Epinephrine

epi

And the winner is…

I rank Epinephrine as my number 1, most essential drug out of the 33 I carry.

Epi has three main uses. For cardiac arrest, for anaphylaxis and for severe asthma.

If I were rating epi only as far as cardiac arrest, I would place it much lower on the list. I have given epi on virtually ever cardiac arrest I have done with the exception of those where my first shock produced a palpable pulse before I was able to get an IV line or shoot the drug down the tube. I have had cardiac arrest saves where the patient was in arrest when I arrived and I rescusitated them with epi and they walked out of the hospital. And I have had many return of spontaneous circulation post epi who made it to hospital admission only to die in the ICU. Do I think epi helped those who walked out of the hospital? Maybe or maybe it was the electricity and the CPR. The science says epi doesn’t make a difference in cardiac arrest, so I am inclined to accept that. I will say I have had many patients who I didn’t get an IV into for awhile, but once I did, and gave them epi, they got pulses back. Now that we have the EZ-IO, as well as a protocol to let us stop resuscitation on patients after twenty minutes without success, I work almost all of my codes where they fell and I get IV assess and epi in much quicker than I did, and I will say I have had a huge increase in my ROSCs. I won’t give up on epi. Maybe if we can improve some of the other aspects of what we do in cardiac arrest, epi may one day be shown to make a difference as the spark that lights a stalled heart, but for now I can only speculate and accept the science.

I have used epi for asthma—There are several limitations on it. The patient must be under 35 and have no hypertension history for use to be able to give it on standing orders. I have had some success, but that may be more attributate to the nebs. I had an asthma code where once I got epi down the tube I was able to save the patient, although unfortunately, she suffered an anoxic injury.

The reason I list epi as my number 1 drug is for anaphylaxis. It is a magic before your eyes life-saver.

When I was precepting many years ago one of my first calls was for a young woman who had just eaten Chinese Food, and almost immediately began to feel sick and have trouble breathing. We were just blocks away, but by the time we arrived, her eyes were closed shut, she was pale, clammy, and we couldn’t palpate a pulse. She was dying in front of us. We hit her with the epi, and by the time we reached the ED she looked like any normal teenager, eyes open, warm, dry skin, good BP.

I’ve done a number of true anaphlyaxis calls over the years, and I can you, I would not want to look in my bag and find the epi gone. Because if it wasn’t there, those patients would be dead, and if the epi was missing because I failed to check my gear, then I would deserve life without parole.

Here’s an old post Nut Allergy-Sneezing from 2007 about using epi on a child.

***

There are certain calls you get that usually turn out to be nothing — baby choking, person slumped over wheel of car, fall with severe bleeding. In fact, just about every call you get, usually turns out to be nothing much. That’s good. Over time it is a great calmer. I usually say to myself, it’s probably nothing.

We get dispatched to a seven year old having an allergic reaction to some medicine he got at church. We are being dispatched to a local supermarket where the patient will be found in a green SUV. I’m sitting in the back of the ambulance as we have a three person crew today, and my EMT partners have been working for the ambulance each for over twenty-five years so they get the front seats. I think about getting the epi out just in case, but I don’t. Whenever I preprepare, it ends up as a wasted effort. I can’t tell you how many packages of defib pads I opened up on the way to “cardiac arrests” when I first started — “cardiac arrests” where we found the patients alert and talking when we arrived.

We pull up and a cop comes over and asks if I have an epi-pen. I have the house bag over my shoulder as I step out — the med bag is in one of the main pouches. He says the boy ate some nuts or something in a brownie or cookie at a church party and he’s allergic to nuts and he started throwing up, and he got hives and his eyes started swelling, so his parents got him in the car, and drove to the supermarket and got him some liquid benadryl. But they don’t have his epi-pen with them.

The mother is holding the boy and I can see the eyes, still open, but swollen, and I can see some hives on his arms. He looks very pale. The mother says the boy was wheezing so they also gave him some puffs from his inhaler. I sit the med bag down on the hood of the car and take out the epi after asking the boy’s age and weight, I draw up .15 mg of epi 1:1000 in a 1cc syringe. The child starts screaming when he sees the needle. The mother has to give the child to the father to hold so I can hit him with the shot. IM, instead of SQ, as our new protocols dictate. I stick the needle in and dodge a fiercesome kick. One of my partners then says to the child, its okay, no more shots. In the back of my mind, I am thinking, don’t make promises you can’t keep. I hope no more shots. I think they did give him some benadryl syrup so I can at least hold off on the benadryl, which would have meant another needle.

I ask the parents which hospital they want to go to, and they ask which one is closest and then they ask for directions, and then I say, no, he needs to go to the hospital in the ambulance, with us, one parent can ride along. He needs to be monitored, I say, just in case. When you ingest an allergen, the reaction can come back.

***

Many years ago I did a call for a large man who had eaten several brownies with peanuts to which he was allergic, but he said that he had been hungry and they were so good, he went ahead and had them, and hoped he wouldn’t have a reaction. He was dripping with sweat and vomiting. I hit him with the epi and he was doing a whole lot better until we got to triage when I turned around to talk to the nurse and then turned back and he was out — his BP went down to 60 and he was pale diaphoretic and mottled, and they had to hit him with more epi. He crashed again on them later in the shift. I never forgot that.

***

We get in the ambulance and the boy stops crying and the swelling around his eyes subsides, although he is still very pale. I put him on the monitor. He is afraid that the stickers will hurt, but I say no, and he lets me put them on. His heart rate of 144 slowly goes down to 116. His lungs are clear. His SAT on ambient air is 100%. We take off to the hospital, non-priority, and mom and I have a nice chat about the dangers of nut allergies, etc, while I write my report up, but still keeping an eye on the child.

I call the hospital and tell them we are just a couple minutes away with a child allergic to nuts, who had a reaction, didn’t have his epi-pen, I gave epi, and the child is better. They like it short and sweet.

I’m looking at the monitor and I see the heart rate start to rise, which I find very odd. It goes to 140, and then 150, and then 160, and then 170. The SAT starts to drop as well, 96, 92, 90, 85, 80. The child looks the same. Equipment failure? I check the sensor. It is on solidly. The boy isn’t shaking his finger. He sneezes. “Bless you,” his mom and I say together. He sneezes again. “Bless you.”

“Are you okay?” I ask.

He doesn’t say anything. I stimulate him and he at least looks at me, then he sneezes again and again. I look at the SAT — it still reads 80. As I reach for an oxygen mask and try to think how I will explain this to the parent, I notice, he is rubbing his legs. I look at where he is rubbing — I don’t see any hives, but the skin almost in front of me starts to turn red. His face is flushed now as well.

“He’s having another reaction,” I say.

Just like that multiplying hives appear like in some sci-fi movie of a human turning into a creature. I touch his red bumpy skin and when I move my hand off I see my finger prints. He’s mottling. We’re in the ER driveway now.

I have the epi out, draw it up quickly and hit him again. No resistance from him this time. For good measure, I give him some benadryl IM also. No messing around worrying about another needle. He doesn’t even flinch.

Wheeling him down the hall, we navigate through a maze of stretchers, patients, staff and other EMS people and visitors. I tell the triage nurse the patient has had another reaction. The boy is crying and scratching himself. The nurse directs us to a treatment room.

The boy is doing better now, the hives have retreated almost magically, but his skin is still somewhat mottled. His Sat is up to 98%, but that’s with the 02. We get him over onto the bed, and I give my report to the nurse.

They put in an IV and give him Solumedrol, and tell the mother they will have to keep him at least 24 hours for observation.

After I’ve written my run form I go back to the room, where the child, a non-rebreather on, the swelling much subsided around the eyes, no hives visible, sleeps under the watchful eyes of his mom, who signs the back of our run form agreeing to let us bill the insurance company, and she smiles, and thanks us for helping them, for all we did, for helping her son.

***

A couple final points on epi 1:1000 in anaphlyaxis.

Epinephrine 1:1000 should be given Intramuscularly (IM) when used for anaphylaxis as opposed to Subcutaneously (SQ). We use to give it SQ, but IM results in more rapid absorption and higher plasma concentrations than SQ in patients suffering shock.

Never give epinephrine 1:1000 IV. (Unless diluted to make it epi 1:10,000). This will likely put the patient into VT or Vfib and can obviously be fatal. This has happened in our system.

Use the 1:10,000 concentration IV with caution, push 0.1 mg slowly over 3 minutes and only in patients who remain hemodynamically unstable after IM administration. The dose may be repeated as needed every two minutes to a maximum of 0.3 mg. I have never had to give it this way. I know medics who have and their patient have had runs of VT from it.

***

Epinephrine 1:10,000

Class: Natural catecholamine, adrenergic

Action: Stimulates both alpha (a) and beta (ß1 and ß2) receptors.

Indication: Cardiac arrest – Adult
Cardiac arrest – Pediatric
Anaphylaxis with shock
Contraindication: Use in pregnant women should be conservative
Pre-existing tachydysrhythmias

Side effects: Tachydysrhythmias
Hypertension
May induce early labor in pregnancy
Headache, nervousness, decreased level of consciousness

Dose: 0.5 to 1.0 mg (usual)

Route: IV, IO
ET if given this route the dose should be doubled
Pedi Dose: 0.01 mg/kg (0.1 ml/kg)

Epinephrine 1:1,000

Class: Same as Epi 1:10,000

Action: Same as Epi 1:10,000

Indication: Severe allergic reaction, status asthmaticus,
laryngeal or lingual edema

Contraindication: Use with caution in the presence of:
Pre-existing tachydysrhythmias
Hypertension
Significant cardiac history
Pregnancy

Side effect: Same as Epi 1:10,000

Dose: 0.3 mg

Route: IM

Pedi dose: 0.01 mg/kg (0.01 ml/kg) to a max. 0.3 mg (0.3ml)
See PALS guidelines
For croup administer 5mg (5ml) nebulized with 2.5-3ml of NS

5 Comments

  • Elizabeth says:

    As a CPR instructor I am amazed at the number of ppl in my classes who say they’re supposed to be carrying an Epi-Pen but they’re not!!I’m allergic to fire ants which in GA are hard to avoid. Thankfully though I’ve managed to avoid getting bitten.

    One side comment about my experience, while being treated in the ER, when the Benedryl was injected into my IV I could literally feel it flowing through my blood stream, cooling the itching as it went. I’ve never felt anything like it before. It was like being in fire internally and someone turned on a sprinkler inside my body. It was awesome!!

    Thanks for all you do folks!

  • PR says:

    Thank you for this set of posts. I’ve been reading now for about two years. You do a great job. Thank you!

  • Ian says:

    This series was wonderful. Thank you for writing and sharing it with us!

  • Brill series.

    Now, what are your 10 favourite pieces of kit?

  • medicscribe says:

    Thanks for the comments. At some later point I may do an equipment series, but I now a backlog of calls to write about.

    Thanks again,

    Peter

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Peter Canning

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