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Underutilizing Epi in Anaphylaxis

Bryan Hayes, PharmD, Aaron Bright, MD, Mizuho Morrison, DO, and Howie Mell, MD
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Regardless of your specialty, we as medical providers are underutilizing epinephrine. Culturally most of us feel that we should only reach for this medication when there is shock or impending closure of the airway. However the reality is, epinephrine is relatively safe, life saving and much faster acting than the cocktail of other medications we administer to someone in anaphylaxis. Don’t wait to use the are only asking for trouble!


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Ian L., Dr -

Important to note the use of glucagon available if a patient is on B -Blockers to push theB -Blocker off the Adrenalin Receptor.Also Adrenalin IM can be repeated after 5 minutes several times .
IV has to be given slowly if possible and also helps reHypotension.Also a fluid bonus 30ml/kg
Do not forget nebuliser adrenalin for croup here you have to crack open up to five 1mg in 1ml ampoules depends on child age/weight !
Reference :Annals of Emergency Medicine 2006 SampsonHA et al .also WAO J 2008 Kemp SF et al Supplement 18-26 of the World Allergy Organisation Journal.

Anita O. -

hello love the program. I face dilemma when I use EPI at our facility, The consensus is to send the patient to the emergency department after use to watch for rebound. I thought one hour was enough but the staff does not agree (MD included). This issue was not discussed. please advise. Anita O'Malley PA

Mizuho M., DO -

HI Anita,
Thanks for the comments. You bring up an excellent topic! In response to your question, we recorded a segment with Dr.Anand Swaminathan to bring you the latest on this controversy. Hang tight, it will be coming down the pike in a couple months. Thanks! ~Mizuho

Anita O. -

OK, Thanks for your response. I can't wait to hear what Dr Swaminathan has to say. Once again great program thanks for all your hard work !!

Bruce W. -

So you're giving the same amount of EPI (0.3 mg) but increasing the volume of the IM injection 10 fold. I realize that the volume is obviously going to be spread across a larger surface area in the muscle, but in a situation where minutes can make a profound difference in the outcome, could we be significantly increasing the absorption time and thereby increasing the time to reach adequate circulating levels of epinephrine?
Bruce Whitwell, PA-C

Mike W., MD -

Hi Bruce. The IM dose should b the higher concentration so you can use a lower total volume. This may have been confusing or misstated. I have always found it curious that the concentration is even discussed in medical lectures - I simply order the dose and do not specify the concentration - that way you will always b right and minimize confusion. Thx for the comment- you are definitely right!

Ian L., Dr -

The apply named 'Dirty Epinephrine Drip' by EM Critic Supra Energiser Scott Weingart :"One ampoule of 1:1000 adrenalin(Aus) Epinephrine (USA ) in one litre of saline : with wide 18G needle 20-30ml of a Litre /min or 20-30ug / min : Check BP response EKG : can introduce faster if squeeze bag with graded pressure or roll clamp the line ."
For critically ill anaphylaxis .
Alternate 0.3ug per minute with Iml of 1:1000 adrenalin ampoule = Three small markings per min ie 0.03 ml or 1/3 0.1ml / min for the Emergency House Visit if patient "really
Bad ." !!

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Death by NSAIDS, PCP and Not Enough Epi! Full episode audio for MD edition 182:05 min - 85 MB - M4AHippo Urgent Care RAP March 2016 Summary 551 KB - PDF