Epipen when Pt is child

PeteBlair

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What would you do if you took a "bee sting call" and found a child (50 lbs) with obvious signs of severe anaphylaxis and all you carry on the truck are adult epi-pens?
 

Handsome Robb

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Per the manufacturer any child over 30 kg (66 lbs) should be prescribed an adult EpiPen.

You're kid is smaller than that but not by much, if they're peri-arrest I'd give it personally.

Look at it this way, the dosage for epi in anaphylaxis for pedis is 0.01mg/kg so at 50 lbs that's approximately 22.5kg so 0.23mg. that's right in between pedi and adult epi pens (0.15 and 0.30 respectively).
 
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teedubbyaw

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Look at it this way, the dosage for epi in anaphylaxis for pedis is 0.01mg/kg so at 50 lbs that's approximately 22.5kg so 0.23mg. that's right in between pedi and adult epi pens (0.15 and 0.30 respectively).

I just typed this out and you edited in :ph34r:

What he said.
 

TheLocalMedic

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Anaphylaxis is deadly if untreated…

For the BLS provider: boogie out of there, call for an ALS rendezvous if possible, make base contact to get permission to use the epi pen, give O2 and treat for shock.

Bigest thing to be mindful of in kids is the increased workload on the heart due to tachycardia. Make sure you support their breathing and try to calm them.
 

Handsome Robb

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What if the child weighed approx. 30 lbs (per mother of child)?


Well I would never be stuck in this situation because we draw our meds.

But without congenital defects or a known history of cardiac problems id give it more often then not.
 

mycrofft

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Hmmmmmm. Got pediatric bendaryl orders?

Sidebar: while it is usually a bad idea to try to titrate antidotes without advanced life support or at least white tile and plenty of nurses around, is there something which could be given to soften the cardiac effects of epi? IS it worth the risk versus time for transport?
 

Medic Tim

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I would give it. With my transport times ( min 2 hours on a very good day)waiting would not be an option. Then again this would not happen to me as I draw meds and can also do iv/io epi if needed.

As for the 30 lb that would make me hesitate and administering it (adult epi pen)would depend on a number of variables . Distance to hospital , severity of reaction, progression, pts past hx. Is there a way to break into the pen and draw up the epi from there.

I can see this being a very difficult call for a BLS crew. Especially if you have a long transport an no ALS backup.
 

mycrofft

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Dishcharge the epipen into a red top blood tube (no additives) then draw it up with a syringe? Ask your medical controller.
 

Handsome Robb

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Hmmmmmm. Got pediatric bendaryl orders?

Sidebar: while it is usually a bad idea to try to titrate antidotes without advanced life support or at least white tile and plenty of nurses around, is there something which could be given to soften the cardiac effects of epi? IS it worth the risk versus time for transport?

While yea benedryl needs to be administered if it truly is an anaphylactic reaction mediated by igE then benedryl isn't going to cut it. It will block further histamine release but doesn't do anything for the massive systemic vasodilation that's already happening along with bronchoconstriction. The Epi is needed not only for it's pretty profound bronchodilatory effects but also the vasoconstriction. Once they're vasoconstricted they need fluids as well since they've third spaced so much already but you already know all of that.

I would give it. With my transport times ( min 2 hours on a very good day)waiting would not be an option. Then again this would not happen to me as I draw meds and can also do iv/io epi if needed.

As for the 30 lb that would make me hesitate and administering it (adult epi pen)would depend on a number of variables . Distance to hospital , severity of reaction, progression, pts past hx. Is there a way to break into the pen and draw up the epi from there.

I can see this being a very difficult call for a BLS crew. Especially if you have a long transport an no ALS backup.

At 30 kg they'd have to be peri-arrest for me to give an adult dose but at that point it's either do nothing and watch them die or do something and deal with the side effects. Definitely something OLMD needs to be involved in. Risk vs benefit. Yea there's risks but there's a massive benefit and on the other side of the coin, well we know where it's headed.

Another thought I had is there's multiple documented cases of pediatrics receiving multiple doses of IM and IV epinephrine and surviving or the reaction being refractory and still dying. Those doses are generally given close together albeit epi has a short half life at ~2 minutes.

Dishcharge the epipen into a red top blood tube (no additives) then draw it up with a syringe? Ask your medical controller.

That's a good idea, didn't even think of that. It would keep the medication as sterile as you're going to be able to. I'd bet if you were really proactive about aseptic technique you could keep it sterile. With that said, I have doubts as to if a BLS crew would have the supplies available to them for this.

You would think that pediatric epipens would be standard equipment if your agency allows administration of them....
 

mycrofft

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Thanks Robb

"While yes benedryl needs to be administered if it truly is an anaphylactic reaction mediated by igE then benedryl isn't going to cut it. It will block further histamine release but doesn't do anything for the massive systemic vasodilation that's already happening along with bronchoconstriction. The Epi is needed not only for it's pretty profound bronchodilatory effects but also the vasoconstriction. Once they're vasoconstricted they need fluids as well since they've third spaced so much already but you already know all of that. "

No, actually I was so drilled into "epi then benedryl" I had forgotten the "why" behind it. My workplace was a strange mix of "prehospital" and "definitive care". Thanks!

Then due to short half-life we need to make sure we have enough epi to keep things on an even keel if transport is long way. Keep in mind how long the trip is and how much epi is on hand.

Re the plain red top blood tube thing, I'll bet it is sterile if you leave the top in place, but I cannot be absolutely sure that all sterile debris are removed. (Even IV bags and tubing sets are found to have debris in them). Since this, if approved by control, is really "off label", I'd use a filter needle to draw up if available and if going IV. Sub-Q or IM, not so big a concern, just get a small sterile abscess.
 

Smash

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What would you do if you took a "bee sting call" and found a child (50 lbs) with obvious signs of severe anaphylaxis and all you carry on the truck are adult epi-pens?

Give it. Pt is smaller? Give it.
 

usalsfyre

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The main problem with adult epi pens is not dose, but rather needle size. The adults tend to be long enough to reach bone in pediatric patients.

As far as dose. An overdose of epi might (very small chance) kill a pedi. True anaphylaxis that's left untreated WILL kill your patient.
 

mycrofft

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Posterior hipshot?

We popped an expired one into an orange once. 3/4:censored:inch long fine needle.

The style they show in some videos is a little alarming, backfisting on a sitting pt same as self-admin on a standing pt. There are nerves and vessels and bone you don't want to be risking like that. I'd want to use a syringe if possible.
 

Smash

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As far as dose. An overdose of epi might (very small chance) kill a pedi. True anaphylaxis that's left untreated WILL kill your patient.

Damn right. The single biggest failure in the treatment of anaphylaxis is not giving epi. Irrational fear of epi must surely contribute.
 

mycrofft

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But creating an iatrogenic death is a valid concern. Especially in a child where you are starting out with certain knowledge that you are overdosing the patient. This is in combination with other potentially lethal contraindications (hyperthyroid, cardiac issues being two).

I think if your pants are long enough to give a drug, it ought to be given properly then; draw up the proper dose and give it, instead of relying on an automated and invariable-dose, expensive device. Either the protocol writers are lazy, or impressed by the convenience of the pen, or don't trust their practitioners. (If you consider it, the device wasn't invented for professional use but for use by a layperson in an emergency situation; I bet that comes out when someone tries to sue the manufacturer as well as the practitioner if someone gets the wrong dose).

So, this thread unearths two prime issues: how far do you trust your techs in the field, and how do you act when to do so may be as harmful as the condition you are reading? (The answer to #2 is…..)
 

mycrofft

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…same as in a hospital. Titrate to effects and monitor, and have either a countermeasure or an alternative treatment in your armamentarium.

The ED docs might have a good perspective on this. What condition patients would they rather receive?
 
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