# Epinephrine Error



## VentMedic (Sep 17, 2009)

*This is not to bash the Paramedics involved but to point out how easily errors can be made. Learn from the mistakes of others so you do not make headlines.*


*3 Acushnet paramedics cited in flawed emergency call*

http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20090916/NEWS/909160333/-1/NEWSMAP




> As the paramedics were working on the patient, Mentzer and Gonsalves noticed the patient's tongue was swelling, a symptom that indicated to Mentzer an anaphylactic reaction, and Gonsalves administered *epinephrine, or adrenalin, through the patient's intravenous line,* according to the report.
> 
> That, according to the report, was a mistake: *The concentration of epinephrine Gonsalves gave the patient should have been administered through an injection under the skin, a less direct route, rather than intravenously.*


 


> Gonsalves, who admitted to giving the medication incorrectly, also told an investigator "she may not have had enough information to have even gone down that treatment pathway because she lacked a full set of vital signs or a clear history of the present illness," the report stated.
> 
> Neither Gonsalves nor Farland conducted a patient assessment, instead relying on information from Mentzer, the first paramedic at the scene, according to the report.
> 
> ...


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## silver (Sep 18, 2009)

Hmm not good.

Now how can we systematically reduce or eliminate this error from happening again?


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## Sasha (Sep 18, 2009)

silver said:


> Hmm not good.
> 
> Now how can we systematically reduce or eliminate this error from happening again?



By doing a proper assesment on every patient, not getting lazy, and paying attention to what you're doing.


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## VentMedic (Sep 18, 2009)

Proper assessment and know the five rights of drug administration.

Right drug
Right dose
Right route
Right time
Right patient


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## medicdan (Sep 18, 2009)

We need to build in system controls that make this mistake harder to make again. Does that mean we supply the concentrations for IV use seperately from IM? Make it impossible for needles used for IM injections to be used for IV (I know, they are the same)? Modify the ePCR to operate like a CPOE (computerized physician order entry) in hospitals, rechecking all dosages, routes, etc? 

How can we build safety nets into our systems, so there are checks on human error?


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## JPINFV (Sep 18, 2009)

On one hand, she should be commended on admitting her mistake freely. It doesn't excuse the rest of the stupidity, but it's better than covering it up.


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## VentMedic (Sep 18, 2009)

Even though I titled this thread "Epinephrine Error", I find more fault with the assessment done on scene by the 3 Paramedics than I do the Epinephrine administration. 

Medication errors are made fairly often and the system in place should not be there to punish those committing them if that person catches the error themselves. 

There were 3 Paramedics on this scene who should have established some priorities and got some type of assessment done. If someone had assessed the airway, they may have been able to establish some type of control over it to buy time to do a proper assessment. Someone also had time to establish the IV through which the medication was given.



> Mentzer immediately recognized the patient was seriously ill and called the EMS dispatcher for additional assistance; Farland arrived as the patient was being loaded into the ambulance, and Gonsalves got there soon after, according to the report.


 
And, why was the last Paramedic to join the scene and who probably knew the least about the patient giving the meds?

I am not bashing these Paramedics. This is actually a very common response in places, like Collier county (or Florida and California), where an ALS engine may respond first with 2 - 4 Paramedics, a Fire Rescue Truck may be behind it with 2 more Paramedics and then another 2 Paramedics in the transporting ambulance take the patient to the hospital.


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## JPINFV (Sep 18, 2009)

emt.dan said:


> We need to build in system controls that make this mistake harder to make again. Does that mean we supply the concentrations for IV use seperately from IM? Make it impossible for needles used for IM injections to be used for IV (I know, they are the same)? Modify the ePCR to operate like a CPOE (computerized physician order entry) in hospitals, rechecking all dosages, routes, etc?
> 
> How can we build safety nets into our systems, so there are checks on human error?



A mechanical control might work well in situations like this. Anyone remember the pediatric heparin dose issue from a few years ago?


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## Sasha (Sep 18, 2009)

JPINFV said:


> A mechanical control might work well in situations like this. Anyone remember the pediatric heparin dose issue from a few years ago?



This one? http://www.foxnews.com/story/0,2933,312357,00.html


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## JPINFV (Sep 18, 2009)

Yep.


> Although heparin overdoses are a rare occurrence, the same error killed three infants and harmed three others late last year at Methodist Hospital in Indianapolis. This prompted a warning from Baxter Healthcare and the FDA about the potential for medication mix-ups between the two dosage vials, which both had blue labels.
> ...
> The company introduced new packaging in October to address the problem, King said. The labels now have separate color combinations for the two dose vials, a large red alert symbol, 20% larger type fonts, and a tear-off "turtleneck."



http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/7469


If memory serves me correctly, the same issue occured with people mixing up an OTC eye drop with an OTC ear drop solution.


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## VentMedic (Sep 18, 2009)

Due to the large number of medications used in a hospital the list of errors that have been made and those situations which could allow for errors to be made are many.  

This is why we now have standardized abbreviations  and have eliminated some of those that did create errors in the past.  As well, drug manufacturers are being more cautious with their packaging.  The dispensing machines are also more sophisticated with bar scanners which  identify the medications the patient is listed with to the actual medication.

But, EMS does not carry 300 different medications nor does one Paramedic pass over 100 -300 medications per 8 or 12 hour shift with multiple patients at one time in their responsibility.


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## JPINFV (Sep 18, 2009)

Regardless, if a manufactured solution can be found to prevent similar errors, it's worth exploring regardless of if it's for the provider with 1000 medications to administer or just 2. Manufactured solutions, or the lack there of, also doesn't dismiss blame for the blantant stupidity shown on this specific EMS call.

Should hospitals be denied manufactured safe sharps because their environment is much more controlled and stable than EMS?


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## VentMedic (Sep 18, 2009)

What do your 1:1000 Epinephrine vials look like and what do the containers carrying 1:10,000 look like?


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## JPINFV (Sep 18, 2009)

I've not dealt with epi, but I've dealt with heparin. Halfway through my thesis, my labs supply of heparin changed from (if I recall correctly) 1000 unit vials to 5000 unit vials. Now since it was diluted into phosphate buffer solution anyways, it was a simple calculation to change the volumes used. However the difference between the two concentrations was the color in a little box that the concentration was in and it wasn't very noticeable.


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## VentMedic (Sep 18, 2009)

JPINFV said:


> Regardless, if a manufactured solution can be found to prevent similar errors, it's worth exploring regardless of if it's for the provider with 1000 medications to administer or just 2. Manufactured solutions, or the lack there of, also doesn't dismiss blame for the blantant stupidity shown on this specific EMS call.


 
Manufacturers are responding to the errors made due to packaging. Hospitals are continuously updating, educating and training their employees. What more do you want? The hospital staff know mistakes can easily be made. We even now are only allowing one RN/RRT in the med room at a time to get their meds so they are not distracted. 

I again said I was not bashing these Paramedics except for someone not taking responsibility to see things where done in an orderly manner so the correct procedures and medication could be done. 




JPINFV said:


> Should hospitals be denied manufactured safe sharps because their environment is much more controlled and stable than EMS?


 
I have no clue what you mean by this. I already stated hospital staff have made many med errors. We care for large numbers of patients with large numbers of medications given to each patient. The staff, the hospitals and the drug manufacturers are doing whatever they can to make the hospital a safer environment. Why shouldn't hospitals have safeguards in place? Why shouldn't EMS have safeguards in place to ensure all present have similiar information especially the one pushing the medications.


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## VentMedic (Sep 18, 2009)

JPINFV said:


> I've not dealt with epi, but I've dealt with heparin. Halfway through my thesis, my labs supply of heparin changed from (if I recall correctly) 1000 unit vials to 5000 unit vials. Now since it was diluted into phosphate buffer solution anyways, it was a simple calculation to change the volumes used. However the difference between the two concentrations was the color in a little box that the concentration was in and it wasn't very noticeable.


 
Very, very, very few EMS trucks will carry heparin. Only Flight, Specialty and some CCTs might carry it. And again, the heparin manufacturers have agreed to change their packaging and many hospitals have changed their storage situation. 

The med error here was with Epinephrine. 

Usually there is a noticable difference in packaging of the 1:1000 and the 1:10,000.

Correct route.  Correct dose.


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## JPINFV (Sep 18, 2009)

VentMedic said:


> Manufacturers are responding to the errors made due to packaging. Hospitals are continuously updating, educating and training their employees.  What more do you want?  The hospital staff know mistakes can easily be made.  We even now are only allowing one RN/RRT in the med room at a time to get their meds so they are not distracted.
> 
> I have no clue what you mean by this.  I already stated hospitals have made many med errors.   We care for large numbers of patients with large numbers of medications given to each patient.   The staff, the hospitals and the drug manufacturers are doing whatever they can to make the hospital a safer environment.   Why shouldn't hospitals have safeguards in place?    Why shouldn't EMS have safeguards in place to ensure all present have similiar information especially the one pushing the medications.




Nothing more can be asked except to produce manufactured solutions where possible regardless of who is ultimately at fault in the end. Maybe I misread your earlier posts,  but it seemed like you were saying that EMS doesn't need manufactured solutions (like improved labeling) because of the comparatively low amount of pharmaceuticals used (both in variety and total number) compared to the hospital. My view on this is that where manufactured solutions can be developed and implemented is a separate issue from the specifics of any case. If a manufactured solution could be produced that would prevent a 'right route' error then it should be implicated regardless of if providers are failing to conduct a proper assessment.


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## JPINFV (Sep 18, 2009)

VentMedic said:


> Very, very, very few EMS trucks will carry heparin. Only Flight, Specialty and some CCTs might carry it. And again, the heparin manufacturers have agreed to change their packaging and many hospitals have changed their storage situation.



I never claimed that they did, nor that I was using it in an EMS function. The heparin was ordered, delivered, and used earlier in this year. Of course how I used it (including storage) would never fly with human administration anyways, but that's a difference between research and medical care. 

As far as epinephrine, I'll freely admit that the only epinephrine that I've ever had the chance to use (which I never had the opportunity to use) came in a device resembling more of a pen than anything else.


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## VentMedic (Sep 18, 2009)

JPINFV said:


> but it seemed like you were saying that EMS doesn't need manufactured solutions (like improved labeling) because of the comparatively low amount of pharmaceuticals used (both in variety and total number) compared to the hospital.


 
News flash! Most of the meds used on EMS trucks are the same ones used in hospitals. In fact, some hospitals are set up to restock the ambulance with meds. 

3 Paramedics on scene with one patient. In many places there may be 10 Paramedics with one patient. If someone doesn't have some control or idea of who is doing what, it is chaos and errors occur.

Do you also not see where it can be easy for an RN who may be responsible for handing out 300 medications in one shift to make an error? Therefore, it has become a major issue with safeguards being placed.

I just find it unbelievable that some in EMS get offended when something like medication errors, assessment and scene organization are discussed.   This thread probably would have more successful if I had not asked for the crew members not to be blatantly bashed.  However, some are more comfortable with that then they are patient care and safety concerns.


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## rescuepoppy (Sep 18, 2009)

silver said:


> Hmm not good.
> 
> Now how can we systematically reduce or eliminate this error from happening again?



  Education continuing education,staying alert and not getting lazy or taking things for granted. While the chances for a medication error are always going to be there we all need to be aware of what we are doing. In the case where someone else draws up or takes a med out of the bag for you take a second to make sure you are getting what you need. None of us are perfect and most do not mind if you look at the package a med came out of or check the dosage before you administer it. As for the evaluation I was not there so I don't know what happened but we all need to take time to insure that we take care of the basics first.


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## boingo (Sep 18, 2009)

Our 1:10,000 epi comes in a bristojet, the 1:1,000 in a small glass ampule. I would guess theirs is packaged the same way.  I'm guessing they were suspecting anaphylaxis and decided to give epi IV however used the 1:1,000 instead of the 1:10,000.  The dose is the same however the concentration is much different.  As far as what was assessed or not, hard to say.  Did they find someone with an unmanageable airway?  Were two medics dealing with that while the third established a line, drew up meds etc?  I give them credit for reporting their mistake.  I don't think this should be an issue of discipline at all.  Addressing the mistake from a clinical standpoint makes sense.  Not reporting an error is a much different story.


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## thowle (Sep 18, 2009)

emt.dan said:


> We need to build in system controls that make this mistake harder to make again. Does that mean we supply the concentrations for IV use seperately from IM? Make it impossible for needles used for IM injections to be used for IV (I know, they are the same)? Modify the ePCR to operate like a CPOE (computerized physician order entry) in hospitals, rechecking all dosages, routes, etc?
> 
> How can we build safety nets into our systems, so there are checks on human error?



Computers are good for a lot of things.  In an emergency situation where time counts, it may not always be 100% time effective to use the computer.. however, I suppose that we could always develop a system where there would be a touchscreen LCD mounted near the primary shelf in the back, somewhere around the CPR bench, and have it with large display and touchscreen buttons that would allow entry of information of a patient to aid with the administration of treatment/medication; however -- it still doesn't take the place of knowledge and double-checking each other by verbal response.

There is always room for error; one wrong push of a button, or not enough information and then you have the computer confirming something that isn't correct.

You could always have it operate as an MDT where you are directly communicating with the medical director or ED; possible even with remove broadcast using a camera -- but still, the time delay may become a factor at times.

Speech-to-text?  Not always accurate -- how often do you call the Google 411 and it gets what you request correct the first time?  Try it now with the fan, siren, and other noises from the back of the rig?  Even if you're wearing a remote/wireless neck/mic harness.  It would for sure add to the fustration levels associated with the job already.

Interface with LifePak monitor and PulseOx?  Sure, we're getting somewhere now; but then we can only get some information from the patient.

Again, computers are good and great for a lot of things; but chances are this would not really "help", and only add fustration to the situation... we just need a comprehensive method for checks-and-balances to be taken place during treatment; other than that... mistakes happen; learn from it; study what you did, why you did it, what you could have done different/better, and apply it next time -- don't get discouraged (even though sometimes for some people we might think they need to ).


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## 46Young (Sep 18, 2009)

All meds, and I do mean ALL meds should be treated as if they have the potential to kill, and be respected as such. 

On my second shift as a newly released ALS provider, my senior medic partner and I were treating a stat ep. I couldn't get a line for anything, and he pulled out the valium. He asked me what the dose is, and I told him correctly (5mg). He then handed me the syringe and told me to push it IM. It didn't sound right, though I couldn't remember exactly why. I figured that, as an FTO, he knew the right thing to do, so I did it. Valium only goes IV here. Ativan goes IM. The Sz didn't break. The pt turned out okay, thankfully, and we both received remediation and 6 months probation (that was 18 months total for me). The next med error would result in termination, no questions asked, and rightfully so. It unfortunately takes actually making a mistake and suffering the consequences to straighten you out.

Partners will look at me and ask why I'm calling out the med, conc, doseage, exp, intended route, and handing them the syringe with the needle still in the vial. This is over four years later after that error that I'm still doing this. I occasionally hand a partner the wrong med to draw up, if time is not of the essence, to see if they catch it, to not become complacent.

I advise everyone to watch your partner, and question them if needed, even if they outrank you, such as a "lead" medic, or an Lt/Capt. Some agencies, such as mine, regard an EMT-I and an EMT-P as one and the same (puzzles me). The courts don't, however. If your lead is of a lower cert level as such, it's your neck (job, successful lawsuit, P-card) on the line if things go wrong. 

I've imposed my will on lazy/complacent med officers for pt care issues when needed. I'm lucky that the ones in my station are not that way. Detail officers and OT personnel can vary.


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## usalsfyre (Sep 18, 2009)

*a dose is a dose is a dose......*

If I'm not mistaken a milligram of epi is a milligram of epi no matter whether it's in 1ml, 10mls or 1000mls. Getting hung up on what concentration is given IV seems a little ridiculous. Didn't anyone used to carry the 30mgs in 30ml multidose vials for "extended transports". 

The real issue is why did no one do a complete assessment (including V/S)initially. And what "airway management" was done at the five minute mark?


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## rescue99 (Sep 18, 2009)

boingo said:


> Our 1:10,000 epi comes in a bristojet, the 1:1,000 in a small glass ampule. I would guess theirs is packaged the same way.  I'm guessing they were suspecting anaphylaxis and decided to give epi IV however used the 1:1,000 instead of the 1:10,000.  The dose is the same however the concentration is much different.  As far as what was assessed or not, hard to say.  Did they find someone with an unmanageable airway?  Were two medics dealing with that while the third established a line, drew up meds etc?  I give them credit for reporting their mistake.  I don't think this should be an issue of discipline at all.  Addressing the mistake from a clinical standpoint makes sense.  Not reporting an error is a much different story.



Wow..not an disciplinary issue..really? There's a big issue with giving the wrong (any) concentration of epi to a victim of an unassessed problem. I'm not sure...was this an allergic reaction or orolingual angioedema for some other reason? Some neuro patients will present with a swollen tongue for example. What was the likely cause of the edema? 

There were enough people there to have done what they needed yet, there simply wasn't enough information gathered. No differentials were even mentioned from what little I gathered in the article.


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## VentMedic (Sep 18, 2009)

rescue99 said:


> Wow..not an disciplinary issue..really? There's a big issue with giving the wrong (any) concentration of epi to a victim of an unassessed problem. I'm not sure...was this an allergic reaction or orolingual angioedema for some other reason? Some neuro patients will present with a swollen tongue for example. What was the likely cause of the edema?


 
Angioedema?  Ace Inhibitors for one or reactions with prescription and street meds like meth.

If the person reports their own med error there should not be a severe punishment.  Med errors are encouraged to be reported as quickly as possible so action can be taken to prevent it from becoming deadly.   As I stated before, med errors occur in the hospital.  Those that recognize their mistakes quickly rarely suffer harsh consequences.  It is those that attempt to cover up their mistakes or practice "what happens in the truck stays in the truck" mentality are the ones who need to face a disciplinary hearing.

Does any state require "Medical Errors" as part of their CEs and certification renewal?


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## rescue99 (Sep 18, 2009)

VentMedic said:


> Angioedema?  Ace Inhibitors for one or reactions with prescription and street meds like meth.
> 
> If the person reports their own med error there should not be a severe punishment.  Med errors are encouraged to be reported as quickly as possible so action can be taken to prevent it from becoming deadly.   As I stated before, med errors occur in the hospital.  Those that recognize their mistakes quickly rarely suffer harsh consequences.  It is those that attempt to cover up their mistakes or practice "what happens in the truck stays in the truck" mentality are the ones who need to face a disciplinary hearing.
> 
> Does any state require "Medical Errors" as part of their CEs and certification renewal?



The point was...something is warrented.


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## usalsfyre (Sep 18, 2009)

If the error was self reported, and there wasn't a history of med error, remediation and a record of the error for future tracking is probably all that's waranted. Punishing medical errors encourages hiding medical errors, this is an area where EMS is FAR behind the times.


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## VentMedic (Sep 18, 2009)

rescue99 said:


> The point was...something is warrented.


 
Med errors should not be punished if that individual made their mistake known.  There are probably many other things that could get a reprimand on this call but it shouldn't be for the epinephrine. 

Of course, there are a handful of errors with medications that are blatant negligence like failing to check the patiency of an IV and failing to notice an infiltrate.  Assuming responsibility for a med you know little to nothing about and that includes the med pump it might be attached to is another critical error but that pertains more to judgment than the med.


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## el Murpharino (Sep 18, 2009)

usalsfyre said:


> If I'm not mistaken a milligram of epi is a milligram of epi no matter whether it's in 1ml, 10mls or 1000mls.



1 mg of epi 1:1,000 is NOT the same as 1 mg epi 1:10,000...


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## usalsfyre (Sep 19, 2009)

el Murpharino said:


> 1 mg of epi 1:1,000 is NOT the same as 1 mg epi 1:10,000...



What (other than 9mls of solution) is the difference?


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## Crepitus (Sep 19, 2009)

usalsfyre said:


> What (other than 9mls of solution) is the difference?




It often used to be that the 1:1000 in the small glass ampules was an oil based product designed for SC/IM use.  We did carry the 30 mg vials of 1:1000 in the days of high does epi.  They were the conventional base for mixing different doses.

I have had a physician order 1:1000 IV  - an order we were able to wiggle out of and not give.  I've given the 1:10,000 IV for anaphalaxis, though the service I worked for at the time did not endorse that route for that condition.

But overall I guess I was under the same impression as you.  I thought 1 mg of epi is 1 mg of epi (other than the oil based forumulation).  If you know how to get the right concentration in the right place can't you make just about anything work in a pinch?


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## Shishkabob (Sep 19, 2009)

1 mg of a drug is 1 mg of a drug.

If I put a tablespoon of salt in a glass, and a tablespoon of salt in a pool, there's still a tablespoon of salt.  The only difference is the concentration.



Unless I'm totally missing something?


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## Ridryder911 (Sep 19, 2009)

Linuss said:


> 1 mg of a drug is 1 mg of a drug.
> 
> If I put a tablespoon of salt in a glass, and a tablespoon of salt in a pool, there's still a tablespoon of salt.  The only difference is the concentration.
> 
> ...



True, but many of those in EMS do not understand dilution principles as described by diluting Epi 1:10,000 for 1:1,000. Look up the proper dilution procedures and one will find that it would be a major medication error. 

R/r 911


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## medic_texas (Sep 26, 2009)

So if 1mg of Epi is... 1mg of Epi.. why the hell do we have 2 different concentrations?  

1:10,000
1:1,000

Also, the vial isn't "oil based" and can be given IV - how do you think we mix epi- drips?  1 vial + 250ml of NS or D5W (this is in another thread as well). 

I'm not even going to explain this but I think everyone who posted in this thread needs to read about dilution, concentration, and the differences between the two epinephrine meds that are on almost every EMS unit.

<speechless>


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## DV_EMT (Sep 26, 2009)

Epi is Epi... but concentrations differ.

as for the oil based statement.... way way off there. Just as medic_tx stated... epi bags are diluted. its not oil otherwise the epi would just sit on top or bottom of the bag...

 as for the concentration question.... one is designed for pediatric pts. It goes the same for atropine I believe (if my memory isn't faulty). I think its a good idea to have the two strengths because it "CAN" reduce medication dosing error. if you give an adult a Ped size.. theres no problem. but if you go the other way.... BIG PROBLEM. I think keeping people to the "big size - big person; Small Size - small person" mentality... there'd be a lot lower medication error....

and put them away from each other. designate a PED area vs. ADULT area... that way you know the right package is in the right spot. I actually checked another pharmacist the other day by intentionally putting a different drug to be checked... same route and size... and they both started with the letters "DO..." though they were very different drugs they were the same size vials and roughly same concentration (and same box for that matter)

The pharmacist did their job, caught the error, and informed me. I then showed the pharmacist that there could be potential med errors like this in the future because the drugs were located right next to each other and someone could easilly be in a hurry and grab the wrong drug. 

It just goes to show... stock rotation can be very very helpful.... esp in the case of an emergency


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## Shishkabob (Sep 26, 2009)

medic_texas said:


> So if 1mg of Epi is... 1mg of Epi.. why the hell do we have 2 different concentrations?
> 
> 1:10,000
> 1:1,000
> ...




Errr???





 In both a 1:10 and 1:1 solution, there is 1mg of Epi, AT ALL TIMES. The only difference between the 2 is how concentrated it is.  1:1 has 1mg in 1ml of fluid, while 1:10 has 1mg in 10ml, or .1mg in 1ml of fluid.

If you give 1ml of each, then yes, there is less Epi in the 1:10, but if you give the whole thing, there's still 1mg in both.




Again, a tablespoon of salt in a pool and a tablespoon of salt in a glass... there's still a tablespoon of salt.


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## medic_texas (Sep 26, 2009)

Linuss said:


> Errr???
> 
> 
> 
> ...



Where did I say there was a difference in the milligram?  I want people to think why there is 2 different concentration ratios of Epi.  

Why do we have 2 different concentrations?  

I'm glad you cleared up the concentration ratio for everyone, but I'm already aware.  No use trying to give me flak by quoting my post.  I think you misunderstood my post and were pretty quick to try and "prove me wrong".    

Obviously there is a huge issue on this because 3 medics on a call can't figure out the right medication, the right dose, the right route, the right patient, and the right time.  I find that some of the people that post here are just as scary.


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## Shishkabob (Sep 26, 2009)

I read

"So if 1mg of Epi is... 1mg of Epi.. why the hell do we have 2 different concentrations? "


And extrapolated that you were saying they were not the same.  If that's not the case, I'm sorry.  If that is the case, that's why I wrote the post.


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## medic_texas (Sep 26, 2009)

Linuss said:


> I read
> 
> "So if 1mg of Epi is... 1mg of Epi.. why the hell do we have 2 different concentrations? "
> 
> ...



Ok, glad we cleared that up.   

I was just annoyed at all of the posts that I read through and some of the inaccurate information that was given.  You should have read my original post before I edited it.  lol


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## Shishkabob (Sep 26, 2009)

Wouldn't be the first time something was taken wrongly on the internet ^_^


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## medic_texas (Sep 26, 2009)

Linuss said:


> Wouldn't be the first time something was taken wrongly on the internet ^_^



lol - very true.


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## Crepitus (Sep 26, 2009)

Linuss said:


> Wouldn't be the first time something was taken wrongly on the internet ^_^



Looks like I may have created part of the issue as well and should retract the 'oil based' comment.  Years ago we carried two vials of 1:1000 epi.  One was clearly marked for SC use only, the other did not carry that descriptor.  Our service required that we mix up our high dose epi/epi drips from the second vial, never the first.

I remember having the conversation asking what the difference was between the two vials of 1:1000 and was told the base was different between the two.  Evidently that might not be true.  

Though that was 15 years ago or so I remember the issue because around that time we ran a call where a physician suffered anaphalaxis, was given 3 injections with epi pens by a physician colleague who was with him.  When my partner and I arrived we were instructed to give additional 1:1000 epi IVP by the second physician (an anesthesiologist as I recall).  He repeated the order multiple times and eventually had to be separated from the call to calm him down (it was one of those calls).  He and the patient complained to the medical director, they were told that even if we had wanted to comply that we did not carry epi that could given be that route.  This call was run before we added the second epi vial and we added epi drips.  Prior to that we only carried the small epi vials marked SC use only.

So for these years I have presumed that I was informed correctly - that epi could be consituted differently.  Perhaps it was strictly matter of labelling by the manufacturer labelling it for SC use only.

I was only offering the comment as a off hand comment Usalsfyre as a potential *partial* explanation to his question and I hereby publically declare that folks should be skeptical of my 'oil based' comment.

But I'm with the other posters in the thread that are noting that epi is epi.  It comes in different concentrations, that are typically used for specific applications and certainly could create a significant med error if concentrations are ignored.  But a milligram of epi is a milligram of epi.  

I would always try to avoid diluting 1:1000 epi for IV use, but I have seen it done before and believe someone with Jr. High math skills should be able to do it if necessary.

Have a great weekend everyone.


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## MrBrown (Sep 27, 2009)

Linuss said:


> I read
> 
> "So if 1mg of Epi is... 1mg of Epi.. why the hell do we have 2 different concentrations? "



Because it depends on the route of administration

IV in cardiac arrest we use 1:1000
IV we use 1:1000 diluted in 1,000mls to make 1:100,000 (0.01mg)
IM we use 1:1000 diluted in 10mls to make 1:10,000 (0.3-0.5mg)
Neb we use 5mg 

Now technically with an arrest we do dilute up to 10ml so it could be classed as 1:10,000 but I have generally seen 1mg drawn up into a 1cc syringe and given undiluted followed by a 10-20ml flush.


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## Smash (Sep 27, 2009)

MrBrown said:


> Because it depends on the route of administration
> 
> IV in cardiac arrest we use 1:1000
> IV we use 1:1000 diluted in 1,000mls to make 1:100,000 (0.01mg)
> ...



What is the rationale behind diluting epinepherine in cardiac arrest?

I'm also curious as to why you would dilute it to give IM?  Giving 0.3 - 0.5ml (0.3 - 0.5mg) is far kinder than ramming home 5ml of solution IM.

Oh, and 1mg in 1 liter is 0.001mg/ml (1mcg/ml)


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## EMTinNEPA (Sep 27, 2009)

VentMedic said:


> What do your 1:1000 Epinephrine vials look like and what do the containers carrying 1:10,000 look like?



1:10,000 is in a pre-filled syringe (you know, the ones that _Emergency!_ fans like to prepare by "Johnny Gage-ing" it) and the 1:1,000 is in an ampule and needs to be drawn up.

EDIT: We also carry epinephrine auto-injectors.


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## MrBrown (Sep 27, 2009)

Smash said:


> What is the rationale behind diluting epinepherine in cardiac arrest?
> 
> I'm also curious as to why you would dilute it to give IM?  Giving 0.3 - 0.5ml (0.3 - 0.5mg) is far kinder than ramming home 5ml of solution IM.
> 
> Oh, and 1mg in 1 liter is 0.001mg/ml (1mcg/ml)



Hang on I've *totally* got that round the wrong way!

*IM is 1:1,000 so 1mg:1ml*
*IV is 1mg in 1 litre - 0.01mg in 10ml*

We do not "dilute" in a cardiac arrest; my preference is 1mg in a 1cc syringe (1:1000) that you push then follow with a flush.  Lazy medics here I've seen draw up 1:10,000 ie 1mg in 10mls and push that with no flush.



EMTinNEPA said:


> 1:10,000 is in a pre-filled syringe (you know, the ones that _Emergency!_ fans like to prepare by "Johnny Gage-ing" it) and the 1:1,000 is in an ampule and needs to be drawn up.
> 
> EDIT: We also carry epinephrine auto-injectors.



We looked at pre-filled but they are *very* expensive (7-10x more so as a 1mg amp of adrenaline is like a dollar) so we carry brown ampoules of adrenaline.

Tell me, I've never seen a pre-filled in real life (coz we don't have them) you pop the yellow caps and what, screw the two parts of the syringe together, how does that work? :unsure:


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## EMTinNEPA (Sep 27, 2009)

MrBrown said:


> Tell me, I've never seen a pre-filled in real life (coz we don't have them) you pop the yellow caps and what, screw the two parts of the syringe together, how does that work? :unsure:



Pretty much, yeah.  There's the glass tube with the medication in it, which screws into the part with the needle.  Expensive?  I just looked them up on www.boundtree.com and a pre-filled syringe of 1:10,000 epi was $5.70...

We carry epi, atropine, bicarb, D50, calcium chloride, nalaxone, and adenosine in pre-filled syringes.


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## MrBrown (Sep 27, 2009)

EMTinNEPA said:


> Pretty much, yeah.  There's the glass tube with the medication in it, which screws into the part with the needle.  Expensive?  I just looked them up on www.boundtree.com and a pre-filled syringe of 1:10,000 epi was $5.70...
> 
> We carry epi, atropine, bicarb, D50, calcium chloride, nalaxone, and adenosine in pre-filled syringes.



If you take adrenaline;1mg ampoule of adrenaline costs us a dollar; a 10ml plastic ampoule of saline, a 10ml syringe and an aspican needle about fifty cents each.

That's about .... $2.50 compared to $5.70 for a pre-filled model which *is* easier than having to manually draw it up; but it is also a lot more expensive


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