Paramedics Often Fail to Give Epinephrine for Anaphylaxis

[shfd739]

Good point.

Personally, I'll aggressively give Epi to younger individuals, when it's appropriate.

Why just younger people?

I've used Epi IV on severe anaphylaxis. It was needed and my medical director happened to be the recieving ER doc each time thankfully. I got a strange look then he agreed with the use. I knew it was going out on a limb and out of protocol but I was able to justify the use.

 

[mycrofft]

Here's a personal question/scenario: you administer epi to an anaphylaxis case who could not tell you she/he has cardiac contraindications to epi. Now you are looking at an accelerating and increasingly irregular pulse (and the irregularity of which your automated monitor probably can't interpret).

Ok, now what? Are you balancing anaphylaxis tx against arrhythmia tx?

What I was looking at was more like this: pt is in anaphylaxis; epi given sq; heart rate becomes irregular and very rapid, BP initially rises then may level off or actually fall. Pt c/o chest pain then passes out. Are you going to give a counter-agent and benadryl, try to ride it out, or ?? Wouldn't a counteragent reverse impact on s/s anaphylaxis?

I hate to start trying to titrate TWO drugs with interactions.

 

[Aidey]

Why just younger people?

Because epi is really hard on the heart. If a patient has pre-existing heart disease they can develop some nasty side effects. Younger people with healthy hearts tend to tolerate it much better than older people.

 

[Jon]

Because epi is really hard on the heart. If a patient has pre-existing heart disease they can develop some nasty side effects. Younger people with healthy hearts tend to tolerate it much better than older people.

Exactly. If someone were to have a cardiac history, or be older... I'm going to use caution, and I may start off with Benadryl and Albutorol if at all possible. I'll still go with epi, but I'm not going to be as quick to give it.

Whereas a pediatric patient or adult, I'm going to aggressively give Epi if it's indicated. It is remarkable how quick the patient can better.

 

[OfficerEvenEMT]

Exactly. If someone were to have a cardiac history, or be older... I'm going to use caution, and I may start off with Benadryl and Albutorol if at all possible. I'll still go with epi, but I'm not going to be as quick to give it.

Whereas a pediatric patient or adult, I'm going to aggressively give Epi if it's indicated. It is remarkable how quick the patient can better.

What do you do when the protocols specifically say epi first?

 

[Jon]

What do you do when the protocols specifically say epi first?

Hence the base of this study.

PA's protocols, for example, do specify immediate Epi in severe allergic reactions, but also talk about using caution w/ giving Epi to patients over 50.
So I have 2 options - First is to call it "moderate" vs. severe, and 2nd is to "use caution".

There's no one right answer, In the end it comes down to being a clinician vs. blindly following the cookbook.

 

[Medic Tim]

What do you do when the protocols specifically say epi first?

Treat the pt to the best of your knowledge and ability. Protocols should not take the place of sound clinical judgment/ common sense*. In the systems I have worked in/currently work in, as long as we can back up why/what we did, there is never an issue (For something major... if time permits we may call OLMC). We are encouraged to treat the pt and not force them into the closest protocol we have, then follow it blindly. (clinician vs technician)

*that is assuming the provider(s) have any

I have never worked or have experience with an all basic system but I would guess deviation from protocols is frowned upon due to limited scope and minimal education (not a slam against basics). I am sure there are ALS services as well where the medical director expects you to not have a brain and follow the cookbook.

 

[VFlutter]

*that is assuming the provider(s) have any

That is a pretty big assumption to make and you know what they say about assuming....

 

[shfd739]

Hence the base of this study.

PA's protocols, for example, do specify immediate Epi in severe allergic reactions, but also talk about using caution w/ giving Epi to patients over 50.
So I have 2 options - First is to call it "moderate" vs. severe, and 2nd is to "use caution".

There's no one right answer, In the end it comes down to being a clinician vs. blindly following the cookbook.

Same as our protocols.

Even if it is severe and they are older i can use smaller doses instead of not using at all.

Case by case based on the patient and their history for me.

 

[OfficerEvenEMT]

Treat the pt to the best of your knowledge and ability. Protocols should not take the place of sound clinical judgment/ common sense*. In the systems I have worked in/currently work in, as long as we can back up why/what we did, there is never an issue (For something major... if time permits we may call OLMC). We are encouraged to treat the pt and not force them into the closest protocol we have, then follow it blindly. (clinician vs technician)

*that is assuming the provider(s) have any

I have never worked or have experience with an all basic system but I would guess deviation from protocols is frowned upon due to limited scope and minimal education (not a slam against basics). I am sure there are ALS services as well where the medical director expects you to not have a brain and follow the cookbook.

Aren't deviations from protocols what causes successful malpractice lawsuits?

 

[Veneficus]

Aren't deviations from protocols what causes successful malpractice lawsuits?

no.

 

[usalsfyre]

Aren't deviations from protocols what causes successful malpractice lawsuits?

Nope. Blindly following the wrong or inappropriate protocol will cause you problems just as surely.

 

[STXmedic]

Aren't deviations from protocols what causes successful malpractice lawsuits?

Attempting to hide deviating (intentionally or unintentionally) from protocols certainly will. Not so much if its documented/reported appropriately.

 

[Medic Tim]

Aren't deviations from protocols what causes successful malpractice lawsuits?

Not at all......as long as you are doing it for the right reasons, within scope and report it.

 

[KellyBracket]

Great topic! It's a good area to review, and paramedics should know this stuff cold.

That said, there's a lot of misinformation, myth, or outdated stuff out there. I've reviewed this topic a few times in "Anaphylaxis Knowledge Among Paramedics", " New Guidelines for Anaphylaxis ", and " Anaphylactic reactions - 5 things. ".

Let me just put out a few "controversial" statements that are actually part of the conventional thinking, based in the research, and are in the guidelines (read my reviews for links to sources).

Epi is the only medicine for anaphylaxis.
There is no evidence that steroids or antihistamines do anything for anaphylaxis, or even that do they do anything to prevent "biphasic" anaphylaxis. One study protocol used only epi for anaphylaxis (and O2 and NS), and patients did fine.

Anaphylaxis is more than hypotension and stridor.
In fact, GI symptoms are a very concerning element of anaphylaxis, and are part of the standard definition of anaphylaxis. Urticaria and vomiting, after exposure to a likely allergen, is anaphylaxis, according to the experts.

Anaphylaxis causes MIs
While there are case reports of people having problems with epi, usually after receiving whopping IV doses (e.g 100 µg), there are also plenty of reports of people having MIs due to untreated anaphylaxis - it's called Kounis syndrome.

There are no absolute contraindications to epi
Is someone just has some itchy skin, that's not anaphylaxis. But true anaphylaxis needs true treatment, and the expert EPs and allergists agree (pdf download) - there is no absolute contraindication to epi.


If you think I'm being controversial, just check out the sources, and see what you think!

 

[OfficerEvenEMT]

Attempting to hide deviating (intentionally or unintentionally) from protocols certainly will. Not so much if its documented/reported appropriately.

That doesn't make much sense, sorry. If you tell the PT they need a ride in a UFO and this will stop them from bleeding you can't successfully defend a malpractice suit even if you document it in your PCR.

Documentation in PCR ≠ immunity from a lawsuit

Following protocols = good defense

 

[ffemt8978]

following correct protocols = good defense

ftfy

 

[Aidey]

That doesn't make much sense, sorry. If you tell the PT they need a ride in a UFO and this will stop them from bleeding you can't successfully defend a malpractice suit even if you document it in your PCR.

Documentation in PCR ≠ immunity from a lawsuit

Following protocols = good defense

That isn't malpractice.

What Poetic is saying is that if you deviate from protocol for a good reason and document it thoroughly you are in a much better position than if you deviate from protocol and don't document it or try and hide it. There are plenty of legitimate reasons to deviate from protocol, such as the patient is allergic to the medication indicated for their condition, or the little old lady who fell down is super kyphotic and you can't get her in a c-collar.

And following protocols do not save you from malpractice lawsuits. Following protocols will possibly save you from your company and medical director, but they will not save you from anyone else.

 

[OfficerEvenEMT]

That isn't malpractice.

What Poetic is saying is that if you deviate from protocol for a good reason and document it thoroughly you are in a much better position than if you deviate from protocol and don't document it or try and hide it. There are plenty of legitimate reasons to deviate from protocol, such as the patient is allergic to the medication indicated for their condition, or the little old lady who fell down is super kyphotic and you can't get her in a c-collar.

And following protocols do not save you from malpractice lawsuits. Following protocols will possibly save you from your company and medical director, but they will not save you from anyone else.

Attorneys for the plaintiff will not see if that way and often convince juries of just that. Juries hear "did not follow protocol" and not "sound clinical judgement". In this case, however, the study seems to say that avoiding epi when it is indicated is poor clinical judgement.

 

[VFlutter]

Following protocols = good defense

Just FYI...that BS excuse may keep you out of trouble but it really doesn't fly in the medical community. If a medic ever gave me the "following protocols" line in regards to rationale for patent care then I would immediately lose all respect for that individual as a compotent healthcare practioner. From that point on they are noting more than a cookbook technician and about as valuable as a trained monkey, but less cute.


/End rant