Allergic reaction meds

[cointosser13]

New medic student here. My class was running a simulation on a female who was having an allergic reaction. My role was to insert an IV in the dummy. Our lead (who is also a medic student) was telling us what specific roles we had. As I was inserting the IV, I kept getting mixed up in my head, what is the right process for an allergic reaction patient? We had a patient with a severe allergic reaction. There was audible wheezing, urticaria, and from what we were told, there was accessory muscle use. Lead told us to first give .3 mg of 1:1 Epi, then Benadryl. After we saw slight improvement, the lead told me to give the patient a nebulizer, with albuterol and Solu-medrol. Is this all correct? It was kind of confusing, and some how I have a feeling we got something mixed up. What do you do for a patient with an allergic reaction?

 

[STXmedic]

That all sounds good to me, with one clarification: Methylprednisolone is typically IV or IM (It's difficult to tell if you're referring to it being nebulized or not)

 

[Akulahawk]

Aside from not knowing exactly what route those meds were to be given, the meds themselves sound pretty standard as far as sequence they were to be given. In the future, when you're asking about medications, include the proposed route they're to be given because that very much can change things. As an example, Epi is normally given subcutaneously. Even through that route, it has a very fast onset. If you were to give the same dose by IV, the result would likely be a whole lot different than what you'd expect from the subcutaneous route...

In any event, I'm glad you're asking this stuff. It means you've got a desire to learn and that's not something that can be instilled in someone. We won't spoon-feed you the answers. We want you to really learn, so don't just ask away, tell us what you think and why, and we'll help you from there.

 

[broken stretcher]

Are there others out there with no capability to give meds Sub-Q? We can't so were giving .3-1:1000 IM

 

[STXmedic]

We used to give subcuteneous, but switched to intramuscular about two years ago.

 

[Aprz]

There's a very nice blog post about epinephrine SC vs IM.

http://millhillavecommand.blogspot.com/2012/08/new-guidelines-for-anaphylaxis.html

It's written by KellyBracket.

 

[Handsome Robb]

IM is preferred over SQ in anaphylaxis.

 

[TheLocalMedic]

There's a very nice blog post about epinephrine SC vs IM.

http://millhillavecommand.blogspot.com/2012/08/new-guidelines-for-anaphylaxis.html

It's written by KellyBracket.

Interesting that the thigh is emphasized over the deltoid... that isn't mentioned in our protocols at all, and I hadn't heard that before.

That being said, I had an anaphylaxis patient a few weeks ago that turned around after the second dose of Epi 1:1k IM in the deltoid. Seemed to work great, but that graph in the study on his blog definitely gives me pause...

 

[teedubbyaw]

I would have started with albuterol, but not knowing how severe the patient was, sounds good...as long as that 1:1 Epi wasn't given IV.

 

[chaz90]

I would have started with albuterol, but not knowing how severe the patient was, sounds good...as long as that 1:1 Epi wasn't given IV.

If it's anaphylaxis, it could be detrimental to delay Epi. In severe allergic reactions, epinephrine needs to be the first medication administered.

 

[STXmedic]

I would have started with albuterol, but not knowing how severe the patient was, sounds good...as long as that 1:1 Epi wasn't given IV.

Why can't 1:1000 be given IV? Other than IM being preferred (to not delay vascular access), and 1:10,000 being more convenient?

 

[jwk]

Lead told us to first give .3 mg of 1:1 Epi,

What is 1:1 epi?

 

[Akulahawk]

Why can't 1:1000 be given IV? Other than IM being preferred (to not delay vascular access), and 1:10,000 being more convenient?

While it can, you're basically making the entire 0.3mg of a very potent vasopressor, inotrope, and chronotrope immediately available. It's a lot like stomping on the gas of a powerful car while you're sitting at a stoplight. Everything suddenly revs up. Give that same dose very slowly, and IM/SC naturally does this, and it's more like having a heavy foot on the throttle but you're not mashing it down so that you're still launching off the line, but none of the drivetrain are immediately overstressed and you're not burning rubber. It's possible to do this IV but you have be extremely good at slow IV push. It's probably easier to control the epi dose as a drip than attempt to slowly push it.

 

[STXmedic]

Yes, it was an attempt to point out that it's the same dose of epi.

As was mentioned in another thread previously, 1:1000 can be put in to a IV line and infused in while the line runs.

But yes, IM is effective and typically preferred.

 

[Akulahawk]

Yes, it was an attempt to point out that it's the same dose of epi.

As was mentioned in another thread previously, 1:1000 can be put in to a IV line and infused in while the line runs.

But yes, IM is effective and typically preferred.

Oh, it's very much the same dose...

 

[KellyBracket]

Well, not much more for me to say here! I'm a little boggled by the delay in adopting the IM/thigh route, considering that it has been recommended for years by national and international organizations. Despite Twitter, #FOAMems, EMTLIFE, etc, change moves at a glacial pace in medicine!

One thought about giving epinephrine IV; it's a very easy way to screw up, and most of the complications and bad outcomes involve IV epinephrine given as a bolus. Although 100 - 300 µg IV is often described as "typical," there are plenty of case reports of cardiac problems (MI, arrhythmia) after giving that high a dose.

OTOH, delivering an infusion of epi, diluted in 500 - 1000 ml, is pretty darn safe. Very hard to screw up, but also effective. In my post "Anaphylaxis Knowledge Among Paramedics" I include the treatment protocol from an anaphylaxis study. They gave IV epi at a dose of 5 - 15 µg/minute, with very good outcomes.

Buuut, if you give that 0.3 mg of epi IV, instead of IM, that dose is 20 times what the anaphylaxis experts used!

I also reviewed a supposed epi-related MI in "'Cardiac anaphylaxis' after IM epinephrine?" Frankly, I don't believe this was an epi complication, but check it out!

 

[Akulahawk]

Well, not much more for me to say here! I'm a little boggled by the delay in adopting the IM/thigh route, considering that it has been recommended for years by national and international organizations. Despite Twitter, #FOAMems, EMTLIFE, etc, change moves at a glacial pace in medicine!

One thought about giving epinephrine IV; it's a very easy way to screw up, and most of the complications and bad outcomes involve IV epinephrine given as a bolus. Although 100 - 300 µg IV is often described as "typical," there are plenty of case reports of cardiac problems (MI, arrhythmia) after giving that high a dose.

OTOH, delivering an infusion of epi, diluted in 500 - 1000 ml, is pretty darn safe. Very hard to screw up, but also effective. In my post "Anaphylaxis Knowledge Among Paramedics" I include the treatment protocol from an anaphylaxis study. They gave IV epi at a dose of 5 - 15 µg/minute, with very good outcomes.

Buuut, if you give that 0.3 mg of epi IV, instead of IM, that dose is 20 times what the anaphylaxis experts used!

I also reviewed a supposed epi-related MI in "'Cardiac anaphylaxis' after IM epinephrine?" Frankly, I don't believe this was an epi complication, but check it out!

That was pretty much the point I was trying to make, that giving epinephrine as a bolus wouldn't be a good thing, that if you give it by IV, it's easier to control if you dilute it. You just said it a whole lot better! Thanks!!!

I must say that I'm sure I've heard from somewhere that the lateral thigh is a better spot... and not only because it's a larger target...

 

[KellyBracket]

I must say that I'm sure I've heard from somewhere that the lateral thigh is a better spot... and not only because it's a larger target...

From this study: Epinephrine absorption in adults: intramuscular versus subcutaneous injection.

I have the graph reproduced in the blog post that was mentioned early on. Pretty definitive graph - much early & higher epinephrine levels!

 

[the_negro_puppy]

Don't forget the IV NS bolus for marked hypotension.

 

[mycrofft]

Being able to titrate the administration of epi (anywhere from "Chinese Water Torture" to "Niagra Falls") sounds very good to me*.

The one shot/one dose epi thing seems to me to be a leftover from olden times (and Epipens).




*Mr Atrial Fib, who gets tight with dental lidocaine-plus-epi