Paramedics Often Fail to Give Epinephrine for Anaphylaxis

[Milla3P]

Stepping away from the dead horse and back towards medicine...

Does anybody else have terbutaline in their bag of tricks for elderly/cardiac Hx? Thoughts? I've seen it be pretty effective.

 

[DrParasite]

Correct. Because I am asking permission to administer a medication that is not in protocol for the specific purpose I would like to use it for. For example if I want to administer 5mg of valium to relieve severe back spasm. Has no grounds in the protocol book anywhere whatsoever but I can still do it.

And what if he says no? are you permitted to administer it anyway? you can ask for permission to be creative, but remember, a doctor still needs to approve you deviating from protocol.

At the same time I can also tell that doctor "no" i will not do something he asks of me in the event I feel it would have a negative outcome for the patient.

really? so if the doctor orders you to administer epinephrine, and you decide not to because you think it won't be good for the patient, you can do that? didn't i see that on an early episode of Rescue 77 10+ years ago?

What would the reaction be if the doctor filed a complaint with your supervisor over it, would your supervisor back you or the doctor?

But I will tell you that your agency is in fact flawed or your teaching and understanding what protocols are is flawed. Your chief can implement whatever standing orders he wants but if you perform it, and you cause harm to the patient, you are at fault. Your protocols won't save you if you commit any form of non/mal/misfeasance or tort.

ummm, yes and no. while you are at fault, as long as you have written protocol backing your action, the AGENCY should bear the brunt of any lawsuit, not the individual.

Now, if you deviate from protocol WITHOUT permission from medical control, and there is a negative outcome, expect your agency to hang you out to dry, and you to be on the hook for everything that results from it, both civilly and criminally.

By the way, you might keep your cert if you have a justifiable reason to deviate from protocol, without approval of medical control, especially if it's based on current medical practices. But you might not keep your job with your employer.

 

[ffemt8978]

We've strayed a bit from the original topic into a debate about following protocols. Let's get back on topic, and if you want to talk about following protocols please start a new thread.

 

[VFlutter]

really? so if the doctor orders you to administer epinephrine, and you decide not to because you think it won't be good for the patient, you can do that? didn't i see that on an early episode of Rescue 77 10+ years ago?

Speaking from an RN point of view (I assume it would be the same with a paramedic) you have every right to refuse to perform a procedure or give a medication if you think it will result in patient harm. However, you better be able to back it up with evidence. Already in my short career I have witnessed doctors giving inappropriate orders and then getting angry when nurses refuse to do it. They can complain all they want but the RN still has a license to protect and can be reprimanded even for following a direct order from an MD

 

[DrParasite]

They can complain all they want but the RN still has a license to protect and can be reprimanded even for following a direct order from an MD

Can an RN be reprimanded for refusing to follow a direct order from an MD? One that she doesn't think should be given, but the doctor has a clinical reason backed by education that he wants to have it done?

 

[ffemt8978]

Back on topic, please.

 

[DrParasite]

Back on topic, please.

With all due respect, I don't believe we are that off topic.

As I read it, the OP's question was that Paramedics are not giving the proper medications based on the current lines of medicine by the allergy doctors. The logical explanation (at least in my eyes) is that a paramedic can know that they aren't giving the proper medication, but due to their medical directors protocol, they still have to follow the rules.

Yes, it's a much more general discussion, but it can be very relevant to the topic at hand (if a paramedic knows their is a medication that is better suited, can they go outside of protocol and give it).

 

[ffemt8978]

When we're discussing the legalities of following protocols, then we've strayed off topic.

 

[OfficerEvenEMT]

Is Epi the quickest acting med to use for anaphylaxis? The original article seemed to say that it's effects were very quick but medications like benadryl take a very long time. I also see that steroids are used. Why? Does it have something to do with the immune system, like the steroids used for antirejection meds?

 

[VFlutter]

Can an RN be reprimanded for refusing to follow a direct order from an MD? One that she doesn't think should be given, but the doctor has a clinical reason backed by education that he wants to have it done?

If the RN has a legitimate concern then most likely not. For example, lets say a MD orders you to push an IV med that you think is not supposed to be IV or is at too high of a dose for IV admin then you have the right to refuse until it is cleared by pharmacy or another MD. He can sit there and yell all he wants about his previous experience or current recommendations that are not yet published but it really won't get him anywhere if I do not feel comfortable pushing it. Or the typical nurse response is "you push it yourself then". Lets say I pushed that med, under direct MD supervision/order, and the patient dies. I could still lose my license.

 

[mycrofft]

Epi is quick in and quick out, unless you give a sustained release version.
Benadryl is not given until acute s/s of anaphylaxis are controlled, per NIH; however, also per this website, injectable diphenhydramine (Benadryl) is "fast acting".
http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=1029

 

[Veneficus]

Or the typical nurse response is "you push it yourself then"

Could you teach other nurses this line?

I have no problem pushing the meds myself. In fact I prefer it.

 

[VFlutter]

Could you teach other nurses this line?

I have no problem pushing the meds myself. In fact I prefer it.

In regards to all meds or just emergent situations?

During clinical one RN refused to give a 100mg IV lasix bolus to a patient who's Bp was soft so the doctor said he would do it himself. He walked in and literally slammed the bolus in under 30 seconds and walked right out. We were all speechless. The patient was fine. The doctor was not really mad about it more just annoyed. I totally believe he knew what he was doing however it went against everything I was taught and used to so I would have still been uncomfortable doing it myself.

 

[Veneficus]

In regards to all meds or just emergent situations?

All meds. Particularl IV antibiotics.

During clinical one RN refused to give a 100mg IV lasix bolus to a patient who's Bp was soft so the doctor said he would do it himself. He walked in and literally slammed the bolus in under 30 seconds and walked right out. We were all speechless. The patient was fine. The doctor was not really mad about it more just annoyed. I totally believe he knew what he was doing however it went against everything I was taught and used to so I would have still been uncomfortable doing it myself.

I have encountered this recently. I am of the opinion that lack of understanding of both volume of distribution and potential or experienced pathophysiology of various "fast push" medications is not well understood by nurses and leads to often unreasonable dogma being accepted as fact.

The best way I can describe it is that experience does not equal understanding.

 

[systemet]

Is Epi the quickest acting med to use for anaphylaxis?

Yes. Of the commonly-used medications it has the most rapid onset of effect. It's even quicker given IV, as you would imagine. This carries additional risks and is only usually used in extremis.

The original article seemed to say that it's effects were very quick but medications like benadryl take a very long time. I also see that steroids are used. Why? Does it have something to do with the immune system, like the steroids used for antirejection meds?

Yes. Anaphylaxis is an immune system response to a previously sensitised allergen. If you suppress the immune system response, you may reduce the severity of the anaphylactic episode. However, steroids take several hours to peak effect. So they're unlikely to be beneficial during the prehospital phase, but there's a certain wisdom that if you're already giving a bunch of adjunctive meds like benadry, maybe getting the steroids in a half hour or an hour earlier might be beneficial. Anaphylactic reactions can often be biphasic, and a dose of steroids may mitigate a secondary response.

I haven't read the article, but would be interested in seeing how they defined anaphylaxis. I'm skeptical of the numbers, but anaphylaxis can occur with a wide range of presentations, and without characteristic uriticaria, pruritis or angioedema.

 

[NYMedic828]

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!

Quick question for you doc,

I noticed when these anaphylaxis discussions arise you are always an advocate of IM epi being given in the lateral aspect of the thigh.

In my relatively short time as a medic, it seems to be common practice to use the deltoids for any IM injection we give. In my program they usually teach the deltoids to be the most useful site for any medication we carry IM up to 3ccs I believe. (on adults)

What is the actual medical reason that the thigh is superior? Is it superior for all IM medications? I have only given epi a handful of times and every time it has been in the delt. (granted it has worked every time)

 

[Medic Tim]

Quick question for you doc,

I noticed when these anaphylaxis discussions arise you are always an advocate of IM epi being given in the lateral aspect of the thigh.

In my relatively short time as a medic, it seems to be common practice to use the deltoids for any IM injection we give. In my program they usually teach the deltoids to be the most useful site for any medication we carry IM up to 3ccs I believe. (on adults)

What is the actual medical reason that the thigh is superior? Is it superior for all IM medications? I have only given epi a handful of times and every time it has been in the delt. (granted it has worked every time)

I once had a partner (lower license level) report me for giving epi in the AL thigh because they said it was dangerous lol.. I guess they were taught to give all IMs in the delt.

 

[KellyBracket]

Consolidated responses...

 

[KellyBracket]

Quick question for you doc,

I noticed when these anaphylaxis discussions arise you are always an advocate of IM epi being given in the lateral aspect of the thigh.

In my relatively short time as a medic, it seems to be common practice to use the deltoids for any IM injection we give. In my program they usually teach the deltoids to be the most useful site for any medication we carry IM up to 3ccs I believe. (on adults)

What is the actual medical reason that the thigh is superior? Is it superior for all IM medications? I have only given epi a handful of times and every time it has been in the delt. (granted it has worked every time)

I just want to be clear - it's not my own crackpot opinion! This reccomendation comes from, basically, every reference document and (current) textbook out there.

This is mostly based on two studies, one in kids & the other in adults, that showed that IM in the thigh was the only route that demonstrated a real bump in epi levels. IM in the deltoid, by contrast, was close to placebo! I reproduced the graphs in reviews here and here.

As for whether it is superior for all medications, I can't say. You certainly don't want to give heparin or vitamin K IM. but that's for different reasons!

 

[NYMedic828]

I just want to be clear - it's not my own crackpot opinion! This reccomendation comes from, basically, every reference document and (current) textbook out there.

This is mostly based on two studies, one in kids & the other in adults, that showed that IM in the thigh was the only route that demonstrated a real bump in epi levels. IM in the deltoid, by contrast, was close to placebo! I reproduced the graphs in reviews here and here.

As for whether it is superior for all medications, I can't say. You certainly don't want to give heparin or vitamin K IM. but that's for different reasons!

Haha, definitely not assuming its your own opinion. I was just curious because my program advocated the deltoid. My assumption is that it is due to 1 part laziness and 1 part misinformation. The delt is definitely easier to access in most patients and If the instructor doesn't know it, odds are the students aren't going to learn it.

As far as it having a placebo effect in the deltoids i find that a little hard to believe. I have seen it work perfectly fine when given in the deltoids. I would be hard pressed to believe that patients are subconsciously increasing their HR to 150+ bpm. It just doesn't seem possible especially if they don't know what you gave them.




While we are on the topic of paramedics and anaphylaxis, could you take a moment to break down why we don't give atrovent in conjunction with albuterol for treating broncho-constriction in anaphylaxis?

At least here in NYC we don't. We give albuterol only. I have been told in the past we do not give it because anaphyalxis is not a cholinergic mediated process but at the same time wouldn't decreasing parasympathetic tone indirectly increase sympathetic tone aiding in bronchodilation with albuterol and epi?