Would benadryl help anaphylaxis any?

GloriousGabe

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Im pretty sure Chaz has been doing this job longer than you and may know a thing or two more than you. Just a thought, take it with a grain of salt.

I'm curious, in going back to the original topic would you @GloriousGabe give your buddy PO benadryl?
Not in my protocols.
 

chaz90

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How long have you been in EMS? Not long enough. Yes, there are lawyers who desire to scour everything and then sue. I'm on my third case now.
Have any been successful in getting anything from you? EMS providers are occasionally named in suits, but cases where they are determined to actually be at fault are rare and often well deserved.

That's as much as I want to contribute to derailing this thread. Let's try to keep the topic on Benadryl and OTC med administration in general, but you can of course have the last word if desired.
 

CALEMT

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Not in my protocols.
Well if you're willing to let someone suffer just because you're off duty and may loose your license then I'm sorry. If it were me I would give PO benadrly in a heartbeat. If I loose my license then so be it. I am not going to stand by and let a friend suffer knowing damn well there was something I could've done.

Its benadryl for crying out loud.
 
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Summit

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Glorious Distraction needs to start his own posts because every thread he posts in when his extraordinarily limited 15 years as an emt in one limited place "does not compute" with a world of multidisciplinary practice, it turns into a total derail as he demands others Google everything beyond his limited knowledge base for him.
 

chaz90

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Yup. As above, we're back to discussing the finer points of benadryl administration for anaphylaxis. Let's keep it on topic, because I really don't want to lock yet another thread.
 

EMSComeLately

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I probably don't have the personal comfort level with altering the nature of how the manufacturer designed the medication delivery, even if it sounds like a good idea.

Personally, I'd have no issue suggesting the administration of the OTC Benadryl PO that was available, as is. I don't think I'd feel comfortable doing any McGuyver actions that may unknowlingly actually serve to lessen the efficacy.
 

Tigger

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I am certain there are no protocols that allow an EMT to give out OTC medications. I asked my state EMS board about that and they said it's only in the domain of nurses and up. Can you kindly post a copy of your protocols so that I can show my state EMS board that it does exist?
Not sure why you think I would just make this up. This is all it says in the protocols. Per the medical director, "use them for what they are for." No tylenol for pedi fevers, use liquid ibuprofen if that's what around. I suppose you will also need proof that EMS start IVs in Colorado.
tcOTC.jpg
 
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GloriousGabe

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Not sure why you think I would just make this up. This is all it says in the protocols. Per the medical director, "use them for what they are for." No tylenol for pedi fevers, use liquid ibuprofen if that's what around. View attachment 2597
Very, very interesting. I am willgoing to send this to my state EMS board. They were adamant it was way outside the scope of an EMT-B to ever give OTCs. Thank you.
 

Seirende

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Oh, geez. The first time that I learned to give Benadryl for an allergic reaction was in a Wilderness First Aid course I took through the Boy Scouts of America. You don't need any sort of license to hand a friend an OTC medication; teenagers in first aid courses are taught to do it. If a friend asks me for a Tylenol, I don't call up my medical director before digging in my backpack, and parents aren't getting sued for giving their kids cough syrup. While playing the part of an EMT, we're both more restricted and more free in what we can do, but the original question was about pharmacology, not legality. So off-topic.
 

Seirende

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A instructor in above-mentioned course did mention that snorting a crushed tablet might be a expedited method of getting the medication on board, so you might be onto something, Gurby.
 

wilderness911

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A instructor in above-mentioned course did mention that snorting a crushed tablet might be a expedited method of getting the medication on board, so you might be onto something, Gurby.
I hope it is acceptable for me to revive a month-old thread here, but as it is directly relevant to the OPs question I figured it is okay to show up late to the party.

As a wilderness paramedic and snakebite medicine specialist in Africa, I have encountered a number of anaphylaxis cases in the remote medicine environment (i.e. bush hospital in the middle of west Africa remote - very limited supplies and the buck stops at your feet). Most of these cases involved pediatric patients suffering from acute anaphylaxis in response to antivenom therapy. Over time, I have developed my own protocol for handling these cases and it pretty much meshes with what was discussed earlier.

At the earliest onset of symptoms indicating an allergic reaction, I immediately crush up 25 or 50 mg of diphenhydramine (depending on size of patient), mix it with a half oz or so of water, and have my patient knock it back while I have an airway. Infants or peds patients who could not swallow received IM promethazine 0.1 mg/kg. In all of these patients I had already established large bore IVs for antivenom administration, so venous access was already taken care of and I would throw a bag of NS or RL on the line and open it up wide. If I had injectable diphenhydramine available that would have been ideal and I would have pushed it IV, but the only diphenhydramine I had available was the bottle I brought with me and the only injectable H1 available in country was promethazine. No interest in destroying a tiny vein with IV phenergan hence the IM administration. Moving on...

First sign of anaphylaxis in all patients I treated was a dry cough of increasing frequency, followed by restlessness and pruritis. So at the first dry cough I got an H1 on board, generally a crushed up Benadryl slurry, set my watch for 30' (the time it took for the Benadryl to kick in across the board), and aggressively managed with fluids, Epi, and/or dexamethasone or betamethasone depending on what drug we had available at the time (constant shortages of essential drugs, even ran out of Epi once). The idea behind the Benadryl PO or phenergan IM was to head off the anaphylaxis before additional drugs became necessary, and in roughly 40% of cases I treated it seemed to do just that. Diphenhydramine slurry PO took 30' to kick in across the board, while the patients I treated with cetirizine did not benefit until the 60' mark. If I had ranitidine with me I would have given that too, but it was not an option.

Because I was working in the middle of nowhere in a constant state of triage with limited medications, I withheld Epi until it was necessary and stuck to fluids and antihistamines as long as possible. This meant watching each patient like a hawk from the time when the diphenhydramine was knocked back onwards. At the first sign of airway compromise, respiratory distress, decompensation, etc I would push Epi and/or corticosteroids depending on what I had available. Care was taken to prevent cardiac arrest from severe BP drop in the peds patients (fluids and positioning) and I was reading vitals every minute or so as the clinical picture developed.

Epi (1:1000) was administered 0.25 mc/kg generally working out to 0.25 mg IM for the youngsters and 0.5 mg IM for the adults, always in the lateral aspect of the thigh. Since I didn't have the luxury of weighing a critical patient in the middle of nowhere, I estimated on the generous side and gave an appropriate dose (i.e 0.5 mg Epi for adults vs 0.3, 0.25mg for most of my peds patients instead of 0.125). This was done because I was consistently finding the need to administer multiple doses of Epi to crashing patients before any benefit was achieved. Oftentimes I would have to transfuse a bag of whole blood to treat the critical anemia caused by the snake venom (carpet vipers cause a DIC syndrome), so some of these patients were getting a bag of blood as well as fluids and whatever drugs I was pushing. But many did not, and required only minimal care: preloading with a PO dose of diphenhydramine at the onset of symptoms, clinical observation, and Epi if the Benadryl was unable to head off the anaphylaxis.

Once stabilized, I put all patients on a regimen of antihistamines (phenergan, diphenhydramine, or cetirizine - but generally cetirizine at this point due to the longer half life) or an oral course of corticosteroids for the next 36-72 hours to prevent recurrence of anaphylaxis, which is uncommon but entirely possible.

Lastly, for those of us operating in the backcountry here, a practical means of doing this follows. Get your Epi pen ready by rubber-banding a few blister packs of diphenhydramine and ranitidine to the case. This way you won't lose it and will remember that it is there if you need it. At the onset of symptoms, sit your patient down and make them chew up the antihistamines if you have an airway available. If you have to give Epi, immediately after giving it remove the preloaded syringe from the plastic case by following the instructions from the paper "Retrieval of additional doses of epinephrine from autoinjectors". I highly recommend that everyone takes a look at this paper. Most of my patients have required several doses of Epi, and if you don't know how to get it out then you are sitting there with a dead patient and approximately 9 additional doses of epinephrine in your hand.

Direct link here:

http://www.wemjournal.org/article/S1080-6032(13)00094-X/pdf

Hope that proves helpful, or at least interesting!

-Wilderness911
 

wilderness911

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Have to ask, how did you find yourself in this position? Sounds like a really interesting experience!
Started my career as a herpetologist studying venomous snakes of Africa. Used to do the Steve Irwin thing and catch venomous snakes in the field to collect venom and tissue samples for research. Discovered a passion for medicine when I took a wilderness EMT back in 2010 (which I took because I was always running around Africa getting into the sh*t) and changed gears to focus on my research on snakebite medicine, particularly in rural sub Saharan Africa. Decided to go for the long haul so my next move will hopefully be an MD (or a PA if I can't make the money work for med school). Spent the last few years in and out of Africa doing antivenom research, ran a clinical trial on a new antivenom for west Africa, served as the primary snakebite medicine specialist for a small west African nation for 7 months 24/7, trained doctors/nurses/military medics how to manage snakebite patients in the remote medicine environment. Ive been working on devising new systems for rapid assessment, diagnosis, treatment, and clinical management of snakebite patients in rural Africa for a while as wel, based on the premise that we should stop trying to identify the snake responsible and focus on a syndromic approach based on the symptoms expressed by the patient. Snakebite medicine is a small field and primarily populated by guys like me who started out as snakemen and then became docs or PhDs. Hoping to become the guru on this stuff in future.
 

Gurby

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Started my career as a herpetologist studying venomous snakes of Africa. Used to do the Steve Irwin thing and catch venomous snakes in the field to collect venom and tissue samples for research. Discovered a passion for medicine when I took a wilderness EMT back in 2010 (which I took because I was always running around Africa getting into the sh*t) and changed gears to focus on my research on snakebite medicine, particularly in rural sub Saharan Africa. Decided to go for the long haul so my next move will hopefully be an MD (or a PA if I can't make the money work for med school). Spent the last few years in and out of Africa doing antivenom research, ran a clinical trial on a new antivenom for west Africa, served as the primary snakebite medicine specialist for a small west African nation for 7 months 24/7, trained doctors/nurses/military medics how to manage snakebite patients in the remote medicine environment. Ive been working on devising new systems for rapid assessment, diagnosis, treatment, and clinical management of snakebite patients in rural Africa for a while as wel, based on the premise that we should stop trying to identify the snake responsible and focus on a syndromic approach based on the symptoms expressed by the patient. Snakebite medicine is a small field and primarily populated by guys like me who started out as snakemen and then became docs or PhDs. Hoping to become the guru on this stuff in future.
Wow! Med schools are going to fight over you! Most everyone takes out big loans for medical school, but If you have a reasonable GPA and MCAT I bet you could get a free ride somewhere.
 

wilderness911

paramedic student
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26
18
...and you're going to be bored out of your mind running BLS in Seattle.
Heh. Means to an end, my friend. Beats working at McDs...well, not economically speaking of course, but in the sense that it's medicine and gives me an opportunity to keep learning while I get ready to make my next move. Trying to stay positive here, DE! It's just a wee bit smaller scope of practice, right?
 
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