Epi

[Remeber343]

Hello Everyone!

I have been thinking about different uses for EPI, in our region, we have just moved away from Epi-Pens and have gone to amps. We draw up our own now, apparently cheaper, anyway, back to the question!

We are a fairly medic heavy county, but there has been quite a few times where all the medics are on fires and EMTs are the only ones to respond.

Our protocols state we can our epi for Anaphylaxis. During our monthly ongoing training we were also told that if no medics were available, and you had a sever asthma pt, we are able to call medical control with pt info, state you want to give your epi for ____ reasons and they would give it a green light. So my question is, if all medics are out on fire, or for some reason tones are going like crazy and there is none to cover, and tones drop for a decent trauma. The pt's vitals are starting to decompensate, what would be your thoughts on calling med control, giving them the pt info, saying no medics are available, and that you would like to give epi for vasoconstriction because their BP is in the tiolet. I'm not sure how much of an effect it would have, but our transport times are usually 20-40mins to the nearest hospital. Any ideas? It came to me the other night and i figured i'd ask here. The only thing EMT-Bs can really do is trendelenburg (which isn't all that effective because we are only able to get the feet up and not the whole body) blankets, and treat for shock/hemorrhaging the best you can.

Thanks in advance!

 

[Cawolf86]

That's why people not trained in pharmacology shouldn't be given a drug they don't know anything about. Not to be harsh - but that sort of intervention would do a lot more harm than good. If they are bleeding and hypotensive from trauma - their body ALREADY is releasing epinephrine. That's why they may be tachy, pale, cool, and diaphoretic. They need surgery and maybe some fluid in the meantime. So no, just no.

 

[the_negro_puppy]

Hello Everyone!

I have been thinking about different uses for EPI, in our region, we have just moved away from Epi-Pens and have gone to amps. We draw up our own now, apparently cheaper, anyway, back to the question!

We are a fairly medic heavy county, but there has been quite a few times where all the medics are on fires and EMTs are the only ones to respond.

Our protocols state we can our epi for Anaphylaxis. During our monthly ongoing training we were also told that if no medics were available, and you had a sever asthma pt, we are able to call medical control with pt info, state you want to give your epi for ____ reasons and they would give it a green light. So my question is, if all medics are out on fire, or for some reason tones are going like crazy and there is none to cover, and tones drop for a decent trauma. The pt's vitals are starting to decompensate, what would be your thoughts on calling med control, giving them the pt info, saying no medics are available, and that you would like to give epi for vasoconstriction because their BP is in the tiolet. I'm not sure how much of an effect it would have, but our transport times are usually 20-40mins to the nearest hospital. Any ideas? It came to me the other night and i figured i'd ask here. The only thing EMT-Bs can really do is trendelenburg (which isn't all that effective because we are only able to get the feet up and not the whole body) blankets, and treat for shock/hemorrhaging the best you can.

Thanks in advance!

Giving adrenaline is a no-no for haemorrhagic shock. Read up a bit on the pathophysiology of the different type of shock and this might give you a better understanding of why.

Intensive care paramedics here can give small amounts of adrenaline to treat shock (excluding haemorrhagic) to patients that are unresponsive to fluid resus.

Even if you could give it, I assume you can't even place them on a cardiac monitor? a haemorrhagic shock patient is hypovolemic and needs volume replacement as a priority. They will already be tachycardic and peripherally vasoconstricted and you want to give them a drug that will increase the force of contraction and rate of the heart?

A more realistic questions would be to seek a medical consult to give epi IM for asthma imminent arrest

 

[systemet]

Hello Everyone!

So my question is, if all medics are out on fire, or for some reason tones are going like crazy and there is none to cover, and tones drop for a decent trauma. The pt's vitals are starting to decompensate, what would be your thoughts on calling med control, giving them the pt info, saying no medics are available, and that you would like to give epi for vasoconstriction because their BP is in the tiolet.

As others have pointed out, pressor use in trauma is very controversial.

Your major issues here are a loss of volume, causing a decrease in stroke volume, and a loss of oxygen carrying capacity, i.e. RBCs (anemia).

The body attempts to increase stroke volume by stimulating the heart (inotropy), and attempts to maintain cardiac output by increasing heart rate (CO = HR * SV). It also attempts to increase peripheral vascular resistance, to maintain blood pressure, i.e. BP = CO * SVR. For smaller amounts of blood loss, these mechanisms may be able to preserve the pressure.

We can attempt to replace volume with crystalloid, e.g. normal saline, Ringer's. If this fluid remains in the vascular space, it will increase stroke volume. But we've done nothing to replace the lost red blood cells, so we have no increase in oxygen carrying capacity. So much of this increase in stroke volume is useless -- we're just hoping that even if we've diluted our red blood cells, that more of them move through hypoxic tissue beds, and that we increase oxygen delivery.

A major risk with this approach is that we dilute out clotting factors, and as we increase pressure we can increase the rate of hemorrhage (more loss of RBCs).

Now if we give epinephrine, we introduce additional problems. The primary action is to cause vasoconstriction. As BP = CO * PVR, we may increase blood pressure, if the cardiac output stays the same or increases. But this carries with it the same risk of accelerating hemorrhage, compounding our original problem.

We've also created an additional problem. By increasing peripheral vascular resistance (or afterload), we've increase the force the heart has to pump against. So we run the risk of further decreasing stroke volume ---- compounding our original problem!

Now our epinephrine produces tachycardia, which may help maintain cardiac output (CO = HR * SV). But, there's a limit to how much tachycardia we have, before there's inadequate ventricular filling time, which will reduce stroke volume, so that even though HR is increasing, SV decreases more rapidly, producing a decreased CO. Again, compounding our original problem.

On top of this, we've now produced supraphysiologic vasoconstriction in many of our organ beds, setting ourselves up for ischemic injury to the gut, which is going to compound in-hospital management, and increase the risk of sepsis. Compounding our original problem.

And we now have to think about cardiac ischemia. If we increase heart rate, increase afterload, and increase inotropy, we're producing a massive increase in cardiac oxygen demand. If mean arterial pressure falls as a result of epinephrine, which is a risk, then we've also compromised supply. So this can produce or worsen cardiac ischemia, leading to myocardial irritability and VF / VT. Compounding our original problem.

Even giving epinephrine, or other pressors, IV with a controlled infusion is fraught with hazard. Trying to produce stable plasma concentrations if you're giving it IM or SQ in a hypoperfused state is going to be... well.. impossible. In short, this is a very bad idea, for a number of reasons.

 

[MedicJon88]

Another point- You are probably only trained to give the EPI SC and maybe IM... making it only ideal for anaphylaxis and other related respiratory symptoms due to long onset time, and previously mentioned absorption/dosage control problem. Plus there are different dosages/concentration for different things.. you can't just dump ampules of epi into a patient...

However, for Bradycardia and hypotension to the point of syncope with obvious signs of poor systemic perfusion... I can see medical control giving the good ahead for Epi administration in addition to the BLS interventions such as supplemental O2 and Trendelenburg- when expecting long transporting times...

but definitely not for hypotension due to hemorrhage.

 

[18G]

No need to repeat what has already been said... but definitely a BIG NO for epi in the primary trauma patient.

 

[usafmedic45]

So my question is, if all medics are out on fire, or for some reason tones are going like crazy and there is none to cover, and tones drop for a decent trauma. The pt's vitals are starting to decompensate, what would be your thoughts on calling med control, giving them the pt info, saying no medics are available, and that you would like to give epi for vasoconstriction because their BP is in the tiolet.

Sure if you want to make them bleed more and pretty much otherwise screw them over.

During our monthly ongoing training we were also told that if no medics were available, and you had a sever asthma pt, we are able to call medical control with pt info, state you want to give your epi for ____ reasons and they would give it a green light.

I seriously doubt any compotent emergency physician is going to "green light" a basic EMT pushing epi on an asthmatic especially given what a crap job most of them do on judging "severe" asthma. Can you give albuterol? That's a much safer option for asthmatics and you're a lot less likely to add "myocardial infarction" to the patient's list of problems. Even in hospital, I am hesitant to give epi to an adult asthmatic no matter how severe their symptoms.

 

[18G]

Sure if you want to make them bleed more and pretty much otherwise screw them over.


I seriously doubt any compotent emergency physician is going to "green light" a basic EMT pushing epi on an asthmatic especially given what a crap job most of them do on judging "severe" asthma. Can you give albuterol? That's a much safer option for asthmatics and you're a lot less likely to add "myocardial infarction" to the patient's list of problems. Even in hospital, I am hesitant to give epi to an adult asthmatic no matter how severe their symptoms.

It's interesting to hear that you are that hesitant about giving IM epi to a severe asthma patient not responding well to albuterol/atrovent and CPAP.

How do you feel about terbutaline in place of Epi?

 

[usafmedic45]

It's interesting to hear that you are that hesitant about giving IM epi to a severe asthma patient not responding well to albuterol/atrovent and CPAP.

How do you feel about terbutaline in place of Epi?

I'm much more comfortable with terbutaline and it was used in the field for this purpose where I used to work. If the patient isn't responding to maximal therapy (BiPAP, albuterol, steroids, mag, etc) they need to be tubed. Repeated doses of albuterol will tend to have already maxed out the sympathetic bronchodilator effects before you would ever get to epi. Especially in patients over the age of 30 the risk of myocardial ischemia is simply too high to warrant routine use of epi in severe asthmatics. If you don't have medics available, drive faster to somewhere with the capability of fixing the problem.

 

[Shishkabob]

Giving adrenaline is a no-no for haemorrhagic shock.

Correction: Epi is not used for UNCONTROLLED hemorrhagic shock. I have seen its use in the ICU for certain trauma patients, but it, like Dopamine and Levophed, is a last ditch type of thing, and not something to be done in the field with relatively short transports (even 40 minute transports) but from what I was able to gather, it wasn't necessarily due to only the hemorrhage but due to several factors.



The BEST thing would be give blood, but we don't always have the option.




Permissive hypotension with IV fluids is the name of the game. And it's no where near what an EMT should be able to do.

 

[18G]

I'm much more comfortable with terbutaline and it was used in the field for this purpose where I used to work. If the patient isn't responding to maximal therapy (BiPAP, albuterol, steroids, mag, etc) they need to be tubed. Repeated doses of albuterol will tend to have already maxed out the sympathetic bronchodilator effects before you would ever get to epi. Especially in patients over the age of 30 the risk of myocardial ischemia is simply too high to warrant routine use of epi in severe asthmatics. If you don't have medics available, drive faster to somewhere with the capability of fixing the problem.

My thinking is this... if an asthma patient is so bronchoconstricted with such a decreased tidal volume where nebulized medication can't reach its target area, IM epi or terbutaline is a must. Hopefully, after the IM epi or terbutaline tidal volume can increase enough to allow for good delivery of the inhaled medications.

Agree, IM epi should be given only in cases of real severity and not jumped to quickly. Even if we intubate these patients in extremis, we now have caused a further increase in airway resistance and have new problems to deal with without fixing the underlying problem.

 

[usafmedic45]

My thinking is this... if an asthma patient is so bronchoconstricted with such a decreased tidal volume where nebulized medication can't reach its target area, IM epi or terbutaline is a must. Hopefully, after the IM epi or terbutaline tidal volume can increase enough to allow for good delivery of the inhaled medications.

Which is one reason why we should stop being so :censored::censored::censored::censored:ing stubborn and start doing what the rest of the world does: IV albuterol (or rather, salbutamol). The idea of nebulized medications is actually rather inane unless you have a compelling reason not to give it IV.

 

[Shishkabob]

I've given Epi to 2 asthmatics... one I ended up RSIing, the other I did not. One was too far gone for the Epi to have had the desired effects, and the other it worked for. One old, one young. <_<