go for the jugular.


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## DV_EMT (Dec 4, 2011)

JPINFV said:


> Well... obviously the key is to use 3 pens... and go for the jugular.



Absolutely!!! That'd be the best way to do it... do it right or dont do it at all.


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## 18G (Dec 4, 2011)

IM Epi (ie Epi-Pen) will not have any effect in a cardiac arrest. 

Alternative use of an Epi-Pen for severe asthma in case of no ALS is realistic.


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## DV_EMT (Dec 4, 2011)

18G said:


> IM Epi (ie Epi-Pen) will not have any effect in a cardiac arrest. /QUOTE]
> 
> We can dream can't we


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## systemet (Dec 4, 2011)

18G said:


> IM Epi (ie Epi-Pen) will not have any effect in a cardiac arrest.
> 
> Alternative use of an Epi-Pen for severe asthma in case of no ALS is realistic.



Agreed, as long as there's some thought given to distinguishing between the true asthmatic, and the COPDer who thinks they have asthma, but actually has bronchitis / emphysema.  And some thought given to what severe means, and the risks associated with IM epi in patients with cardiac hx / risk factors.


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## hippocratical (Dec 4, 2011)

JPINFV said:


> Well... obviously the key is to use 3 pens... and go for the jugular.



I concur:


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## Fish (Dec 4, 2011)

hippocratical said:


> I concur:



Holy Gawd! What movie is that from?

Wait, why do they all look like they are in backwards?


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## hippocratical (Dec 5, 2011)

Fish said:


> Holy Gawd! What movie is that from?



It's from Blade - I just happened to watch it like 2 days ago. Head vampire getting killed. Stupid, yet fun movie.


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