Paramedics Often Fail to Give Epinephrine for Anaphylaxis

[OfficerEvenEMT]

From: http://www.medscape.com/viewarticle/774828

Of the 52 patients with anaphylaxis, 25 (48.1%) were given oxygen, 8 (15.4%) were given epinephrine, 6 (11.5%) were given intravenous fluids, 10 (19.2%) were given albuterol, and 13 (25.0%) were given methylprednisolone. The majority (42; 80.8%) were given diphenhydramine.

"It is apparent from these results that paramedic education in the use of epinephrine for allergic reactions and anaphylaxis needs to be implemented. We have done that since we collected these data," Dr. El Sanadi noted.

It looks like paramedics are giving the wrong medication when it comes to anaphylaxis. Whaddya all think?

 

[ffemt8978]

FYI - Medscape requires a login to view the entire article/study.

 

[Aidey]

I don't see any wrong medications. There is a difference between not being aggressive with epi and an incorrect med. All of the medications listed are indicated in anaphylaxis.

 

[OfficerEvenEMT]

I don't see any wrong medications. There is a difference between not being aggressive with epi and an incorrect med. All of the medications listed are indicated in anaphylaxis.

It further says:

"Epinephrine is the first treatment — not [diphenhydramine], not steroids — because epinephrine works fast and reverses the anaphylactic reaction in about 30 seconds. [Diphenhydramine] doesn't work for...almost an hour. For some reason, people are afraid to use it, perhaps because it is an injection, but they shouldn't be because it is the treatment of choice. Why wouldn't you use the 30 second drug if a patient is having a life-threatening reaction?"

It seems that the diphenhydramine is the wrong med to use as it takes too long, but epi is the right med to use because it's effect is so quick. Whaddya think?

 

[MediMike]

I'd like to be able to read the whole article, and see what exact determining factors they use to denote "anaphylaxis". Since you have access to it would you mind looking through it and throwing out their criteria?

 

[mycrofft]

I've seen benedryl IV work a lot faster than an hour, and epi doesn't reverse the reaction, it staves it off for a little while. We used to use Susphrine to get the fast onset then longer results than regular epi, but if there was an issue or there was too much Susphrine, then we had cauised another problem.

 

[Medic Tim]

I know a number of areas that have strict protocols for when epi is given /what qualifies as anaphylaxis vs severe allergic reaction. I have heard of a system that required a sys bp of 90 or less for epi to be given regardless of pt presentation and others vitals/signs/symptom. The places I have worked, management/cqi/medical director feel that it is overtreated and that providers are to quick to jump to epi when it is not needed.

 

[VFlutter]

Where is that data from? Also, did they define how they qualified anaphylaxis? Maybe some of the cases were borderline and not considered to be immediately life threatening to the medics.

 

[bigbaldguy]

not considered to be immediately life threatening to the medics.

of course it's not, the patients the one with the problem

 

[OfficerEvenEMT]

The source is:

American College of Allergy, Asthma & Immunology (ACAAI) 2012 Annual Scientific Meeting: Abstract 58. Presented November 12, 2012.

 

[silver]

How did they determine that the patients met the diagnostic criteria of anaphylaxis initially? Or are they retrospectively looking at diagnosis in ED?

 

[leoemt]

Here in WA Basics can give Epi for Anaphalaxis.

Per King County Protocol, signs and symptoms must be Respiratory Distress and Hypotension. If we give an Epi Pen we need to get ALS on scene or get patient to the doctor.

http://www.emsonline.net/assets/EMTPatientCareProtocols2012.pdf

 

[Veneficus]

I read the study.

It is deeply flawed, based on protocol and not patient presentation is just one problem.

It will carry no weight in my future clinical decisions or opinions on EMS.

 

[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?

 

[silver]

I read the study.

It is deeply flawed, based on protocol and not patient presentation is just one problem.

It will carry no weight in my future clinical decisions or opinions on EMS.

Is it indexed anywhere? I just want to read it, but I don't even know the title...

 

[medic417]

I read the study.

It is deeply flawed, based on protocol and not patient presentation is just one problem.

It will carry no weight in my future clinical decisions or opinions on EMS.

I agree. As with many so called research papers the definition used is based on a persons already preconceived notions.

This would be like saying because a Paramedic told a person they do not need an ambulance yet later the person is admitted to the hospital that the Paramedic was wrong. We all know better than that Most people that are admitted to the hospital need know ambulance. So now if in my perception Paramedics should not be allowed to say no to transport all I have to do to back up my study is say how many patients that the Paramedic said did not need the ambulance ended up hospitalized. The numbers would seem to indicate I was right in saying Paramedics should not make the decision. So obviously while I have numbers to back me my study is flawed big time.

Same with the quoted study

 

[Jon]

I read the study.

It is deeply flawed, based on protocol and not patient presentation is just one problem.

It will carry no weight in my future clinical decisions or opinions on EMS.

Good point.

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

 

[OfficerEvenEMT]

They seem to say that Epi should be used immediately when there is a confirmed anaphylaxic issue, but that it is not. Ideas why?

 

[Veneficus]

They seem to say that Epi should be used immediately when there is a confirmed anaphylaxic issue, but that it is not. Ideas why?

Because it is not confirmed in the field.

 

[Veneficus]

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?

All of critical care is a balance of competing treatments and interactions.

The simple answer is: Yes.

But there are smarter ways of doing it. Rather than a 1 time SQ or preferably IM bolus, you could use a drip.

If somebody is in extremis, then by all means, fire away. But...

"Don't use a cannon to kill a mosquito."