IM Epi in full arrest with anaphylactic etiology.

[PMWQs]

May be a dumb question, but I was mulling over possible cardiac arrest scenarios and anaphylaxis popped into my head. In the event of cardiac arrest due to anaphylaxis with or without a swollen airway, would you still give the IM epinephrine, or would there not be enough circulation from compressions to allow the Epi to take effect?

 

[teedubbyaw]

No. You're giving epi IV/IO already.

 

[PMWQs]

.

 

[PMWQs]

No. You're giving epi IV/IO already.

That's my thought process. Not only that, but if the patient's airway is already compromised due to edema, it becomes a need for a cric or surgical airway.

 

[Underoath87]

No. You're giving epi IV/IO already.

^^ exactly.
Why would you worry about giving a 0.3mg dose of IM epi when you're already going to be pushing 1mg every 3-5 minutes?

 

[NPO]

I have seen books that state that, in severe anaphylaxis where you already have an IV established, 0.3mg epi ca n be administered IV. You're doing better than that by giving 1mg every 3-5 minutes!

 

[FiremanMike]

Our protocol allows for 1:10,000 IVP in severe anaphylaxis. We had one somewhat recently where the patient arrested in front of us after we already had the IV established. She had no obvious signs of anaphylaxis (clear lung sounds, no visible swelling/hives), but we did a few minutes of CPR and she responded immediately to the first dose of IV epi. She was diagnosed as having a severe anaphylactic reaction, discharged with a CPC of 1.

So no, no IM epi..

 

[Seirende]

I realize that this is the ALS section, but how about when working with a BLS rural service with ALS 20 min. away? Would IM epi be worth the time in this anaphylactic arrest scenario?

 

[FiremanMike]

I realize that this is the ALS section, but how about when working with a BLS rural service with ALS 20 min. away? Would IM epi be worth the time in this anaphylactic arrest scenario?

Maybe, but please check your protocol before jumping down that pathway. Remember that circulation is poor, at best, during a cardiac arrest. It's why we're spending so much time and energy to improve our CPR. IM drugs during a cardiac arrest will likely have poor and inconsistent absorption..

 

[Tigger]

I have seen books that state that, in severe anaphylaxis where you already have an IV established, 0.3mg epi ca n be administered IV. You're doing better than that by giving 1mg every 3-5 minutes!

0.3mg is a lot for IV. We start with 0.1 and that's still a pretty big hit.

 

[ExpatMedic0]

Firs things first...
If its a cardiac arrest, your gonna start CPR and follow the latest ACLS algorithm, which states 1mg of eppie 1:10,000 IV/IO push (when the time comes). If your unable to to ventilate for chest rise and fall due to airway swelling and they are already in cardiac arrest, then its surgical airway time. Once your able to perform adequate compression's and ventilation then I would consider H's and T's, HX, and underlying cause more.(maybe this was done simultaneously while you investigated why you could not ventilate)

 

[SpecialK]

For cardiac arrest secondary to anaphylaxis, provided the patient remains in PEA, we give 3 mg of adrenaline as a bolus and then if still unresponsive, 5 mg as a bolus with a minimum of three litres of IV fluid.

I have seen one case of cardiac arrest secondary to anaphylaxis where the patient made a completely normal recovery with good focus on very early administration of IV adrenaline and IV fluid.

 

[FiremanMike]

For cardiac arrest secondary to anaphylaxis, provided the patient remains in PEA, we give 3 mg of adrenaline as a bolus and then if still unresponsive, 5 mg as a bolus with a minimum of three litres of IV fluid.

I have seen one case of cardiac arrest secondary to anaphylaxis where the patient made a completely normal recovery with good focus on very early administration of IV adrenaline and IV fluid.

Did you mean 0.3 and 0.5?

 

[SpecialK]

Did you mean 0.3 and 0.5?

No, I meant 3 mg and 5 mg.

First dose 1 mg, if not responding second dose of 3 mg then third dose of 5 mg then return to 1 mg boluses.

 

[FiremanMike]

I didn't know escalating dose epi was still a thing, haven't seen it in probably 15 years..

 

[jcroteau]

Holy moly that's a lot of epi


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[wanderingmedic]

No, I meant 3 mg and 5 mg.

First dose 1 mg, if not responding second dose of 3 mg then third dose of 5 mg then return to 1 mg boluses.

Where in the world do you work? Escalating epi hasn't been recommended by ILCOR since 2000.

 

[SpecialK]

Where in the world do you work? Escalating epi hasn't been recommended by ILCOR since 2000.

You actually read what I wrote didn't you? This is only for the specific situation of a) cardiac arrest secondary to anaphylaxis, where b) the rhythm is PEA, and c) the patient is unresponsive to an initial dose of 1 mg adrenaline IV.

Provided you give IV adrenaline and IV fluid very early, cardiac arrest secondary to anaphylaxis should likely get ROSC quickly because you are providing absolute treatment for the underlying cause of the cardiac arrest; i.e. reversing the vascular dysfunction, bronchospasm and hypovolaemia.

I have seen it work but only once, and it worked very well.

As for anaphylaxis where the patient is not in cardiac arrest, the same essentially applies, give adrenaline and give it early before you do anything else I've seen people piss-arse around with histamine blockers and gaining IV access and putting people on oxygen and all sorts of useless stuff, just give them 0.5 mg of IM adrenaline already! (provided they are an adult of course)

 

[18G]

There is no need for IM epinephrine in cardiac arrest secondary to anaphylaxis. The patient needs IV epinephrine which they will be receiving during the arrest algorithm.

I have never heard of giving an arrest patient 3-5mg of IV epinephrine. That is a lot of epinephrine. I understand it's only in the anaphylaxis scenario but still. Is there any literature that speaks of this dosing? The US standard for anaphylaxis peri-arrest is usually 0.1mg (100mcg). My state's ALS protocol calls for 10-20mcg q5mins using the push-dose concentration of 1:100,000.

 

[SpecialK]

Push dose adrenaline is a pain and very hard to adjust, for anaphylaxis, asthma, septic shock unresponsive to two or three litres of fluid, and certain bradycardias we put 1 mg into 1 litre of NaCl and run at 2 gtt/s initially and go up/down depending on need. Super easy to make up and super easy to adjust and no fart-arseing around with single bolus aliquots.

The exception is small children who get 1:1,000,000 boluses PRN.