# Pre-hospital Anaphylaxis Treatment



## LIFEGUARDAVIDAS (Feb 17, 2007)

Hi, 

I am a professional lifeguard, a rescue diver, PHTLS advanced provider and hopefuly soon an EMT. 

I work most of the time outdoors, in the U.S. at a summer camp, and in Argentina at different locations. Though they're not always remote locations, EMS is not always immediatly available. 

I would like to know which is the best Pre-hospital Emeregency Treatment for an Anaphylactic Shock. 

I've seen in the U.S. the most widely used one is the Epynephrine kit (like Eppy-pen). In Argentina, since EMS is not as advanced, there are no real Paramedic or EMTs. Ambulances are staffed by a driver, an assistant and (and sometimes) a doctor. Many doctors here recommend Corticoids kit as the treatment method for Anaphylactic Shock.

I will appreciate any comment regarding this issue, just to know what your agencies are using and why. 

Thank you in advance for your interest in this message,

Guri


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## Mercy4Angels (Feb 17, 2007)

we can only use epinephrine aka (epi pen and epi Jr.) for anaphalaxis if the epi is already prescribed to the patient. we do not carry them on the rigs in new jersey. I hear something is in the works but not yet. we have to call medics if no epi pen is available. the epi pen delivers 0.3mg of epinephrine and the Jr. version .015mg.


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## BEorP (Feb 17, 2007)

Mercy4Angels said:


> we can only use epinephrine aka (epi pen and epi Jr.) for anaphalaxis if the epi is already prescribed to the patient. we do not carry them on the rigs in new jersey. I hear something is in the works but not yet. we have to call medics if no epi pen is available. the epi pen delivers 0.3mg of epinephrine and the Jr. version .015mg.


I think its just a typo, but Epipen Jr. is 0.15 mg of epi 1:1000

As for the anaphylaxis... epi and maybe some benadryl could help


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## Ridryder911 (Feb 17, 2007)

I personally over the past thirty years have only seen very few true anaphylactic cases. True anaphylaxis will occur within the first 15 -30 minutes after occurrence. 

I do NOT like Epi unless it is a true reaction in shock or advanced degree of anaphylaxis. As well I only had to administer Epi twice in my career, and I work in a very busy environment that routine runs reaction type calls daily. 

What I have seen and personally prefer is to administer H2 blockers such as Benadryl (25- 50mg) IV, or Pepcid and steroid such as Solu-Medrol or Decadron IV. Again, my clinical experience reveals most of the responses are actually adverse reactions (hives, swelling, itching) and not true anaphylaxis. If one can administer H2 blockers early enough, anaphylaxis may be deferred from occurring. 

We use Epi as last choice.. 0.3mg Epi 1:1000 sub-q or 1mg Epi 1;10,000 IV for severe cases, in conjunction with the other med's I described.

Good luck, 
R/r 911


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## MMiz (Feb 18, 2007)

While I've only been in EMS for a few years, I have never seen Epi administered for anaphylaxis.  It seems as though Benadryl is preferred at the ALS level.

While we carry Epi auto-injectors at the BLS level, I don't know of one that has been used.  O2 is the drug-of-choice for the BLS provider most of the time.


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## Mercy4Angels (Feb 18, 2007)

BEorP said:


> I think its just a typo, but Epipen Jr. is 0.15 mg of epi 1:1000
> 
> As for the anaphylaxis... epi and maybe some benadryl could help




LOL saw that after i typed it yes it was a typo...:excl:


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## BossyCow (Feb 18, 2007)

Washington State requires epi-pens on all ambulances in both adult and child doses.  I guess a pair of wealthy attorneys who lived next door to a state senator had a kid who died from peanut allergy at school. The responding unit didn't have epi and the girl died.  In typical administrative knee jerk reaction the initial law required all EMT's to carry both on their person while on call.  The financial burden to the individual agencies (considering epi pens' fairly short shelf life) was intense and it was later modified to be just the responding EMS units.

I'm concerned that the availability of the epi-pens and the attention placed on it causes it to be overused when Benydryl should be used instead. As Rid said, true anaphylaxis is pretty rare.


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## Epi-do (Feb 18, 2007)

Here, we do not carry epi-pens on our trucks.  At the bls level we are only allowed to assist in administration of them if the patient already has one.  If the patient does not have one, it is high flow O's and request ALS

At the ALS level, it is benedryl first, and then epi if no improvement.

In about 8 years, I have only seen two true anaphylactic reactions, and one of them was myself.  I remember it taking me a moment to figure out what was going on, and man, was it a fast reaction!  Definately a scary thing to go through.


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## Airwaygoddess (Feb 18, 2007)

> In about 8 years, I have only seen two true anaphylactic reactions, and one of them was myself. I remember it taking me a moment to figure out what was going on, and man, was it a fast reaction! Definately a scary thing to go through.


 
Hi Epi-Do! long time no hear! so what was it that set you off?:unsure:


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## Epi-do (Feb 18, 2007)

I know I have been sort of scarce lately.  Just had alot of other stuff going on.  Reading things here when I can, but not much time to post for the last couple weeks.  It looks like things have finally begun to slow down though.

As for the anaphylaxis, I had ended up in the ER with severe lower back pain, and after x-rays and a couple other tests, I was told I had a kidney infection.  I was given a prescription for one antibiotic, but they decided to also give me a dose of levaquin as well.  They brought me my discharge papers and the pill at the same time.  I swallowed the levoquin and walked out to my car.  About 5 minutes later, we were turning the car around and heading back to the ER.  After receiving benadryl, epi, O2, being put on a cardiac monitor, coming very, very close to buying a tube, and being kept for several hours for observation, I was finally released for a second time.

Yep, in my book, levoquin is a bad, bad drug.


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## VentMedic (Feb 18, 2007)

Our BLS ambulances have epi pens.  

One of my most memorable recent cases in the ER was a pt who had just used his new Combivent inhaler given to him by an NP at a Gen Pract. doctor's ofc for "cold" symtoms-"to dry it up". He was seriously allergic to peanuts and probably soy. The more he hit the inhaler the worst he got. It took a little SQ epi, nebulized vaponephrine, Benadryl and a little IV Solu-Medrol to get him out of it. 

Luckily now, Atrovent should have the HFA propellant. Combivent is still CFC which is the offender for people with soy allergies. It too will be change soon. Of course, doctors offices may still have some old CFC versions of Atrovent to hand out.


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## LIFEGUARDAVIDAS (Feb 19, 2007)

*Thanks!!!*

Hi, just wanted to thank you all for your interest, specially to Epi-do, Airwaygoddess, BossyCow, Mercy4Angels, Mmiz, Ridryder911, BEorP and VentMedic. 

I found your comments about your experience and your agency policies very useful!


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## fm_emt (Feb 19, 2007)

:O

I must be a death magnet. I've seen two anaphylaxis patients in the past year! Both got high flow O2 right away, and both of them had an epi-pen appear from a bystander. Both patients were assisted in using their epi-pens, and both of them saw the effects within a couple minutes.

I kind of wish that we could carry the epi-pens. Doctors seem to hand them out like candy around here. Yes, I understand that there are contraindications/etc, and I'd be more than happy to learn them. I just really hate that feeling of helplessness when you have a patient that's turning blue after a crazy allergic reaction.

#1 was to guacamole. #2 was to peanuts.

I'm allergic to shellfish and try to avoid it.


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## KEVD18 (Feb 19, 2007)

we carry two each of the epi and epi jr. i have used each. they were true anaphylaxis. i say this with confidence, because at around age 10, i spent three days in the picu with an ett from an anapylactic reaction. since then, i have been down that road twice. i am well versed in the s/s of the situation


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## FF/EMT Sam (Feb 20, 2007)

We can only give an epi-pen if it's the patient's own, but I really see no reason why BLS providers shouldn't be able to administer one that's not the patient's if it's a legitimate emergency.

Other than that, all that we can give is high flow oxygen and high flow diesel.


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## Airwaygoddess (Feb 20, 2007)

Good Morning Sam!


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## mxjagracer (Feb 24, 2007)

ONE OF MY PARTNER I WORKED WITH HAD TO EPI-PEN HERSELF WHEN SHE FOUND OUT SHE HAD A SEVERE ALLERGY TO LATEX THE HARD WAY AT WORK. HAHAHAHAHHAHAH. But here in Michigan, I believe all of michigan, unless its under protocol ( i dont know, I dont ask, I just do) carries epi pen auto injectors, both for adults, and peds. 



MMiz said:


> While I've only been in EMS for a few years, I have never seen Epi administered for anaphylaxis.  It seems as though Benadryl is preferred at the ALS level.
> 
> While we carry Epi auto-injectors at the BLS level, I don't know of one that has been used.  O2 is the drug-of-choice for the BLS provider most of the time.


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## TKO (Feb 25, 2007)

Here in BC, Canada, Primary Care Paramedics (PCP-Advanced) are licensed to provide Epi by sub-q for true anaphylaxis.  Makes more sense to keep a vial of it available than rely on an injector.  We admin 0.01 mg/kg to a max of 0.30 mg.

Our protocol says the pt must meet the following requirements:

1) A Hx of allergy
2) Exposure to a known allergen
3) S/S of Anaphylaxis (angioneurotic edema/urticaria/hypotension)
4) Unstable condition (decreased LOC/respiratory distress/hypotension)

and of course there are the contraindications to keep in mind.

Given that, we can give the shot and then chase it with some Benadryl tabs (dose dependant on pt age) and transport with an IV in the arm.  We have a complete protocol for this, of course....I'm just simplifying.

If they have asthma or asthma secondary to allergies I can mix up some Ventolin (5 mg in 5 ml NS) for them in the back of the bus too.


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## Recycled Words (Feb 25, 2007)

Mercy4Angels said:


> we can only use epinephrine aka (epi pen and epi Jr.) for anaphalaxis if the epi is already prescribed to the patient. we do not carry them on the rigs in new jersey. I hear something is in the works but not yet. we have to call medics if no epi pen is available. the epi pen delivers 0.3mg of epinephrine and the Jr. version .015mg.



NJ's Interim Epi Policy:
http://www.state.nj.us/health/ems/documents/epi_policy.pdf


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## jeepmedic (Mar 31, 2007)

Here in our little area of the commonwealth EMT-B's can use the epi pen with online-medical control. weather it is the pts. or not.


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