Epi for anaphylaxis route

[LanceCorpsman]

This may be a dumb question. But I am new to this world and have a genuine question. On our standing orders EMTs, AEMTs, and EMT-Is are only allowed to administer Epi Sub Q. Where as Medics can administer IM. I understand that IM works faster, how come it is restricted to medics? What is the difference?

 

[Summit]

IM works. SC doesn't really work for this drug/indication.

If they won't let you draw up and inject IM (and into the thigh), then they should give you EpiPens. If you are giving an Epi Pen, it is going IM and in the thigh.

SC Epi sucks for anaphylaxis as in placebo level suckage: http://www.jacionline.org/article/S0091-6749(01)71625-9/fulltext

 

[EpiEMS]

Kind of surprising that your protocols are like that. I don't think I've ever seen state protocols allowing SubQ but not IM for epi (for non-paramedic providers).

 

[LanceCorpsman]

IM works. SC doesn't really work for this drug/indication.

If they won't let you draw up and inject IM (and into the thigh), then they should give you EpiPens. If you are giving an Epi Pen, it is going IM and in the thigh.

SC Epi sucks for anaphylaxis as in placebo level suckage: http://www.jacionline.org/article/S0091-6749(01)71625-9/fulltext

Our ambulance won't carry epipens due to budget issues. We get them in little viles, I was just curious because I had a peds anaphylactic patient and the SQ didnt do anything.

 

[Summit]

Show them that blinded RCT with a 6 way crossover that I linked to. Maybe they'll change their minds. We have EMTs doing IM epi draw up (we had epi pens but ditched them as it was too expensive).

 

[medichopeful]

Our ambulance won't carry epipens due to budget issues. We get them in little viles, I was just curious because I had a peds anaphylactic patient and the SQ didnt do anything.

IM is generally better for anaphylaxis. Remember, when the body shunts blood, the skin is one of the first things to lose perfusion.

There's also IV epi for anaphylaxis, but it's a different concentration then IM/SC epi.

 

[Summit]

There's also IV epi for anaphylaxis, but it's a different concentration then IM/SC epi.

IV epi would typically be for refractory anaphylaxis and is typically done as an IV drip through a central line with an IV pump (1mg in 250mL NS unless you double concentrate).

One could dilute cardiac epi (1:10K) 1:10 so you have 100mcg/ml and push it a mL at a time as a bolus dose and be OK with a PIV... but I don't know of any EMS protocol covering that.

 

[TransportJockey]

IV epi would typically be for refractory anaphylaxis and is typically done as an IV drip through a central line with an IV pump (1mg in 250mL NS unless you double concentrate).

One could dilute cardiac epi (1:10K) 1:10 so you have 100mcg/ml and push it a mL at a time as a bolus dose and be OK with a PIV... but I don't know of any EMS protocol covering that.

I've never heard of doing a dose like push dose pressors for anaphylaxis. We do it for hypotension, not reactions.

 

[Summit]

I've never heard of doing a dose like push dose pressors for anaphylaxis.

Me neither... thus the 'could' in response to the other post... can't think of a good reason for 'should.'

 

[SomeGuy9005]

In our guidelines we can give 50-100mcg Epi IV in cases of extremis.

 

[medichopeful]

Me neither... thus the 'could' in response to the other post... can't think of a good reason for 'should.'

IV epi is definitely not a first line treatment in most cases, but the option is out there! As was mentioned by others and below, there are risks and side effects for this route.

Here's some discussions on it and some examples of protocols where it exists:
http://www.aaaai.org/ask-the-expert/epinephrine-in-anaphylaxis
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129903/
http://www.wakegov.com/ems/medical/Documents/WCEMSS Standards and Practice 2016 FINAL 6-1-2016.pdf (see page 138)
http://www.mass.gov/eohhs/docs/dph/emergency-services/treatment-protocols-2015-1.pdf (see Protocol 2.2a)
https://www.sussexcountyde.gov/sites/default/files/PDFs/ems/2014 FINAL Paramedic standing orders.pdf (see page 19)
http://www.medscape.com/viewarticle/497498_8

This one below talks more about the IV infusion:
http://www.aafp.org/afp/2003/1001/p1325.html

 

[medichopeful]

Me neither... thus the 'could' in response to the other post... can't think of a good reason for 'should.'

I think the only real reason to use IV bolus epi for anaphylaxis would be peri-arrest (MAYBE also in refractory anaphylaxis, but unless it's peri-arrest I feel that an infusion would be better). Definitely shouldn't be the first line defense in all cases!

 

[medichopeful]

I think the only real reason to use IV bolus epi for anaphylaxis would be peri-arrest (MAYBE also in refractory anaphylaxis, but unless it's peri-arrest I feel that an infusion would be better). Definitely shouldn't be the first line treatment in all cases!