# Would benadryl help anaphylaxis any?



## Alpiner

Your 6 miles in the woods hiking with some buddies with no cell signal when one of your buddies gets stung by a bee, tells you he is deathly allergic and isn't carrying epi. Your other friends leave to go get help while you stay with your buddy who is showing signs of anaphylaxis. You have a basic first aid kit with a few medications that includes antihistamine pills. What do you do?

I understand that people face palm the idea that anyone would consider benadryl for anaphylaxis because ultimately they need epi but in a situation where epi isn't an option would nothing be better than benadryl?


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## chaz90

Histamine blockade is still helpful in treatment of anaphylaxis, even when epinephrine is needed for immediate symptom relief of bronchospasm, hypotension, and edema. 

Preventing further progression by at least attempting to block H1 mediation of continuing symptoms is certainly better than nothing. If you have IM or IV Benadryl, I would administer that in place of PO. If PO Benadryl is all you have, go for it.


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## Gurby

What about dosing in this situation?  Presumably we want to go higher than the standard dosage which is aimed more at hay fever and whatnot?  Antihistamines have a pretty wide therapeutic index, I think... Depending on how deathly allergic he is, maybe have him take 5x the recommended dose on the package?

If all we have is PO, does it make sense to have him chew the tablets up for faster absorption?


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## CALEMT

Whats the regular dose of Benadryl PO? How much can be safely given in this type of situation? Is the airway compromised and does he have the ability to swallow? If so you can always absorb the medication through the gums, kinda like nicotine and glucose. Not really optimal but it sounds like a **** sandwich and you have to take a bite.


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## Summit

If you exceed 50mg of a first gen like benadryl you'll start to see anticholinergic effects. You achieve histamine blockade with 1-2mg/kg but really you never dose more than 50mg whether IV, IM, or PO.

The problem with benadryl is its speed of action and its delivery. We are talking about a drug that reaches peak effect in an hour, not a minute. If you don't have IM/IV, you have PO. You are on the right track with increasing absorption, but think elixir to drink vs aiming for absorption across mucous membranes. Think more along the lines of breaking open a capsule and mixing in water to drink vs chewing (I suggest you try chewing diphenhydramine... you will make your patient puke).

If they are already compromising their airway, it is unlikely they can take PO.

In a true anaphylaxis emergency, we want to treat with drugs that work along multiple timelines and mechanisms: IM epi, nebulized albuterol, histamine blocker, corticosteroid.

If it was just me and my friend, and they got stung on an extremity, and it was that desperate mortal situation, I'd consider a tourniquet to buy time... but there is little evidence that works (just a "good idea" some Dr had that I read somewhere once).

Your friend should have brought an epi pen, because there are better screwball tricks with an epi-pen (getting an extra dose) than trying to get someone to chew up benadryl in desperation.


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## Gurby

If all we have is a box of pills, is it a ridiculous thought to try crushing them up and having him snort them?  A quick google search shows that lots of people do that for fun...

If we're in the situation where he can still take PO, do we have to consider first-pass metabolism?  Are we really that worried about anticholinergic side effects?  If he weighs 100kg, are you still giving only 50mg PO?


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## Alpiner

The body should release some adrenaline on it's own which made me think, would calming him down be a bad idea compared to him being fearful which (I think) causes more epinephrine to be released?


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## Flying

Alpiner said:


> The body should release some adrenaline on it's own which made me think, would calming him down be a bad idea compared to him being fearful which (I think) causes more epinephrine to be released?


Itching, swelling, feeling generally terrible, and not being able to breathe is stressful enough.

Like many other chemicals that are produced intrinsically, the level of epinephrine in the blood is regulated by the nervous system and you will see diminishing returns w/ increased stress.


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## Martyn

Alpiner said:


> The body should release some adrenaline on it's own which made me think, would calming him down be a bad idea compared to him being fearful which (I think) causes more epinephrine to be released?



Hang him over a cliff by his ankles...or tell him there is a bear stalking him


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## Flying

Flying said:


> Itching, swelling, feeling generally terrible, and not being able to breathe is stressful enough.
> 
> Like many other chemicals that are produced intrinsically, the level of epinephrine in the blood is regulated by the nervous system and you will see diminishing returns w/ increased stress.


I am wrong, epinephrine does not self-regulate. We don't release enough of it quickly enough to counteract symptoms.

Anyways, freaking someone out to the point where they can relieve symptoms related to anaphylaxis will cause more problems than its worth. That sounds like something Dr. House will do.


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## Summit

Gurby said:


> If all we have is a box of pills, is it a ridiculous thought to try crushing them up and having him snort them?  A quick google search shows that lots of people do that for fun...
> 
> If we're in the situation where he can still take PO, do we have to consider first-pass metabolism?  Are we really that worried about anticholinergic side effects?  If he weighs 100kg, are you still giving only 50mg PO?



The issue is that H1 blockers like diphenhydramine are adjuncts and largely provide relief for uticaria and other annoying symptoms vs being major lifesavers. 100mg is given sometimes in anaphylaxis, but not usually. You'd be better off giving ranitidine or some other H2 blocker in addition to your 50mg of diphenhydramine vs giving 100mg of diphenhydramine. Diphenhydramine is noncritical enough that they might do RCTs with it. *Diphenhydramine isn't going to solve your upper or lower airway issues.* *It isn't going to fix shock*. *100mg would likely generate adverse effects in the course of achieving minor symptomatic relief.* If all you have is PO, you can give PO cetirizine and get the same benefit... and then you won't have the sedating or psychomotor affects that some people get with diphenhydramine. Actually some people have anticholinergic effects at very low doses, probably 5-10% of people will get amped up 25-50mg benadyrl instead of sleepy.

If you asked me for my first three choices of drugs to have available to treat of anaphylaxis, it would be: 1. Epi 2. Albuterol 3. Glucagon


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## DavidM

A little late to the party but, my second job is as a wilderness trip leader taking teens out on 3-7 week expeditions. We carry epi, bendryl, and prednisone for anaphylaxis. We follow WMA's field protocols (available at: https://www.wildmed.com/wp-content/uploads/2013/10/wma-field-protocols.pdf anaphylaxis is page 2).

The TLDR is that after recognizing anaphylaxis we administer .3mg 1:1000 epi IM (essentially an epi pen but we syringes), 50mg of diphenhydramine every 4-6 hours, normally administer prednisone as well and evacuate asap. Its protocol we've used before and it seems to work. My understanding is that the statistical chances of a severe anaphylactic reaction are fairly low and that a system but not life threatening reaction is far far more common.

Unfortunately some organizations aren't able to get prescriptions for epi so they can only use the benedryl. It become a growing issue. You can learn a little more about the fractured avalibility of epi and the fight to bring it to the backcountry at https://www.outdoored.com/articles/epinephrine-medical-ethical-necessity-or-legal-nightmare


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## GloriousGabe

DavidM said:


> A little late to the party but, my second job is as a wilderness trip leader taking teens out on 3-7 week expeditions. We carry epi, bendryl, and prednisone for anaphylaxis. We follow WMA's field protocols (available at: https://www.wildmed.com/wp-content/uploads/2013/10/wma-field-protocols.pdf anaphylaxis is page 2).
> 
> The TLDR is that after recognizing anaphylaxis we administer .3mg 1:1000 epi IM (essentially an epi pen but we syringes), 50mg of diphenhydramine every 4-6 hours, normally administer prednisone as well and evacuate asap. Its protocol we've used before and it seems to work. My understanding is that the statistical chances of a severe anaphylactic reaction are fairly low and that a system but not life threatening reaction is far far more common.
> 
> Unfortunately some organizations aren't able to get prescriptions for epi so they can only use the benedryl. It become a growing issue. You can learn a little more about the fractured avalibility of epi and the fight to bring it to the backcountry at https://www.outdoored.com/articles/epinephrine-medical-ethical-necessity-or-legal-nightmare



Aren't EMTs prohibited from giving any OTC medications?


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## Tigger

GloriousGabe said:


> Aren't EMTs prohibited from giving any OTC medications?


Our protocols allow for all OTC medications provided they are given for their labelled use.


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## GloriousGabe

Tigger said:


> Our protocols allow for all OTC medications provided they are given for their labelled use.


Really? I thought that was strictly in the domain of a nurse and that EMTs can only do what is allowed under state law and they have protocols for (NTG, ASA, Albuterol, etc). Are you saying EMTs can dispense an OTC provided there is a label on it with their name?


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## Jim37F

I think a lot depends on the local services EMSA rules plus what the local medical director has decided what he wants his/her EMTs to be able todo/not do etc.

Also, correct me if im wrong, but my understanding is that a lot of SAR teams actually operate under Good Samaritan laws if they're not affiliated with the local EMS service?


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## GloriousGabe

Jim37F said:


> I think a lot depends on the local services EMSA rules plus what the local medical director has decided what he wants his/her EMTs to be able todo/not do etc.


What's an EMSA?



> Also, correct me if im wrong, but my understanding is that a lot of SAR teams actually operate under Good Samaritan laws if they're not affiliated with the local EMS service?


Correct. I'm on a SAR but we have no medical director at all. If/when we find a lost person who needs medical help I suddenly transform from a SAR member to an EMT-who-happens-to-be-off-duty-but-in-the-right-place-at-the-right-time.


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## DesertMedic66

GloriousGabe said:


> What's an EMSA?
> 
> 
> Correct. I'm on a SAR but we have no medical director at all. If/when we find a lost person who needs medical help I suddenly transform from a SAR member to an EMT-who-happens-to-be-off-duty-but-in-the-right-place-at-the-right-time.


EMSA= Emergency Medical Service Authority. Also known as LEMSA (Local EMSA). Not every state has "state wide protocols". In states like TX their medical director can have EMT or medics do what ever they please. So if their medical director wants EMT to start IOs and intubate then they are given those skills (obviously with additional training).


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## DesertMedic66

GloriousGabe said:


> Are you saying EMTs can dispense an OTC provided there is a label on it with their name?


Not if it has their name one it. OTC medications don't have names as they are not prescribed. Labeled purpose means the mediation is given for what it treats. If the OTC medication is for allergies then they can only give it for allergy related complaints.


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## EMSComeLately

GloriousGabe said:


> Really? I thought that was strictly in the domain of a nurse and that EMTs can only do what is allowed under state law and they have protocols for (NTG, ASA, Albuterol, etc). Are you saying EMTs can dispense an OTC provided there is a label on it with their name?


No...he's saying that as long as the otc medication is being administered per "it's label" (and is the patient's owned)

EMTs can assist a patient in having them take their own medication. If the truck has a bottle of OTC ibuprofen; however, they could not.  (Typically, that is).


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## Clare

Personally I would not administer it.  The single most effeitve treatment for anaphylaxis is *adrenaline*.

H1 histamine antagonists such as loratadine or diphenhydramine are useful in providing relief from localised symptoms such as rash or itching but I know of no evidence showing they are effectie as a treatment for systemic anaphylaxis.  

Looks like one of those "do it because it's always been done" things ... http://www.medscape.com/viewarticle/706039

Oh, and while oral loratadine is carried it is not used as a treatment for anaphylaxis.


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## NomadicMedic

I'd certainly give the Benadryl, but not expect it to magically reverse the symptoms. The adsorption rate is too slow and the histamine mediation that Benadryl would provide, while important, isn't going to save your buddy's life, if the reaction is severe. He needs epi and fluid. 

http://www.aafp.org/afp/2003/1001/p1325.html


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## Summit

GloriousGabe said:


> What's an EMSA?


http://lmgtfy.com/?q=EMSA
Can the admins make it so when this member hits reply, a google search box pops up before they can access the reply feature?



> Good Samaratin
> 
> 
> 
> Correct. I'm on a SAR but we have no medical director at all. If/when we find a lost person who needs medical help I suddenly transform from a SAR member to an EMT-who-happens-to-be-off-duty-but-in-the-right-place-at-the-right-time.
Click to expand...

You might want to google that too. Good Samaratin laws vary by state and many are NOT designed to protect responders from organized rescue even if they are volunteer. VPA offers some liability limits.


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## NomadicMedic

To the OPs credit, EMSA is a pretty California specific term. In many places it's called the OEMS, DPH or DOH. In Connecticut we always just just called it "the regional council". 

And fully agree about the SAR responders. If you're a rescuer with no medical direction, you're allowed to act as a "lay responder" which is generally viewed as Boy Scout level first aid. If you respond on a incident where you could be reasonably expected to provide patient care, you are most likely NOT covered by any Good Samaritan type legislation if you exceed the level of lay responder. Even carrying medical equipment like a stethoscope or airway adjuncts would simply reinforce the idea that you were responding as a medical professional, not as an EMT who just happened to be in the right place at the right time.


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## Tigger

GloriousGabe said:


> Really? I thought that was strictly in the domain of a nurse and that EMTs can only do what is allowed under state law and they have protocols for (NTG, ASA, Albuterol, etc). Are you saying EMTs can dispense an OTC provided there is a label on it with their name?


We have a protocol for it.  EMTs here can assist the patient in taking their own OTC medications for their intended purposes. Not really a big deal.


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## Tigger

GloriousGabe said:


> What's an EMSA?
> 
> 
> Correct. I'm on a SAR but we have no medical director at all. If/when we find a lost person who needs medical help I suddenly transform from a SAR member to an EMT-who-happens-to-be-off-duty-but-in-the-right-place-at-the-right-time.


Hopefully you are not performing any more than basic first aid then. Does your team carry anything more than basic first aid equipment?


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## GloriousGabe

Tigger said:


> Hopefully you are not performing any more than basic first aid then. Does your team carry anything more than basic first aid equipment?



Just basic first aid, but in that description we include a BVM but not airway adjuncts.


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## GloriousGabe

Tigger said:


> We have a protocol for it.  EMTs here can assist the patient in taking their own OTC medications for their intended purposes. Not really a big deal.


I am certain there are no protocols that allow an EMT to give out OTC medications. I asked my state EMS board about that and they said it's only in the domain of nurses and up. Can you kindly post a copy of your protocols so that I can show my state EMS board that it does exist?


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## Clare

GloriousGabe said:


> I am certain there are no protocols that allow an EMT to give out OTC medications. I asked my state EMS board about that and they said it's only in the domain of nurses and up. Can you kindly post a copy of your protocols so that I can show my state EMS board that it does exist?



Hmm ... here's a list of drugs what we call an Emergency Medical Technician can administer:

Aspirin
GTN spray
Oral glucose
IM glucagon
Paracetamol
Ibuprofen
Oral tramadol
Entonox
Methoxyflurane
Loratadine
Oral ondansetron
Salbutamol nebules
Ipratropium nebules
Oral prednisone
Adrenaline IM and nebules
Ceftriaxone IM (consultation with CSO)


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## TransportJockey

Clare said:


> Hmm ... here's a list of drugs what we call an Emergency Medical Technician can administer:
> 
> Aspirin
> GTN spray
> Oral glucose
> IM glucagon
> Paracetamol
> Ibuprofen
> Oral tramadol
> Entonox
> Methoxyflurane
> Loratadine
> Oral ondansetron
> Salbutamol nebules
> Ipratropium nebules
> Oral prednisone
> Adrenaline IM and nebules
> Ceftriaxone IM (consultation with CSO)


But your emts actually have a real education, unlike bls providers in the us


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## GloriousGabe

Clare said:


> Hmm ... here's a list of drugs what we call an Emergency Medical Technician can administer:
> 
> Aspirin
> GTN spray
> Oral glucose
> IM glucagon
> Paracetamol
> Ibuprofen
> Oral tramadol
> Entonox
> Methoxyflurane
> Loratadine
> Oral ondansetron
> Salbutamol nebules
> Ipratropium nebules
> Oral prednisone
> Adrenaline IM and nebules
> Ceftriaxone IM (consultation with CSO)



You're not in the US. Our BLS education is your very basic first aid course. Your EMT course in our paramedic program.


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## EMSComeLately

GloriousGabe said:


> I am certain there are no protocols that allow an EMT to give out OTC medications. I asked my state EMS board about that and they said it's only in the domain of nurses and up. Can you kindly post a copy of your protocols so that I can show my state EMS board that it does exist?


You aren't reading closely.

You can assist administering "their own" medications, OTC or otherwise.

You can't give ambulance stocked medications, OTC or otherwise. (Typically)


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## GloriousGabe

EMSComeLately said:


> You aren't reading closely.
> 
> You can assist administering "their own" medications, OTC or otherwise.
> 
> You can't give ambulance stocked medications, OTC or otherwise. (Typically)


I am reading very closely. I specifically asked about helping (aka assisting) someone in taking their own meds. The state EMS board said if we did anything other than ASA and NTG we'd lose our certifications. Thanks but no thanks. I don't know how anyone has protocols for that but I would LOVE to see them. Can you post a link?


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## chaz90

GloriousGabe said:


> I am reading very closely. I specifically asked about helping (aka assisting) someone in taking their own meds. The state EMS board said if we did anything other than ASA and NTG we'd lose our certifications. Thanks but no thanks. I don't know how anyone has protocols for that but I would LOVE to see them. Can you post a link?


I don't have a copy of those protocols, but is it that hard for you to believe that many things are different in different areas of the country? Very few things are absolutes. Just because something doesn't reflect your own knowledge or experience doesn't mean it can't exist somewhere.


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## Jim37F

Plus many SAR teams aren't actually run by EMS operations, and who's members aren't often EMT trained and thus don't have a medical director to answer to in the first place


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## EMSComeLately

GloriousGabe said:


> I am reading very closely. I specifically asked about helping (aka assisting) someone in taking their own meds. The state EMS board said if we did anything other than ASA and NTG we'd lose our certifications. Thanks but no thanks. I don't know how anyone has protocols for that but I would LOVE to see them. Can you post a link?


I can't because there is no universal link.

Common sense is always available. If someone needs help getting and holding a glass of water to take their BP meds, you can.  However, you're still supposed to verify the "rights" before assisting.


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## GloriousGabe

chaz90 said:


> I don't have a copy of those protocols, but is it that hard for you to believe that many things are different in different areas of the country? Very few things are absolutes. Just because something doesn't reflect your own knowledge or experience doesn't mean it can't exist somewhere.



Yes it does as EMTs are very explicitly trained and scope is DRILLED into our heads. Therefore anyone who suggests otherwise needs to show proof. Do you you have a link to your protocols?


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## GloriousGabe

EMSComeLately said:


> I can't because there is no universal link.
> 
> Common sense is always available. If someone needs help getting and holding a glass of water to take their BP meds, you can.  However, you're still supposed to verify the "rights" before assisting.


Maybe if you're a paramedic but definitely not if you're an EMT. I once asked if we can use a Pulse Ox (not in our protocols) and was told by the state medical board that I'd be practicing medicine without a license. We can't do anything unless we have a law that permits it and a protocols that tells us.


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## chaz90

GloriousGabe said:


> Yes it does as EMTs are very explicitly trained and scope is DRILLED into our heads. Therefore anyone who suggests otherwise needs to show proof. Do you you have a link to your protocols?


This applies if we were discussing YOUR protocols. Of course you have to work under your own scope. We're trying to explain that other people may have rules that seem unfamiliar to you and don't reflect your experience. You seem to be stuck in some kind of attitude where everything is black and white, and the way you learned something is the only possible way. Just as you learned that you cannot do something like use pulse oximetry or administer OTC medications doesn't mean other EMTs in other jurisdictions were not taught something completely different. 

Again, I do not have a link to the protocols, but I am open minded enough to realize that they exist.


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## GloriousGabe

chaz90 said:


> This applies if we were discussing YOUR protocols. Of course you have to work under your own scope. We're trying to explain that other people may have rules that seem unfamiliar to you and don't reflect your experience. You seem to be stuck in some kind of attitude where everything is black and white, and the way you learned something is the only possible way. Just as you learned that you cannot do something like use pulse oximetry or administer OTC medications doesn't mean other EMTs in other jurisdictions were not taught something completely different.
> 
> Again, I do not have a link to the protocols, but I am open minded enough to realize that they exist.



Proof please. I'm very agreeable to believing what I see.


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## NomadicMedic

GloriousGabe said:


> Proof please. I'm very agreeable to believing what I see.



St Charles County MO


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## GloriousGabe

DEmedic said:


> St Charles County MO
> 
> View attachment 2594


That's pretty much the same as my own scope. Definitely not the carte blanche you indicated.


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## NomadicMedic

Whatcom County WA


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## chaz90

GloriousGabe said:


> Proof please. I'm very agreeable to believing what I see.



http://www.dmemsmd.org/sites/default/files/Quick Reference Guide.pdf

Here is one of the first links when I Googled "EMT OTC medication." It appears to be standing order Denver Metro guidelines. Page 1, in the upper left, lists EMT standing orders and states "OTC Medications: Aspirin; Ibuprofen; etc."

For future reference, since you clearly have Internet access, you may get more productive discussion when you do your own basic searches for information that most people understand to be intuitive. 

Choosing to have intelligent debates using facts is great, but repeatedly implying that since you haven't seen it before it must not exist is not conducive to any kind of dialog.


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## chaz90

Picture form, for ease of access.


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## GloriousGabe

Yeah that's definitely within the same scope as what we got in my retched BLS system. Definitely not the "any OTC as long with a label".


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## DesertMedic66

GloriousGabe said:


> Maybe if you're a paramedic but definitely not if you're an EMT. I once asked if we can use a Pulse Ox (not in our protocols) and was told by the state medical board that I'd be practicing medicine without a license. We can't do anything unless we have a law that permits it and a protocols that tells us.


Please remember that you are just in one state. EMS changes greatly based on the area. Take my area for example, EMTs can not use a King airway, intubate, start an IV, IO, or give Narcan. Now if we slide over to Texas there are medical directors who have given their EMTs protocols or better yet guidelines that include King Airway, intubation, IVs, IOs, and Narcan. 

CA has a statewide protocol list that county medical directors can not add on additional things to (unless they get approved for a trial study). Our medical directors can have use operate to the full extent of what is in the state protocols or can narrow it down as much as they want. Now you have other states who don't have statewide protocols and instead leave it up to the individual medical director to make protocols or guidelines that they want (which may include OTC medications). 

Calling your state EMS board will get you responses based on your states protocols. So if your state does not have protocols for OTC meds then you are operating out of your scope (same with pulse ox). Just because that is true for your state doesn't mean it's true for other states. 

I think I gave OTC meds once as an EMT but I got a base order from the doctor.


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## CALEMT

GloriousGabe said:


> I am reading very closely. I specifically asked about helping (aka assisting) someone in taking their own meds. The state EMS board said if we did anything other than ASA and NTG we'd lose our certifications. Thanks but no thanks. I don't know how anyone has protocols for that but I would LOVE to see them. Can you post a link?



Since you would LOVE to see protocols I am going to give them to you.

http://www.remsa.us/policy/
Treatment Protocol: REMS 4101
Universal Pt. "Flow chart": REMS 4102
Chest Pain protocol that *ALLOWS* the EMT to *ASSIT* with administration on prescription of Nitro and other clinically indicated medication: REMS 4402
Respiratory protocol that *ALLOS* the EMT to *ASSIST* with administration of prescription MDI AND Nitro or other appropriate med: REMS 4408
Hypoglycemia protocol that is a *STANDING ORDER *which *ALLOWS* the EMT to give Oral Glucose PO: REMS 4501
Anaphylaxis protocol that* ALLOWS* the EMT to *ASSIST* with administration of prescription Epi Pen or other clinically indicated medication: REMS 4601

So you see, yes there are places which allow you to administer prescribed medication. Furthermore, your way of thinking that every place is like yours is absolutely driving me up the freaking wall. Every county and state is different and just because you can't do something does not mean that I can't also. Oh and for the record we can use SP02 AND tritrate 02 and still be within our scope of practice (REMS 4102).


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## GloriousGabe

Thanks, guys!


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## EMSComeLately

CALEMT said:


> Since you would LOVE to see protocols I am going to give them to you.
> 
> http://www.remsa.us/policy/
> Treatment Protocol: REMS 4101
> Universal Pt. "Flow chart": REMS 4102
> Chest Pain protocol that *ALLOWS* the EMT to *ASSIT* with administration on prescription of Nitro and other clinically indicated medication: REMS 4402
> Respiratory protocol that *ALLOS* the EMT to *ASSIST* with administration of prescription MDI AND Nitro or other appropriate med: REMS 4408
> Hypoglycemia protocol that is a *STANDING ORDER *which *ALLOWS* the EMT to give Oral Glucose PO: REMS 4501
> Anaphylaxis protocol that* ALLOWS* the EMT to *ASSIST* with administration of prescription Epi Pen or other clinically indicated medication: REMS 4601
> 
> So you see, yes there are places which allow you to administer prescribed medication. Furthermore, your way of thinking that every place is like yours is absolutely driving me up the freaking wall. Every county and state is different and just because you can't do something does not mean that I can't also. Oh and for the record we can use SP02 AND tritrate 02 and still be within our scope of practice (REMS 4102).


Ah, but in Gabe's way of protocol-as-gospel way of thinking, getting the patient some of the patient's juice for mild hypoglycemia wouldn't be allowed.  It'd be glucose paste or nothing.


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## GloriousGabe

EMSComeLately said:


> Ah, but in Gabe's way of protocol-as-gospel way of thinking, getting the patient some of the patient's juice for mild hypoglycemia wouldn't be allowed.  It'd be glucose paste or nothing.


Just watch a lawyer win when that happens.


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## SandpitMedic

I can see Gabe is only on day 2 of EMS.


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## GloriousGabe

SandpitMedic said:


> I can see Gabe is only on day 2 of EMS.


Huh? 
Been in this game for a while.

Not my first rodeo.


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## SandpitMedic

Oh... My bad.


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## CALEMT

GloriousGabe said:


> Huh?
> Been in this game for a while.
> 
> Not my first rodeo.



That right there is the mentality that we're all talking about.


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## GloriousGabe

CALEMT said:


> That right there is the mentality that we're all talking about.


Glad I can help.


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## chaz90

GloriousGabe said:


> Just watch a lawyer win when that happens.


Is this based on reality or fear mongering in EMT class? There aren't squadrons of vicious lawyers lurking in the shadows waiting to prey on minimum wage EMTs assisting patients with orange juice and Tylenol.


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## GloriousGabe

chaz90 said:


> Is this based on reality or fear mongering in EMT class? There aren't squadrons of vicious lawyers lurking in the shadows waiting to prey on minimum wage EMTs assisting patients with orange juice and Tylenol.


How long have you been in EMS? Not long enough. Yes, there are lawyers who desire to scour everything and then sue. I'm on my third case now.


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## EMSComeLately

chaz90 said:


> Is this based on reality or fear mongering in EMT class? There aren't squadrons of vicious lawyers lurking in the shadows waiting to prey on minimum wage EMTs assisting patients with orange juice and Tylenol.


Regardless, perhaps Gabe could list the 4 elements of negligence. Of course standard of care needs to be considered in that.

Scenario for Gabe.  You're a BLS crew responding to a sick person call.  Conscious patient who can follow commands with BGL of 50 who refuses oral glucose, but states he has juice and crackers that normally works just fine, but can't walk to get them due to "whatever".

Do you whip out the refusal of care form?  Do you excitedly phone med control?  What do you do?


----------



## CALEMT

GloriousGabe said:


> How long have you been in EMS? Not long enough. Yes, there are lawyers who desire to scour everything and then sue. I'm on my third case now.



Im pretty sure Chaz has been doing this job longer than you and may know a thing or two more than you. Just a thought, take it with a grain of salt.

I'm curious, in going back to the original topic would you @GloriousGabe give your buddy PO benadryl?


----------



## GloriousGabe

CALEMT said:


> Im pretty sure Chaz has been doing this job longer than you and may know a thing or two more than you. Just a thought, take it with a grain of salt.
> 
> I'm curious, in going back to the original topic would you @GloriousGabe give your buddy PO benadryl?


Not in my protocols.


----------



## chaz90

GloriousGabe said:


> How long have you been in EMS? Not long enough. Yes, there are lawyers who desire to scour everything and then sue. I'm on my third case now.


Have any been successful in getting anything from you? EMS providers are occasionally named in suits, but cases where they are determined to actually be at fault are rare and often well deserved. 

That's as much as I want to contribute to derailing this thread. Let's try to keep the topic on Benadryl and OTC med administration in general, but you can of course have the last word if desired.


----------



## CALEMT

GloriousGabe said:


> Not in my protocols.



Well if you're willing to let someone suffer just because you're off duty and _may_ loose your license then I'm sorry. If it were me I would give PO benadrly in a heartbeat. If I loose my license then so be it. I am not going to stand by and let a friend suffer knowing damn well there was something I could've done.

Its benadryl for crying out loud.


----------



## Summit

Glorious Distraction needs to start his own posts because every thread he posts in when his extraordinarily limited 15 years as an emt in one limited place "does not compute" with a world of multidisciplinary practice, it turns into a total derail as he demands others Google everything beyond his limited knowledge base for him.


----------



## SandpitMedic

If you've been sued 3 times... You're ****ing up.


----------



## chaz90

Yup. As above, we're back to discussing the finer points of benadryl administration for anaphylaxis. Let's keep it on topic, because I really don't want to lock yet another thread.


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## EMSComeLately

chaz90 said:


> Yup. As above, we're back to discussing the finer points of benadryl administration for anaphylaxis. Let's keep it on topic, because I really don't want to lock yet another thread.



You already answered it perfectly in the second post.

http://www.emtlife.com/threads/would-benadryl-help-anaphylaxis-any.42553/#post-592661

/thread


----------



## CALEMT

EMSComeLately said:


> You already answered it perfectly in the second post.
> 
> http://www.emtlife.com/threads/would-benadryl-help-anaphylaxis-any.42553/#post-592661
> 
> /thread



With Gabe's logic he would just sit there and watch his friend suffer. In this case something is better than nothing. Im a fan of Summit's idea. Break a capsule and mix it with water.


----------



## EMSComeLately

I probably don't have the personal comfort level with altering the nature of how the manufacturer designed the medication delivery, even if it sounds like a good idea.

Personally, I'd have no issue suggesting the administration of the OTC Benadryl PO that was available, as is.  I don't think I'd feel comfortable doing any McGuyver actions that *may* unknowlingly actually serve to lessen the efficacy.


----------



## Chimpie

chaz90 said:


> *Yup. As above, we're back to discussing the finer points of benadryl administration for anaphylaxis. Let's keep it on topic, because I really don't want to lock yet another thread.*


*THIS!*


----------



## Tigger

GloriousGabe said:


> I am certain there are no protocols that allow an EMT to give out OTC medications. I asked my state EMS board about that and they said it's only in the domain of nurses and up. Can you kindly post a copy of your protocols so that I can show my state EMS board that it does exist?


Not sure why you think I would just make this up. This is all it says in the protocols. Per the medical director, "use them for what they are for." No tylenol for pedi fevers, use liquid ibuprofen if that's what around. I suppose you will also need proof that EMS start IVs in Colorado.


----------



## GloriousGabe

Tigger said:


> Not sure why you think I would just make this up. This is all it says in the protocols. Per the medical director, "use them for what they are for." No tylenol for pedi fevers, use liquid ibuprofen if that's what around.
> 
> 
> 
> 
> 
> 
> 
> 
> 
> View attachment 2597


Very, very interesting. I am willgoing to send this to my state EMS board. They were adamant it was way outside the scope of an EMT-B to ever give OTCs. Thank you.


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## Seirende

Oh, geez. The first time that I learned to give Benadryl for an allergic reaction was in a Wilderness First Aid course I took through the Boy Scouts of America. You don't need any sort of license to hand a friend an OTC medication; teenagers in first aid courses are taught to do it. If a friend asks me for a Tylenol, I don't call up my medical director before digging in my backpack, and parents aren't getting sued for giving their kids cough syrup. While playing the part of an EMT, we're both more restricted and more free in what we can do, but the original question was about pharmacology, not legality. So off-topic.


----------



## Seirende

A instructor in above-mentioned course did mention that snorting a crushed tablet might be a expedited method of getting the medication on board, so you might be onto something, Gurby.


----------



## wilderness911

Seirende said:


> A instructor in above-mentioned course did mention that snorting a crushed tablet might be a expedited method of getting the medication on board, so you might be onto something, Gurby.



I hope it is acceptable for me to revive a month-old thread here, but as it is directly relevant to the OPs question I figured it is okay to show up late to the party. 

As a wilderness paramedic and snakebite medicine specialist in Africa, I have encountered a number of anaphylaxis cases in the remote medicine environment (i.e. bush hospital in the middle of west Africa remote - very limited supplies and the buck stops at your feet). Most of these cases involved pediatric patients suffering from acute anaphylaxis in response to antivenom therapy. Over time, I have developed my own protocol for handling these cases and it pretty much meshes with what was discussed earlier. 

At the earliest onset of symptoms indicating an allergic reaction, I immediately crush up 25 or 50 mg of diphenhydramine (depending on size of patient), mix it with a half oz or so of water, and have my patient knock it back while I have an airway. Infants or peds patients who could not swallow received IM promethazine 0.1 mg/kg. In all of these patients I had already established large bore IVs for antivenom administration, so venous access was already taken care of and I would throw a bag of NS or RL on the line and open it up wide. If I had injectable diphenhydramine available that would have been ideal and I would have pushed it IV, but the only diphenhydramine I had available was the bottle I brought with me and the only injectable H1 available in country was promethazine. No interest in destroying a tiny vein with IV phenergan hence the IM administration. Moving on...

First sign of anaphylaxis in all patients I treated was a dry cough of increasing frequency, followed by restlessness and pruritis. So at the first dry cough I got an H1 on board, generally a crushed up Benadryl slurry, set my watch for 30' (the time it took for the Benadryl to kick in across the board), and aggressively managed with fluids, Epi, and/or dexamethasone or betamethasone depending on what drug we had available at the time (constant shortages of essential drugs, even ran out of Epi once). The idea behind the Benadryl PO or phenergan IM was to head off the anaphylaxis before additional drugs became necessary, and in roughly 40% of cases I treated it seemed to do just that. Diphenhydramine slurry PO took 30' to kick in across the board, while the patients I treated with cetirizine did not benefit until the 60' mark. If I had ranitidine with me I would have given that too, but it was not an option. 

Because I was working in the middle of nowhere in a constant state of triage with limited medications, I withheld Epi until it was necessary and stuck to fluids and antihistamines as long as possible. This meant watching each patient like a hawk from the time when the diphenhydramine was knocked back onwards. At the first sign of airway compromise, respiratory distress, decompensation, etc I would push Epi and/or corticosteroids depending on what I had available. Care was taken to prevent cardiac arrest from severe BP drop in the peds patients (fluids and positioning) and I was reading vitals every minute or so as the clinical picture developed.

Epi (1:1000) was administered 0.25 mc/kg generally working out to 0.25 mg IM for the youngsters and 0.5 mg IM for the adults, always in the lateral aspect of the thigh. Since I didn't have the luxury of weighing a critical patient in the middle of nowhere, I estimated on the generous side and gave an appropriate dose (i.e 0.5 mg Epi for adults vs 0.3, 0.25mg for most of my peds patients instead of 0.125). This was done because I was consistently finding the need to administer multiple doses of Epi to crashing patients before any benefit was achieved. Oftentimes I would have to transfuse a bag of whole blood to treat the critical anemia caused by the snake venom (carpet vipers cause a DIC syndrome), so some of these patients were getting a bag of blood as well as fluids and whatever drugs I was pushing. But many did not, and required only minimal care: preloading with a PO dose of diphenhydramine at the onset of symptoms, clinical observation, and Epi if the Benadryl was unable to head off the anaphylaxis. 

Once stabilized, I put all patients on a regimen of antihistamines (phenergan, diphenhydramine, or cetirizine - but generally cetirizine at this point due to the longer half life) or an oral course of corticosteroids for the next 36-72 hours to prevent recurrence of anaphylaxis, which is uncommon but entirely possible. 

Lastly, for those of us operating in the backcountry here, a practical means of doing this follows. Get your Epi pen ready by rubber-banding a few blister packs of diphenhydramine and ranitidine to the case. This way you won't lose it and will remember that it is there if you need it. At the onset of symptoms, sit your patient down and make them chew up the antihistamines if you have an airway available. If you have to give Epi, immediately after giving it remove the preloaded syringe from the plastic case by following the instructions from the paper "Retrieval of additional doses of epinephrine from autoinjectors". I highly recommend that everyone takes a look at this paper. Most of my patients have required several doses of Epi, and if you don't know how to get it out then you are sitting there with a dead patient and approximately 9 additional doses of epinephrine in your hand.

Direct link here:

http://www.wemjournal.org/article/S1080-6032(13)00094-X/pdf

Hope that proves helpful, or at least interesting!

-Wilderness911


----------



## Gurby

wilderness911 said:


> As a wilderness paramedic and snakebite medicine specialist in Africa



Have to ask, how did you find yourself in this position?  Sounds like a really interesting experience!


----------



## wilderness911

Gurby said:


> Have to ask, how did you find yourself in this position?  Sounds like a really interesting experience!



Started my career as a herpetologist studying venomous snakes of Africa. Used to do the Steve Irwin thing and catch venomous snakes in the field to collect venom and tissue samples for research. Discovered a passion for medicine when I took a wilderness EMT back in 2010 (which I took because I was always running around Africa getting into the sh*t) and changed gears to focus on my research on snakebite medicine, particularly in rural sub Saharan Africa. Decided to go for the long haul so my next move will hopefully be an MD (or a PA if I can't make the money work for med school). Spent the last few years in and out of Africa doing antivenom research, ran a clinical trial on a new antivenom for west Africa, served as the primary snakebite medicine specialist for a small west African nation for 7 months 24/7, trained doctors/nurses/military medics how to manage snakebite patients in the remote medicine environment. Ive been working on devising new systems for rapid assessment, diagnosis, treatment, and clinical management of snakebite patients in rural Africa for a while as wel, based on the premise that we should stop trying to identify the snake responsible and focus on a syndromic approach based on the symptoms expressed by the patient. Snakebite medicine is a small field and primarily populated by guys like me who started out as snakemen and then became docs or PhDs. Hoping to become the guru on this stuff in future.


----------



## Gurby

wilderness911 said:


> Started my career as a herpetologist studying venomous snakes of Africa. Used to do the Steve Irwin thing and catch venomous snakes in the field to collect venom and tissue samples for research. Discovered a passion for medicine when I took a wilderness EMT back in 2010 (which I took because I was always running around Africa getting into the sh*t) and changed gears to focus on my research on snakebite medicine, particularly in rural sub Saharan Africa. Decided to go for the long haul so my next move will hopefully be an MD (or a PA if I can't make the money work for med school). Spent the last few years in and out of Africa doing antivenom research, ran a clinical trial on a new antivenom for west Africa, served as the primary snakebite medicine specialist for a small west African nation for 7 months 24/7, trained doctors/nurses/military medics how to manage snakebite patients in the remote medicine environment. Ive been working on devising new systems for rapid assessment, diagnosis, treatment, and clinical management of snakebite patients in rural Africa for a while as wel, based on the premise that we should stop trying to identify the snake responsible and focus on a syndromic approach based on the symptoms expressed by the patient. Snakebite medicine is a small field and primarily populated by guys like me who started out as snakemen and then became docs or PhDs. Hoping to become the guru on this stuff in future.



Wow!  Med schools are going to fight over you!  Most everyone takes out big loans for medical school, but If you have a reasonable GPA and MCAT I bet you could get a free ride somewhere.


----------



## NomadicMedic

...and you're going to be bored out of your mind running BLS in Seattle.


----------



## wilderness911

DEmedic said:


> ...and you're going to be bored out of your mind running BLS in Seattle.



Heh. Means to an end, my friend. Beats working at McDs...well, not economically speaking of course, but in the sense that it's medicine and gives me an opportunity to keep learning while I get ready to make my next move. Trying to stay positive here, DE! It's just a wee bit smaller scope of practice, right?


----------



## Carlos Danger

Do the H2's really help at all? My understanding is they do not. I give them (along with H1's and steroids) pre-emptively at times, but when I do, it unfortunately it has as much to do with legal indications as clinical ones.


----------



## wilderness911

Remi said:


> Do the H2's really help at all? My understanding is they do not. I give them (along with H1's and steroids) pre-emptively at times, but when I do, it unfortunately it has as much to do with legal indications as clinical ones.



There is some clinical evidence indicating a benefit to using both h1 and h2 blockers for symptomatic treatment of anaphylaxis. Read the paper a while ago, can dig it up if you would like?

Countering the release of histamine at the H2 receptors could help with GI, cardiac, and vasodilation aspects of anaphylaxis if my understanding is correct. Probably not necessary, but the data there is indicates it may be better than h1 blockers alone. I haven't seen any large scale and incredibly compelling RCT/studies to really sink the point home though. Hope that helps!


----------



## SpecialK

wilderness911 said:


> There is some clinical evidence indicating a benefit to using both h1 and h2 blockers for symptomatic treatment of anaphylaxis. Read the paper a while ago, can dig it up if you would like?



They might help relieve symptoms but the definitive treatment is adrenaline so should be given first.


----------



## Fred weber

Gurby said:


> What about dosing in this situation?  Presumably we want to go higher than the standard dosage which is aimed more at hay fever and whatnot?  Antihistamines have a pretty wide therapeutic index, I think... Depending on how deathly allergic he is, maybe have him take 5x the recommended dose on the package?
> 
> If all we have is PO, does it make sense to have him chew the tablets up for faster absorption?


 First off I’m not a EMT in anyway.  So a lot of the terminology mentioned is over my head .  
Secondly 
You guys can kick me off after this comment I’ll still be able to read the answer. 

 My grandson is allergic to bee venom so I’ve looked into this quite a bit. 

  Under the same circumstances  as in the op “you’re 6 miles deep in the woods with no EpiPen and only Benadryl “.

 From what I’ve read one of the main problems  with Benadryl is that it takes to long to  enter the bloodstream. 

 Absorption is very fast in the nasal passages .   So the  neophyte in me ask’s. Would administration that way be a good idea?   If the airway is restricted it could be blown up their nose with a straw, hollow pen casing or something similar. 

 Thanks in advance 

 Worried grandpa


----------



## luke_31

Fred weber said:


> First off I’m not a EMT in anyway.  So a lot of the terminology mentioned is over my head .
> Secondly
> You guys can kick me off after this comment I’ll still be able to read the answer.
> 
> My grandson is allergic to bee venom so I’ve looked into this quite a bit.
> 
> Under the same circumstances  as in the op “you’re 6 miles deep in the woods with no EpiPen and only Benadryl “.
> 
> From what I’ve read one of the main problems  with Benadryl is that it takes to long to  enter the bloodstream.
> 
> Absorption is very fast in the nasal passages .   So the  neophyte in me ask’s. Would administration that way be a good idea?   If the airway is restricted it could be blown up their nose with a straw, hollow pen casing or something similar.
> 
> Thanks in advance
> 
> Worried grandpa


We don’t give medical advice on this forum.


----------



## Gurby

Fred weber said:


> First off I’m not a EMT in anyway.  So a lot of the terminology mentioned is over my head .
> Secondly
> You guys can kick me off after this comment I’ll still be able to read the answer.
> 
> My grandson is allergic to bee venom so I’ve looked into this quite a bit.
> 
> Under the same circumstances  as in the op “you’re 6 miles deep in the woods with no EpiPen and only Benadryl “.
> 
> From what I’ve read one of the main problems  with Benadryl is that it takes to long to  enter the bloodstream.
> 
> Absorption is very fast in the nasal passages .   So the  neophyte in me ask’s. Would administration that way be a good idea?   If the airway is restricted it could be blown up their nose with a straw, hollow pen casing or something similar.
> 
> Thanks in advance
> 
> Worried grandpa



Really this is a conversation that should be had with your grandson's physician / his parents.  If he is at risk of having an anaphylactic reaction from a bee sting, he probably should have an EpiPen with him if he's going into the woods (or an adult should be carrying one). 

If the airway is constricted or the person's blood pressure is dropping, Benadryl is unlikely to solve those problems even if you could have it be absorbed immediately.

For example: https://www.ncbi.nlm.nih.gov/pubmed/25141245


> Although histamine is involved in anaphylaxis, treatment with antihistamines does not relieve or prevent all of the pathophysiological symptoms of anaphylaxis, including the more serious complications such as airway obstruction, hypotension, and shock.


----------



## DrParasite

Fred weber said:


> First off I’m not a EMT in anyway.  So a lot of the terminology mentioned is over my head .
> Secondly
> You guys can kick me off after this comment I’ll still be able to read the answer.
> 
> My grandson is allergic to bee venom so I’ve looked into this quite a bit.
> 
> Under the same circumstances  as in the op “you’re 6 miles deep in the woods with no EpiPen and only Benadryl “.
> 
> From what I’ve read one of the main problems  with Benadryl is that it takes to long to  enter the bloodstream.
> 
> Absorption is very fast in the nasal passages .   So the  neophyte in me ask’s. Would administration that way be a good idea?   If the airway is restricted it could be blown up their nose with a straw, hollow pen casing or something similar.
> 
> Thanks in advance
> 
> Worried grandpa


As was said, we don't give medical advice here.

That being said, as a general rule, blowing any non-nasal medication up anyone's nose is not something I would do.  if a medicine isn't designed by the manufacturer to go in a certain orifice, I'm not going to try something new just because of something I read on the internet.   Just my general rule, not about your situation.

If you are that concerned, I would have a sit down with his pediatrician.  He could give you some much better advice on what to do and what not to do.


----------



## Fred weber

Gurby said:


> Really this is a conversation that should be had with your grandson's physician / his parents.  If he is at risk of having an anaphylactic reaction from a bee sting, he probably should have an EpiPen with him if he's going into the woods (or an adult should be carrying one).
> 
> If the airway is constricted or the person's blood pressure is dropping, Benadryl is unlikely to solve those problems even if you could have it be absorbed immediately.
> 
> For example: https://www.ncbi.nlm.nih.gov/pubmed/25141245


 Thank you sir


----------



## css

Hi, 
I found this thread with an online search after having a surprise allergy discovery.
And wanted to post an experiance with a situation in the same spirit as the original question(super old thread, I know) but you never know if the info might come in handy somewhere...... 

So, stung by bald faced hornets. (no history of any kind of allergy , I even kept bees for a few years! got stung every now and then) didnt think much of it, kept working in the yard.. a few minutes later...
I found myself alone at home having throuble breathing, lips swelling, heart pounding in my chest, a few other odd sensations, blurred vision etc...then as I get in the house Everything started to fade out and back in again....not good....

I was stung in the ear which was swelling up pretty good so I felt sure it was the sting. Found some benadryl in the bathroom, someone had left behind after a visit, took two and chewed them. ( I do not recomend this 😒...The flavor is pretty bad and it screwed up my sense of tase for a day or so....)

 A few minutes later, back in the living room sitting down .... (Quick history, raised to never ever call 911 unless someone was going to die. "Your redirecting emergency sevices from someone else who might truly need it" was the standard saying ....grew up in very rural areas where help was limited over huge expanses ...) anyway, feeling like I was going to go down and not sure what would happen after that... I called it in ....after a minute or two and a transfer from dispatch and a little Q&A from local I started to feel the world stablize under me and felt bit clearer..heart ,breathing got a bit better ....I canceled the call, (dispatch was nice enough to try talking me out of it) and after a few, feeling fairly stable, I drove to the urgent care down the way....( please no" pass out at the wheel" lectures! I'm an overly responsible person and wouldn't dive unless certain...) 

So did it help? I'm not sure where the raction rates on the severity scale .. .....and I am still not 100% sure that chewing made the difference , the MD seemed to think so... Followed by...."Its not a  replacement for an epi pen though" ...
..The heart pounding and dizzy/faint feeling passed in minutes,breathing soon after, swelling took a bit and dose or two more.... But,It seemed to work.....

Sorry..... this was a reeeeally long response! And done at typo speed....
Thanks!


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## DrParasite

css said:


> I found myself alone at home having throuble breathing, lips swelling, heart pounding in my chest, a few other odd sensations, blurred vision etc...then as I get in the house Everything started to fade out and back in again....not good....


the symptoms you are describing are a classic anaphylactic reaction.


css said:


> A few minutes later, back in the living room sitting down .... (Quick history, raised to never ever call 911 unless someone was going to die. "Your redirecting emergency sevices from someone else who might truly need it" was the standard saying ....grew up in very rural areas where help was limited over huge expanses ...)


well, considering you can die from an anapylactic reaction, calling 911 is likey appropriate.





css said:


> anyway, feeling like I was going to go down and not sure what would happen after that... I called it in ....after a minute or two and a transfer from dispatch and a little Q&A from local I started to feel the world stablize under me and felt bit clearer..heart ,breathing got a bit better ....I canceled the call, (dispatch was nice enough to try talking me out of it) and after a few, feeling fairly stable, I drove to the urgent care down the way....( please no" pass out at the wheel" lectures! I'm an overly responsible person and wouldn't dive unless certain...)


and lets say you passed out behind the wheel.... or the symptoms returned and your throat started to swell up.... or your vision got blurry.... are you sure you weren't just lucky, because that could have easily gone another way, especially if you did pass out and causes a head on collision with a soccer mom, killing her and her 5 kids... would you like to tell her husband "but I was certain i could drive, I'm overly responsible!" That's also why we tell people not to follow the ambulance to the hospital, because people do weird stuff when they or their family members are sick. The drive of the ambulance is not as emotionally involved in the situation, and will not be affected by the patient's medical condition 





css said:


> So did it help? I'm not sure where the raction rates on the severity scale .. .....and I am still not 100% sure that chewing made the difference , the MD seemed to think so... Followed by...."Its not a  replacement for an epi pen though" ...
> ..The heart pounding and dizzy/faint feeling passed in minutes,breathing soon after, swelling took a bit and dose or two more.... But,It seemed to work.....


Probably.  the reaction you felt was likely a massive histamine reaction; taking an anti-histamine helped to reverse it.

Most allergic reaction protocols involve both benedryl and epi.  But for a really bad reaction, epi will save your life, and benedryl will help you feel better.


----------



## css

Interesting.....it seems you are simply being critical here ...just for the sake of having something to say.....

I didn't ask for a response or want one, I was simply relating an experience that resembled the original question.

 A What if ...hiking in the woods ....no epi pen,only Diphenhydramine...

I'm from a very large extended east coast family, several generations, fire, police and medicine. I know the lay of the land.Hell, some of them were the true blue old guard, I mean the real deal, the men that the nubes would here stories about and eveyone would stand up straight and tall when they walked into a station.

I have a considerable amount of exposure to emergency situations and behaviors that result from stress. And personally, I have been under intense combative situations and been pushed to my extremes.I have an very clear idea of my physical limitations and capabilities...I have had the conversation you are talking about given to me and provided it on anothers behalf ...if you ever have the misfortune to give news of that nature to someone you will never again use that example, its not a toy to play with...

..... Just from your response here you are over confident which is more dangerous than just ignorant, the over confident guy or gal is most terrifying one to have your back in any situation. 

Please take a moment and research... Your not exactly wrong but your a bit off on accuracy..... PLEASE DO NOT GOOGLE IT! Just a few seconds with a Merck manual...The Information may be critical at some point (sorry but you put Dr. In front of your name, even if its just an affectation in an online forum you should be 100% ...perfect in your information) 

Sorry to be aggressive/ hit and run here...it sucks I know....I'm not interested in a Troll on Troll fight .... I know you will want to respond....and rightfully so, I threw a couple of stones at you...I'm going to respond or continue the thead...honestly I'm unlikely to even read your response....life is way to short ....
It was just a hypothetical question and I had real time experience that I wanted to relate, because you never know, someone might remember it when it fit their situation .....


----------



## Summit

css said:


> I didn't ask for a response or want one


And yet... here ya are...



> Sorry to be aggressive/ hit and run here...it sucks I know....I'm not interested in a Troll on Troll fight


And yet... here ya are...



> I have a considerable amount of exposure to emergency situations and behaviors that result from stress.  Please take a moment and research...


Please state your healthcare education/licensure, and experience? We know DrP is an experienced fire medic with over a decade of practice. That doesn't make him always right, but what is your basis because you haven't actually pointed out factually errors, much less provided counterclaims, just insinuated that others need to bow to your experience and "research" and "read"?


----------



## CALEMT




----------



## DesertMedic66

css said:


> Interesting.....it seems you are simply being critical here ...just for the sake of having something to say.....
> 
> I didn't ask for a response or want one, I was simply relating an experience that resembled the original question.
> 
> A What if ...hiking in the woods ....no epi pen,only Diphenhydramine...
> 
> I'm from a very large extended east coast family, several generations, fire, police and medicine. I know the lay of the land.Hell, some of them were the true blue old guard, I mean the real deal, the men that the nubes would here stories about and eveyone would stand up straight and tall when they walked into a station.
> 
> I have a considerable amount of exposure to emergency situations and behaviors that result from stress. And personally, I have been under intense combative situations and been pushed to my extremes.I have an very clear idea of my physical limitations and capabilities...I have had the conversation you are talking about given to me and provided it on anothers behalf ...if you ever have the misfortune to give news of that nature to someone you will never again use that example, its not a toy to play with...
> 
> ..... Just from your response here you are over confident which is more dangerous than just ignorant, the over confident guy or gal is most terrifying one to have your back in any situation.
> 
> Please take a moment and research... Your not exactly wrong but your a bit off on accuracy..... PLEASE DO NOT GOOGLE IT! Just a few seconds with a Merck manual...The Information may be critical at some point (sorry but you put Dr. In front of your name, even if its just an affectation in an online forum you should be 100% ...perfect in your information)
> 
> Sorry to be aggressive/ hit and run here...it sucks I know....I'm not interested in a Troll on Troll fight .... I know you will want to respond....and rightfully so, I threw a couple of stones at you...I'm going to respond or continue the thead...honestly I'm unlikely to even read your response....life is way to short ....
> It was just a hypothetical question and I had real time experience that I wanted to relate, because you never know, someone might remember it when it fit their situation .....


TYFYS


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## DrParasite

You know, I was gonna let it go.... but it's a slow day at work......


css said:


> Interesting.....it seems you are simply being critical here ...just for the sake of having something to say.....
> 
> I didn't ask for a response or want one, I was simply relating an experience that resembled the original question.


you came here, and posted your story..... your experience is not invalid, however there are several things about it that I wanted to point out.  Sorry your feelings were hurt.





css said:


> A What if ...hiking in the woods ....no epi pen,only Diphenhydramine...


so pop as much Diphenhydramine until you fall asleep, especially if that's all you have.  

how about this: What if ...hiking in the woods ....no epi pen, no Diphenhydramine, only dihydrogen monoxide... now what should you do?  well, in that case, i'd say get as ampped up as possible, hope your body's natural fight or flight response kicks in (maybe challenge a bear to a wrestling match), and pray that your own adrenal glands dumps enough epinephrine into your system to stop the anapylactic reaction before your throat swells shut and you pass out.  I mean, it's better than doing nothing, and just dying in the middle of the woods.....  but it's also completely hypothetical, not all that realistic and has nothing to do with your story.  Especially because in your "story," those that could have given you the epi were just a phone call away, but you didn't want them to come.


css said:


> I'm from a very large extended east coast family, several generations, fire, police and medicine. I know the lay of the land.Hell, some of them were the true blue old guard, I mean the real deal, the men that the nubes would here stories about and everyone would stand up straight and tall when they walked into a station.


I'm sure your family is awesome.  And if they were with you, they might even be able to give you some sound advice.  Even better if one of your family members was an ER physician (which I am not).  Heck, my great great great grandfather was in a general in the military, but that doesn't make me an expert in strategist for how to invade France....  Nor should anyone salute me when I walked into a station.  but it's not really relevant, but it's cool that you have some awesome family members.


css said:


> I have a considerable amount of exposure to emergency situations and behaviors that result from stress. And personally, I have been under intense combative situations and been pushed to my extremes.I have an very clear idea of my physical limitations and capabilities...I have had the conversation you are talking about given to me and provided it on anothers behalf ...if you ever have the misfortune to give news of that nature to someone you will never again use that example, its not a toy to play with...


 not really relevant, but thank you for your service. 


css said:


> ..... Just from your response here you are over confident which is more dangerous than just ignorant, the over confident guy or gal is most terrifying one to have your back in any situation.
> 
> Please take a moment and research... Your not exactly wrong but your a bit off on accuracy..... PLEASE DO NOT GOOGLE IT! Just a few seconds with a Merck manual...The Information may be critical at some point (sorry but you put Dr. In front of your name, even if its just an affectation in an online forum you should be 100% ...perfect in your information)


Hey, I'm not perfect.... if i'm wrong, feel free to explain why, and cite your source.    You have 0 medical training, 0 medical education, and but you have family members in the know....  you'll forgive me if I don't just take your word for it.

I've even help you get started, from some people who are smarter and more educated than me:
Epinephrine: The Drug of Choice for Anaphylaxis--A Statement of the World Allergy Organization
https://www.foodallergy.org/about-fare/blog/know-the-difference-epinephrine-vs-antihistamines 
https://allergynat.com/2017/11/11/the-correlation-between-benadryl-epinephrine-and-anaphylaxis/ 
https://www.aafp.org/afp/2003/1001/p1325.html 
https://www.mayoclinic.org/first-aid/first-aid-anaphylaxis/basics/art-20056608 


css said:


> Sorry to be aggressive/ hit and run here...it sucks I know....I'm not interested in a Troll on Troll fight .... I know you will want to respond....and rightfully so, I threw a couple of stones at you...I'm going to respond or continue the thead...honestly I'm unlikely to even read your response....life is way to short ....
> It was just a hypothetical question and I had real time experience that I wanted to relate, because you never know, someone might remember it when it fit their situation .....


ahhh, so you're just here to be a troll.  at least you can admit it.  Like I said, it's a slow day, otherwise I would just ignore you.

how about this: your story was exciting.  you did some very dangerous things during a potentially life threatening medical emergency, which were dangerous because you didn't care about the potential consequences of your actions, or you were ignorant to the seriousness of your acute medical emergency.  Did you survive?  of course.  could it have went another way?  of course.  if it had gone the other way, would you have died, and taken out several innocents with you?  well........

I don't care If you don't read my response.  Seriously, I don't (other than to learn where I was wrong, and read the sources you used to gain that information, since I can learn something new every day).  What I don't want to happen is some other person who does read your initial post, and tries something that is potentially dangerous, because "some guy on the internet said it worked for him."  Or some newbie EMS person says "we don't need epi (for this classic symptoms of an anapylactic reaction), the person I can just give the guy some OTC benadryl and he will be fine." Or even worse, some random person googles their symptoms, comes to your story, decides to just some benadryl and drive to urgent care, but deteriorates and crashes into my car, killing or injuring me or my family.  That's what i'm trying to avoid.

But your a troll, so I'll let you go back to trolling.


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## Tigger

css said:


> Sorry to be aggressive/ hit and run here...it sucks I know....I'm not interested in a Troll on Troll fight .... I know you will want to respond....and rightfully so, I threw a couple of stones at you...I'm going to respond or continue the thead...honestly I'm unlikely to even read your response....life is way to short ....
> It was just a hypothetical question and I had real time experience that I wanted to relate, because you never know, someone might remember it when it fit their situation .....


...turns out medicine isn't practice based on someone's personal experiences..


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## johnrsemt

No one thought of the obvious answer:  I always carried and use children's Benadryl.  it is liquid so it absorbs fast, and it tastes ok.

Where I used to work the Medical Director wrote the protocols. So every county could have different protocols,  although our medical director was the director for about 15 counties:    So when I was working for the FD, in Indianapolis and a private service we had the same protocols (same medical director).  

  But when I went to work 2 summers at a Boy Scout Summer Camp as a Basic, our Medical Director was a GP doctor who wrote our protocols, with input from my partner and I; and our Medical Director and the Medical Director at the local hospital.  We had about 30 OTC medications we could give, plus Epi 1:1,000; IM Diphenhydramine, Zofran ODT, and quiet a few others.  But we were 35 miles from closest Medic truck and 45 miles from closest ED  and 75 miles from closest helicopter.  With 1,200 Scouts and leaders that changed every week.
  We could also call the hospital when the blank hit the fan.  The transporting medics bi***ed about the fact we had better protocols than they did.

  Did the same type of thing with church camps and Scout Backpacking trips


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## Phillyrube

I was cutting grass a few years ago and hit a yellow jacket nest.  You know them...flying *** holes.  I turned and ran to the house, running into a tree branch sticking out and cutting my nose.  So I present to the wife with a bloody face and multiple stings on my leg.  Forget the face, my leg is starting to swell.  No known allergies, no breathing issues.  Took 100 mg benadryl and fell asleep (SWMBO monitored).  Woke two hours later, another 100 mg and more sleep.   Everything returned to normal so chemical warfare ensued in the yard.

Had a normal check up the following week and mentioned this to my MD.  I ended up with a scrip for epi pens after getting chewed out for being a "dang paramedics always treating yourselves."

Been stung since but no reactions.


"how about this: What if ...hiking in the woods ....no epi pen, no Diphenhydramine, only dihydrogen monoxide... now what should you do? "

Hey that crap is dangerous.  Vapor form is really bad if inhaled.


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## RedBlanketRunner

DrParasite said:


> maybe challenge a bear to a wrestling match


Definitely IV drip+.


css said:


> I have a considerable amount of exposure to emergency situations and behaviors that result from stress. And personally, I have been under intense combative situations and been pushed to my extremes.I have an very clear idea of my physical limitations and capabilities..


Wildlife relocation expert outside Yosemite waking up to a playful cougar kitten landing on his chest: Oh look at the naked man doing the 3 minute mile through our campsite.


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## NomadicMedic

Is it just me, or has this site totally gone sideways?


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## CALEMT

NomadicMedic said:


> Is it just me, or has this site totally gone sideways?



The future is now old man... next thing we know you're going to be yelling at us to get off your lawn and that theres no school like the old school.


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## DesertMedic66

CALEMT said:


> The future is now old man... next thing we know you're going to be yelling at us to get off your lawn and that theres no school like the old school.


Ok boomer


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## VentMonkey

NomadicMedic said:


> Is it just me, or has this site totally gone sideways?


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## RedBlanketRunner

"And up is down and sideways is straight ahead" -Cord the seeker

Returning to the original OP...


Alpiner said:


> Your 6 miles in the woods hiking with some buddies with no cell signal when one of your buddies gets stung by a bee, tells you he is deathly allergic and isn't carrying epi. Your other friends leave to go get help while you stay with your buddy who is showing signs of anaphylaxis. You have a basic first aid kit with a few medications that includes antihistamine pills. What do you do?


_Monitor. If acute respiratory arrest occurs, not just labored breathing, perform an emergency tracheotomy.  Never administering anything by mouth in the event of a respiratory crisis. _From the (outdated?) AHA CPR handbook.


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## mgr22

RedBlanketRunner said:


> _Monitor. If acute respiratory arrest occurs, not just labored breathing, perform an emergency tracheotomy.  Never administering anything by mouth in the event of a respiratory crisis. _From the (outdated?) AHA CPR handbook.



If my buddy can talk, he's getting some of the oral antihistamine mentioned earlier. That might delay or prevent anaphylaxis, and I'm pretty sure the onset of action PO is at least as quick as IM.

As for a tracheostomy, I usually leave my kit at home right next to the umbrella, but I'm thinking I could use a tire iron and a screwdriver. The tire iron would be for sedation.


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## RedBlanketRunner

mgr22 said:


> If my buddy can talk,


It's not a respiratory crisis


mgr22 said:


> As for a tracheostomy,


Your patient is clinically dead. Go for it.


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## mgr22

RedBlanketRunner said:


> It's not a respiratory crisis



yet.


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## RedBlanketRunner

mgr22 said:


> yet.


Grabbing the books...
_Mayo: antihistamines such as diphenhydramine (Benadryl), isn't sufficient to treat anaphylaxis. These medications can help relieve allergy symptoms, but work too slowly in a severe reaction.
* Non intervention - therapeutic
* Contraindicated - may complicate further diagnosis and treatment
* Contraindicated - may cause sedation/somnolence/sleepiness, drowsiness, unsteadiness, dizziness, _headache_, attention disturbance 
* Contraindicated - may cause tremors or convulsions
* Contraindicated - may cause gastrointestinal disturbance, nausea, vomiting,  epigastric distress 
* Contraindicated - may cause palpitations, hypotension, arrhythmia, tachycardia 
* Hypersensitivity - may cause angioedema, anaphylactic shock_

Of course, a lay person can administer anything that comes to hand but a person trained in trauma intervention should not go here.

Respiratory crisis: Gasping for breath. Unable to speak. Respirations have become mostly ineffective.
Tracheotomy. All else fails/unavailable. Keys have been used. Soft metal easily sharpened on a rock. Two small round sticks side by side are sufficient to keep the airway open and provide an air passage.


My personal take. Going into the wilderness means always carrying a first aid kit and the $50 insurance policy:


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## E tank

Having wanted to avoid this dumpster fire, and failed, I'd just like  make a point of order and say that I hope that the topic of surgical airway that is being batted about is actually referencing emergency cricothyroidotomy and not tracheostomy.


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## Summit

Anesthesia == triggered 😂


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## RedBlanketRunner

The etymology of the word tracheotomy comes from two Greek words: the root tom- (from Greek τομή tomḗ) meaning "to cut", and the word trachea (from Greek τραχεία tracheía). The word tracheostomy, including the root stom- (from Greek στόμα stóma) meaning "mouth," refers to the making of a semi-permanent or permanent opening, and to the opening itself. Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the stoma (hole) at the time it is created.

(I have done tracheotomys by the book. I leave tracheostomys to physicians. )


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## jgmedic

What in the actual **** has happened to this site. You have got to be kidding me.


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## CALEMT

Time to break out Michael... this is _almost _as good as the helicopter thread.


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## RedBlanketRunner

jgmedic said:


> What in the actual **** has happened to this site. You have got to be kidding me.


I'm new here. Clue me.
PS  Hey Hemet. I worked with you people twice. San Jac /Idylwild and Junction fires. What's your fav engine?


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## Peak

RedBlanketRunner said:


> It's not a respiratory crisis



Talking does not preclude the presence of respiratory/ventilatory/airway crisis.

Case study:

4 YOM presents to you with barking cough, I/E audible stridor at rest, moderate to severe suprasternal/supraclavicular retractions, moderate intercostal retractions, moderate subcostal retractions, abdominal accessory breathing, nasal flaring, positional comfort in a tripod position, his respiratory rate is limited by how fast he can move air in and out of his airway, dusky appearance to lips and nail beds, cap refill 4-5 seconds.

During exam the patient cries and in a hoarse voice says "I want my mommy."

Does this patient present in extremis?
If he can still swallow secretions are oral or IV steroids preferred?


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## RedBlanketRunner

@Peak That's helpful. I'm still going rote by the AHA guidelines. Lots has changed, obviously. AHA was dumbed down and black and white to get the general idea across to lay persons.
BTW, you brought up a very salient point. Being aware of the entirety of the patient. Nail beds, lips, overall skin appearance. Many things easily missed if the medic goes tunnel vision.


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## Gurby

RedBlanketRunner said:


> The etymology of the word tracheotomy comes from two Greek words: the root tom- (from Greek τομή tomḗ) meaning "to cut", and the word trachea (from Greek τραχεία tracheía). The word tracheostomy, including the root stom- (from Greek στόμα stóma) meaning "mouth," refers to the making of a semi-permanent or permanent opening, and to the opening itself. Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the stoma (hole) at the time it is created.
> 
> (I have done tracheotomys by the book. I leave tracheostomys to physicians. )




You are correct about the "ostomy" vs "otomy" thing.  
The key difference is "cricothyr-" vs "trache-".  

In a cricothyrotomy, you are cutting the cricothyroid membrane. This is apparently easier to do and has fewer complications.  In a tracheotomy/ostomy you are cutting in between the rings of the trachea which I guess is probably more difficult.


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## RedBlanketRunner

So what I've done was actually a crico....... Live and learn.

But really the whole point here should be you, the first responder, should not view that procedure as some esoteric surgery:


mgr22 said:


> As for a tracheostomy, I usually leave my kit at home right next to the umbrella, but I'm thinking I could use a tire iron and a screwdriver. The tire iron would be for sedation.


Dead is dead. Do something or stick your thumb up your wazoo and watch bio death resolve the issue for you.

Just to drive the point home (sorry about that turn of phrase) I 'm now going to stab this person in the neck with my Buck. POKE. Went in like cutting butter. Chest instantly expands. Cyanosis recedes to gone in less than a minute.


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## ffemt8978

RedBlanketRunner said:


> So what I've done was actually a crico....... Live and learn.
> 
> But really the whole point here should be you, the first responder, should not view that procedure as some esoteric surgery:
> 
> Dead is dead. Do something or stick your thumb up your wazoo and watch bio death resolve the issue for you.



Are you seriously advocating for a first responder to operate outside their scope  practice and training?


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## RedBlanketRunner

ffemt8978 said:


> Are you seriously advocating for a first responder to operate outside their scope practice and training?


*ABSOLUTELY!  *When the alternative is death. But when I was teaching CPR we were teaching airway management inclusive of trach/circ to lay persons. Hand the responsibility over to the Reasonable Person Doctrine taking circumstances into account. And please don't get me started on how CPR has been dumbed down into idiot proof little nibbles.


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## mgr22

RedBlanketRunner said:


> Grabbing the books...
> _Mayo: antihistamines such as diphenhydramine (Benadryl), isn't sufficient to treat anaphylaxis. These medications can help relieve allergy symptoms, but work too slowly in a severe reaction.
> * Non intervention - therapeutic
> * Contraindicated - may complicate further diagnosis and treatment
> * Contraindicated - may cause sedation/somnolence/sleepiness, drowsiness, unsteadiness, dizziness, _headache_, attention disturbance
> * Contraindicated - may cause tremors or convulsions
> * Contraindicated - may cause gastrointestinal disturbance, nausea, vomiting,  epigastric distress
> * Contraindicated - may cause palpitations, hypotension, arrhythmia, tachycardia
> * Hypersensitivity - may cause angioedema, anaphylactic shock_
> 
> Of course, a lay person can administer anything that comes to hand but a person trained in trauma intervention should not go here.
> 
> Respiratory crisis: Gasping for breath. Unable to speak. Respirations have become mostly ineffective.
> Tracheotomy. All else fails/unavailable. Keys have been used. Soft metal easily sharpened on a rock. Two small round sticks side by side are sufficient to keep the airway open and provide an air passage.
> 
> 
> My personal take. Going into the wilderness means always carrying a first aid kit and the $50 insurance policy:



So, we've gone from a hypothetical case about a wilderness emergency with limited resources to an illustrated lecture on the dangers of diphenhydramine. Would it be okay if we rolled the tape back to the pretend part of this topic and ditched the Mayo Clinic caveats? Better yet, I'm going to agree with the comment about a thread off the rails and try to find something more constructive to do, like deworming the dog.


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## RedBlanketRunner

mgr22 said:


> So, we've gone from a hypothetical case about a wilderness emergency with limited resources to an illustrated lecture on the dangers of diphenhydramine.


*No. The OP specifically uses the words "antihistamine pills", "Benadryl" and "anaphylaxis". I read right out of the books regarding the use of diphenhydramine, Benadryl, in the event of an anaphylactic episode. *


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## Summit

Maybe if we don't feed it, it will go back under the bridgr


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## RedBlanketRunner

ffemt8978 said:


> Are you seriously advocating for a first responder to operate outside their scope practice and training?


Quick question. What do you think that responder should do?


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## ffemt8978

RedBlanketRunner said:


> Quick question. What do you think that responder should do?



I have no issue with those that are properly trained and equipped performing the procedure when indicated.  My issue is that First Responders do not fall into that category.

I expect them to realize that they are not a doctor, they they legally are not allowed to practice medicine like one, that they can't save everyone, and remember that Good Samaritan laws generally don't cover what is viewed as an advanced or surgical procedure.

I understand that where you are the rules are different, but you need to remember that the rules have changed here in the US since you left. Many members on this forum have fought for years to rid EMS of the wild west mentality that you are advocating.

But hey, if you want to go to prison for years, and lose everything you own to lawsuits that is your choice but please don't encourage our newer members into believing this type of attitude is allowed or even encouraged in today's world.


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## silver

ffemt8978 said:


> I have no issue with those that are properly trained and equipped performing the procedure when indicated.  My issue is that First Responders do not fall into that category.
> 
> I expect them to realize that they are not a doctor, they they legally are not allowed to practice medicine like one, that they can't save everyone, and remember that Good Samaritan laws generally don't cover what is viewed as an advanced or surgical procedure.
> 
> I understand that where you are the rules are different, but you need to remember that the rules have changed here in the US since you left. Many members on this forum have fought for years to rid EMS of the wild west mentality that you are advocating.
> 
> But hey, if you want to go to prison for years, and lose everything you own to lawsuits that is your choice but please don't encourage our newer members into believing this type of attitude is allowed or even encouraged in today's world.



Even individuals well educated in anatomy and the practice of medicine have a hard time reliably identifying the cricothyroid membrane. So its going to be much much worse for a first responder not trained specifically in it...


----------

