Epipen when Pt is child

[chaz90]

And, the EpiPen needs to be given within five to ten minutes of exposure. How often do you get there that fast anyway?

What about the cases of anaphylaxis where primary symptoms don't even begin that soon? Clearly the earlier during the anaphylactic episode Epi can be given the better, but I don't know where this argument really comes into play.

 

[Tigger]

And, the EpiPen needs to be given within five to ten minutes of exposure. How often do you get there that fast anyway?

Go ahead and cite that then.

Seriously I'm not sure how you expect every patient presentation to fall neatly little into perfectly outlined protocol boxes. That's just not how it works and I have no idea where you come up with this stuff. If you can't use a little clinical judgement you have no business as a healthcare provider period. I

 

[Handsome Robb]

I'm going to agree, there is no reason epinephrine cannot be effective in the presence of anaphylaxis after 10 minutes. At 10 minutes the pathophysiology doesn't suddenly change. It's still an IgE mediated reaction.

Anaphylaxis occurs in minutes to hours after exposure to the allergen, it's not always instant.

 

[samiam]

Is there a way to break into the pen and draw up the epi from there.

Though I cannont "officially" recomend this there are a good 3 extra doses u can squeeze out in a
time/wilderness scenario. I will look for a video. They teach it unofficially in wilderness survival/medicine.
http://www.youtube.com/watch?v=Ug6FcA0d-30


Go about 3 min in unless u want to see some pretty pictures for 2 minuites. Again I am not "officially" recommending this.

 

[mycrofft]

Go ahead and cite that then.

Seriously I'm not sure how you expect every patient presentation to fall neatly little into perfectly outlined protocol boxes. That's just not how it works and I have no idea where you come up with this stuff. If you can't use a little clinical judgement you have no business as a healthcare provider period. I

http://www.medscape.com/viewarticle/726456_4

AND I QUOTE:
" Fatality studies suggest that in some patients, there is only a brief window of time during which the low first-aid dose of epinephrine is effective.[17,29–31]"...

17. Pumphrey RSH. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30:1144–1150.
27. Sheikh A, Ten Broek V, Brown SGA, Simons FER. H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2007; 62: 830–837.
28. Choo KJL, Simons FER, Sheikh A. Glucocorticoids for the treatment of anaphylaxis (review). Cochrane Database Syst Rev 2010;3:CD007596.
29. Bock SA, Munoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001–2006. J Allergy Clin Immunol 2007; 119:1016–1018.
30. Pumphrey RSH, Gowland MH. Further fatal allergic reactions to food in the United Kingdom, 1999–2006. J Allergy Clin Immunol 2007; 119:1018–1019.
31. Greenberger PA, Rotskoff BD, Lifschultz B. Fatal anaphylaxis: postmortem findings and associated comorbid diseases. Ann Allergy Asthma Immunol 2007; 98:252–257.
32. Smith PL, Kagey-Sobotka A, Bleecker ER, et al. Physiologic manifestations of human anaphylaxis. J Clin Invest 1980; 66:1072–1080.
33. Brown SGA, Blackman KE, Stenlake V, Heddle RJ. Insect sting anaphylaxis: prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. Emerg Med J 2004; 21:149–154.
===========================
A long article in a journal for and by allergists etc cites a W.H.O. statement that the risks of giving the medicine are outweighed by the risks of not giving it, and I quote again:

http://www.aaaai.org/ask-the-expert/when-administer-epinephrine.aspx

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666145/

" The committee strongly believes that epinephrine is currently underused and often dosed suboptimally to treat anaphylaxis, is underprescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate intramuscular doses."


Epi doesn't reverse anything that's occurred, it only temporarily staves off what's happening. It won't restore lost third-spaced volume from tissues to vessels. It will try to raise pressure to vital levels, but once things progress past a certain point, and that can be a short time, epi becomes less and less effective.

Professional discretion to me means using epi and a syringe where the practitioner judges the appropriate dose, draws it up, and administers it. As the article states and the manufacturer claims, Epipens are a first aid device.

I've obviously sidetracked this thread and I apologize.:blush:

PS: As of this past week, California, jogged by the mother of the young girl who died last year at Camp Sacramento of delayed treatment for a peanut allergy, is about to pass a law enabling schools and camps etc. to get and stock Epipens. It is unclear but apparently the law does not (yet) protect paid individuals from suit if THEY administer the injection.

 

[mycrofft]

1. I'm going to agree, there is no reason epinephrine cannot be effective in the presence of anaphylaxis after 10 minutes. At 10 minutes the pathophysiology doesn't suddenly change. It's still an IgE mediated reaction.

2. Anaphylaxis occurs in minutes to hours after exposure to the allergen, it's not always instant.

1. Pt size and immunological characteristics (recent exposure?) plus dose and route of allergen introduction affect speed of onset and rate of reaction progress.

2. Agreed.

 

[mycrofft]

What about the cases of anaphylaxis where primary symptoms don't even begin that soon? Clearly the earlier during the anaphylactic episode Epi can be given the better, but I don't know where this argument really comes into play.

It's a good argument and a quandary, since the first aid dose in an EpiPen is directed for only after s/s are perceived. If the young lady near Sacramento had been injected, instead of oral benedryl being given, and then promptly transported or at least 911 being called, she might likely have survived.

 

[mycrofft]

I'll stop hogging this. Press on.

 

[chaz90]

It's a good argument and a quandary, since the first aid dose in an EpiPen is directed for only after s/s are perceived. If the young lady near Sacramento had been injected, instead of oral benedryl being given, and then promptly transported or at least 911 being called, she might likely have survived.

My point was that earlier you appeared to imply that if epinephrine couldn't be given within 5-10 minutes it wouldn't be useful. I might have misunderstood your post, but it seemed like you didn't think epinephrine would still be useful further into the progression of symptoms. I understand your post discussing how epinephrine doesn't fix all problems from anaphylaxis (IE, fluid shift), but it certainly goes a long way.

 

[Brandon O]

Epi doesn't reverse anything that's occurred, it only temporarily staves off what's happening. It won't restore lost third-spaced volume from tissues to vessels. It will try to raise pressure to vital levels, but once things progress past a certain point, and that can be a short time, epi becomes less and less effective.

Professional discretion to me means using epi and a syringe where the practitioner judges the appropriate dose, draws it up, and administers it. As the article states and the manufacturer claims, Epipens are a first aid device.

So if I understand your argument, you're saying: since epi is not always effective, and may be less so the longer it's delayed; and since it has some potential for adverse effects which does not decrease with delay; when administered by professionals after a significant delay, it should be administered in a dose-titrated manner in order to minimize the adverse effects?

 

[KellyBracket]

If you have the tools and training, I agree 100%.
...

I would imagine most OLMD's would tell you to give it. I'd like to hear Dr. Walsh weigh in on this.

I like the idea of pre-loaded epinephrine syringes, and I bet that however often weird scenarios like this come up will be far out-weighed by the reduction in med errors. This forum has a good number of people who have pediatric epi doses "hardwired" in their noggins, but this ain't a typical crowd!

If I were alone with my kid in a wilderness setting (he's about 12 kilos), and he started getting hives and SOB after a bee sting, and all I had was an adult Epi-Pen... Sorry Alden, that needle is going in! Probably IM in the thigh, maybe IO, but it's going in!

I'm not sure about a 4.5 kg preemie. (What's she doing in the wilderness anyway?)

The literature is pretty clear on a few points. Kids die of untreated anaphylaxis, and treatment delay is muy mal. There is no hard and fast rule about "10 minutes," since there are few absolute physiologic rules in medicine (golden hour, anyone?), but the principle is the same: Delayed treatment is deadly.

OTOH, I'm not to worried about giving a 50% epi overdose. The real problems are when medics or doctors are giving 10-fold ODs. (See Pediatric Anaphylaxis: Medication errors by EMS )