# Route of Epi Admin



## nwhitney (Nov 10, 2013)

Has anyone heard of administering an Epi-Pen straight into the pt's cheek? Anyone currently do this?


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## Carlos Danger (Nov 10, 2013)

In the cheek? No. Sublingually, yes.


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## teedubbyaw (Nov 10, 2013)

Are you referring to buccal?


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## broken stretcher (Nov 10, 2013)

I hope were not administering an Epi-Pen to the cheek lol thats a good way to get a piercing and a mouth full of epi!


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## Medic Tim (Nov 10, 2013)

we can give it via the Intralingual route


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## nwhitney (Nov 10, 2013)

I bring this up because I have a friend in dental hygiene school and this is taught during their emergency care course. They were taught to administer an Epi-pen straight into the pt's cheek or buccal. I had never heard this before.


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## medicdan (Nov 10, 2013)

Is it possible because many of the dental injections contain some epinephrine (especially the anesthetics), to decrease bleeding, your friend may have confused this, or the concentration/dose of epinephrine needed?


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## chaz90 (Nov 10, 2013)

nwhitney said:


> I bring this up because I have a friend in dental hygiene school and this is taught during their emergency care course. They were taught to administer an Epi-pen straight into the pt's cheek or buccal. I had never heard this before.



This is likely referring to the many local anesthetics that contain small concentrations of Epinephrine to promote vasoconstriction and reduce bleeding.


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## chaz90 (Nov 10, 2013)

Oops. Sorry for repeating Medicdan's point.


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## nwhitney (Nov 10, 2013)

medicdan said:


> Is it possible because many of the dental injections contain some epinephrine (especially the anesthetics), to decrease bleeding, your friend may have confused this, or the concentration/dose of epinephrine needed?



I suppose this could be the case but she was pretty clear that this was for anaphylaxis and not anything else.


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## NomadicMedic (Nov 10, 2013)

Ask to see the textbook where this procedure is described.


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## nwhitney (Nov 10, 2013)

DEmedic said:


> Ask to see the textbook where this procedure is described.



Good idea I'll do that.


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## Christopher (Nov 11, 2013)

Halothane said:


> In the cheek? No. Sublingually, yes.



This was news to me until I read a case report from the late 90's and then saw a Cook County critical care blog which stated it was a "*common *administration route" for epi for peds in cardiac arrest.



Medic Tim said:


> we can give it via the Intralingual route



So, exactly how common is this?


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## Medic Tim (Nov 11, 2013)

Christopher said:
			
		

> So, exactly how common is this?



I don't think it is used all that often. I only know a handful of medics that have done it.


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## chaz90 (Nov 11, 2013)

Medic Tim said:


> we can give it via the Intralingual route



Do you use this for localized airway swelling or an alternative route for peds during arrests as was mentioned?


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## Medic Tim (Nov 11, 2013)

chaz90 said:


> Do you use this for localized airway swelling or an alternative route for peds during arrests as was mentioned?



I have not seen it used in Ped cardiac arrest. I have only heard of it being used in anaphylaxis.


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## alexandermpd (Dec 4, 2013)

That's so weird


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## alexandermpd (Dec 4, 2013)

Never heard of anything like that lol


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## Handsome Robb (Dec 4, 2013)

Medic Tim said:


> I have not seen it used in Ped cardiac arrest. I have only heard of it being used in anaphylaxis.



Samsies


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## Carlos Danger (Dec 4, 2013)

Christopher said:


> This was news to me until I read a case report from the late 90's and then saw a Cook County critical care blog which stated it was a "*common *administration route" for epi for peds in cardiac arrest.



I never heard of it either until my anesthesia training. 

Pediatrics are often put to sleep with gas alone without an IV in place. If epi or sux or atropine are needed before the IV is started, they can be given IM or SL.

But I suppose it could be used for anyone, anytime you need to give an IM med.


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## mycrofft (Dec 4, 2013)

By "cheek" did she megan gluteus maximus?


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## mycrofft (Dec 4, 2013)

NIH says intralingual not as effective…in dogs and monkeys.
http://www.ncbi.nlm.nih.gov/pubmed/99706

NOTHING about buccal.


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## johnrsemt (Dec 10, 2013)

with a needle that is either 5//8 or 7/8 of an inch long (I don't remember which)  how can you put it in the cheek?   Plus how would you trigger it?  you can't push hard enough against the cheek to get it to fire:   and if you pushed it against the gum the patient would hit you:     getting a 27g needle of novacaine to numb the mouth for dental work hurts,  getting a 20 g needle in the gums would feel like a railroad spike


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## mycrofft (Dec 11, 2013)

Not to mention the infarct the epi will cause.


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## Handsome Robb (Dec 11, 2013)

johnrsemt said:


> with a needle that is either 5//8 or 7/8 of an inch long (I don't remember which)  how can you put it in the cheek?   Plus how would you trigger it?  you can't push hard enough against the cheek to get it to fire:   and if you pushed it against the gum the patient would hit you:     getting a 27g needle of novacaine to numb the mouth for dental work hurts,  getting a 20 g needle in the gums would feel like a railroad spike



That's a great point regarding the required pressure to trigger the auto-injector.


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## Underoath87 (Dec 17, 2013)

mycrofft said:


> By "cheek" did she mean gluteus maximus?



That has to be it ("butt cheek").  There's no way they're supposed to jab someone in the face with epi...


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## unleashedfury (Dec 18, 2013)

Is he even sure its a Epi Pen what about Sub Q?


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## KellyBracket (Dec 25, 2013)

nwhitney said:


> Has anyone heard of administering an Epi-Pen straight into the pt's cheek? Anyone currently do this?



There is good research about IM versus SQ epi (IM in the thigh is the way to go), and good research about the safety of IV drips of epi (Don't do boluses, lousy safety profile).

Basically no research on sublingual injections for anaphylaxis that I've ever found.

As for the cheek, no, I've not heard a thing. I wouldn't do that if I were you.


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## unleashedfury (Dec 26, 2013)

KellyBracket said:


> There is good research about IM versus SQ epi (IM in the thigh is the way to go), and good research about the safety of IV drips of epi (Don't do boluses, lousy safety profile).
> 
> Basically no research on sublingual injections for anaphylaxis that I've ever found.
> 
> As for the cheek, no, I've not heard a thing. I wouldn't do that if I were you.



Interesting, 

Now I know the SubQ Epi we carry is 1:1000 concentration The EPI Pen is a 1:2000 Concentration. Our protocol is SubQ so I guess until we catch up to the research. thats the preferred method. 

What about localized reactions such as angio edema? would direct injection Sub Q to the affected site or IM to the thigh be much more beneficial?


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## KellyBracket (Dec 26, 2013)

unleashedfury said:


> What about localized reactions such as angio edema? would direct injection Sub Q to the affected site or IM to the thigh be much more beneficial?



Epi is used locally in a few conditions. For example, epi is nebulized to treat the airway edema of croup. It is also injected into gastric mucosa under ulcers to staunch bleeding through vasoconstriction of the involved arteries.

Anaphylaxis is a systemic disease, however, so I'm not sure what role local therapy might, hypothetically, have. I've never seen any discussion of this, let alone research or evidence. Let me know if you find some!

(Sublingual injection may be in some EMS protocols, but that doesn't count as evidence!)


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## yowzer (Dec 26, 2013)

We're starting to move away from autoinjectors to manually drawn up and injected epi because of cost savings, but it's still just in the thigh.


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## unleashedfury (Dec 27, 2013)

KellyBracket said:


> Epi is used locally in a few conditions. For example, epi is nebulized to treat the airway edema of croup. It is also injected into gastric mucosa under ulcers to staunch bleeding through vasoconstriction of the involved arteries.
> 
> Anaphylaxis is a systemic disease, however, so I'm not sure what role local therapy might, hypothetically, have. I've never seen any discussion of this, let alone research or evidence. Let me know if you find some!
> 
> (Sublingual injection may be in some EMS protocols, but that doesn't count as evidence!)



Ahh the Epi Racemic. 
And forgot about the epi/lido mix, I've only seen it used once in emergency medicine where a ED doc used it to slow the bleeding of a ruptured varicose vein. I've seen it plenty used in dentist's offices for teeth fillings and extractions. 

I was just curious since like you said Anaphylaxis being systemic if there was any benefit of localized therapy. 
In my career I think I used Epi once to treat anaphylaxis, and that was the IM injection to the thigh most allergic reactions I get can benefit from diphenhydramine, and a good bronchiodialtor neb treatment. 

Sublingual epi is not part of our protocol. so this is the first I heard of the S/L route.


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