Epi-Pens: Discussion

[rock_shoes]

Here in Newfoundland and Labrador, EMR's (two week course) can administer 160mg ASA for Ischemic Chest Pain and Cardiogenic Shock, Oral Glucose for Symptomatic Hypoglycemia (can't check blood sugar) and can only assist a patient in administering their own Epipen for moderate or severe allergic reaction (Epinephrine is not carried by EMR's).

So if an EMR suspects a patient has a DLOC due to hypoglycemia they get to risk compromising the patient's airway with Oral Glucose? Frankly you would be better off giving the Glucose rectally. Of course that would probably be considered more invasive than say doing a fingerstick and actually determining whether or not hypoglycemia is the cause of a patient's DLOC(not ignoring other potential causes of course). Sorry I know stupid protocols are not your fault.

As for the use of Auto-injectors I absolutely hate them as an EMS provider, though I will be the first to admit they have saved lives in the hands of the lay person. I don't like pre-filled anything and would rather draw up any required medication from an amp or multi-dose vial. Just a personal preference that's all. Truth be told, I'm a little surprised Auto-injectors have saved as many people as they have when medical professionals often have a difficult time explaining how to use them to patients. Don't believe me? Check out the following study out of Royal Children's Hospital in Melbourne Australia.

Doctor--how do I use my EpiPen?

[Kiwiology]

Perhaps we can liken this to AEDs on ambulances back in the day?

While they may be expensive and seldom used I think autoinjector adrenaline is important.

[Suburban/Rural Medic]

So if an EMR suspects a patient has a DLOC due to hypoglycemia they get to risk compromising the patient's airway with Oral Glucose? Frankly you would be better off giving the Glucose rectally. Of course that would probably be considered more invasive than say doing a fingerstick and actually determining whether or not hypoglycemia is the cause of a patient's DLOC(not ignoring other potential causes of course). Sorry I know stupid protocols are not your fault.

Haha I know what your getting at. I think the protocol is written in such a way that patients with an at risk airway won't get it. But you never know. I will point out that the protocol states 'if symptomatic hypoglycemia indications met' and doesn't specify if its ALL indications met or one or more than one...

I do highly doubt however, that any EMR feels as though they need to give oral glucose to every known diabetic.

EMR & PCP

1. Manage airway as needed

2. O2 100% via non-rebreather mask

3. Administer Oral Glucose or sugared beverage if

symptomatic hypoglycemia indications* met

4. EMR’s should request PCP or ACP intercept if available

ORAL GLUCOSE

Indications: Symptomatic Hypoglycemia and patient able to protect own airway

Contraindications: Unable to swallow or protect own airway

Precautions: Airway compromise due to consistency of medication.

Dose: 30 g PO

*Hypoglycemia Indications for the EMR

· Known diabetic

· Able to swallow

· Cold, clammy skin

· Weakness

· Irritability

· Confusion

PCP Symptomatic Hypoglycemia Protocol continues next page.

[rock_shoes]

Perhaps we can liken this to AEDs on ambulances back in the day?

I don't know. In an ideal world every ambulance would have a monitor/defib onboard with staff who can recognize a shockable vs. a non-shockable rhythm. For use by groups like FRS first responders or as public access units AEDs are excellent. It's clearly proven that early defibrillation is a critical factor in improving cardiac arrest survival rates. What AED's seem to have turned into within EMS is a crutch that has slowed the demand for increased mandatory educational standards.

While they may be expensive and seldom used I think autoinjector adrenaline is important.

Absolutely. It would be unreasonable to expect every person with systemic allergic reactivity to a substance to have the wherewithal to draw up their own epi. The same goes for the lay person tasked with helping these people. What I do believe is a reasonable expectation is that professional responders be able to draw up a weight based dose of epinephrine.

Auto-injectors do have a place. Atropine auto-injectors in response to nerve agent exposure come to mind. I just don't think their place is in my ambulance drug kit.

[Kiwiology]

I don't know. In an ideal world every ambulance would have a monitor/defib onboard with staff who can recognize a shockable vs. a non-shockable rhythm. For use by groups like FRS first responders or as public access units AEDs are excellent. It's clearly proven that early defibrillation is a critical factor in improving cardiac arrest survival rates. What AED's seem to have turned into within EMS is a crutch that has slowed the demand for increased mandatory educational standards.

Yeah most here have a monitor/defibrillator with at least one Officer who is a Paramedic or Intensive Care and can read an ECG. Interestingly 12 lead interpretation is dropping down from an Intensive Care skill to a standard Paramedic (ILS) skill here.

Absolutely. It would be unreasonable to expect every person with systemic allergic reactivity to a substance to have the wherewithal to draw up their own epi. The same goes for the lay person tasked with helping these people. What I do believe is a reasonable expectation is that professional responders be able to draw up a weight based dose of epinephrine.

Auto-injectors do have a place. Atropine auto-injectors in response to nerve agent exposure come to mind. I just don't think their place is in my ambulance drug kit.

I think in your specific jurisdiction where PCPs can draw up and administer adrenaline no they are not required.

As our old IV/Cardiac officers are upskilled to Paramedic (ILS) level which includes IM and IV drugs including adrenaline it will be good as it increases its availability. However that said there will still be ambulances out there with two Technicians (predominantly volunteer) where it would be nice and handy.

Also how long do you reckon it takes to draw up .3 mg of adrenaline out of a glass vial in a critically ill anaphylactic patient who is crashing or about to crash?

1. Open up Thomas pack

2. Select a 1ml syringe

3. Select filter needle

4. Attach filter needle to syringe

5. Do a drug check with your partner ... this is adrenaline 1mg in 1ml, expiry 10/11 ok?

6. Prepare and break ampoule of adrenaline

7. Draw up .3mg (.3ml)

8. Change needles

9. Prepare skin with an alcohol prep

10. Inject drug

.... wouldn't it be easier to pop the cap of your epi-pen, hold against the thigh and click the button?

But that costs $120 .... and a syringe, two needles and a vial of adrenaline costs like $1 is what I will be told from the bean counters

[CBEMT]

.... wouldn't it be easier to pop the cap of your epi-pen, hold against the thigh and click the button?

For you? Yes.

For the patient? I'd imagine a 25 or 27g needle in the arm will hurt a helluva lot less than an 18g in the leg. I've taken an epi pen in the leg, and I assure you that it smarts.

How many of the "omg she's gonna croak right here right now" anyphlayxis do we see, really? For those, yes, I'd consider the pen. For everyone else that I'm considering epi for, there's really no reason we can't draw.

Plus, drawing your own gives you the option of nebulizing.

Edited March 16, 2010 by CBEMT

[Kiwiology]

For you? Yes.

For the patient? I'd imagine a 25 or 27g needle in the arm will hurt a helluva lot less than an 18g in the leg. I've taken an epi pen in the leg, and I assure you that it smarts.

For the "oh my god she is gonna croak right now!" and/or "has alreayd croaked" patients I don't think that bit of smart is an issue. Like our Paramedic level officers being able to cardiovert w/o midaz .... I think if that is required a bit of pain is better than not getting adrenaline or cardioverted.

But these sort of things respond well to my magic line "oh look mate we're helping you, honest!"

[rock_shoes]

Yeah most here have a monitor/defibrillator with at least one Officer who is a Paramedic or Intensive Care and can read an ECG. Interestingly 12 lead interpretation is dropping down from an Intensive Care skill to a standard Paramedic (ILS) skill here.

As long as the education required comes with the skill that’s a good thing all the way around.

As our old IV/Cardiac officers are upskilled to Paramedic (ILS) level which includes IM and IV drugs including adrenaline it will be good as it increases its availability. However that said there will still be ambulances out there with two Technicians (predominantly volunteer) where it would be nice and handy.

If it’s an auto-injector or nothing then by all means use one. You don’t have the luxury of time when dealing with an anaphylactic patient.

Also how long do you reckon it takes to draw up .3 mg of adrenaline out of a glass vial in a critically ill anaphylactic patient who is crashing or about to crash?

Probably less time than it takes to remove your partner from the scene when he accidentally sticks the auto-injector into his thumb because it’s been 18 month since he’s actually needed to use one. In my experience the less than 30 seconds it takes me to draw up a dose of epinephrine has not determined whether or not a patient survived the episode.

1. Open up Thomas pack

2. Select a 1ml syringe

3. Select filter needle

4. Attach filter needle to syringe

5. Do a drug check with your partner ... this is adrenaline 1mg in 1ml, expiry 10/11 ok?

6. Prepare and break ampoule of adrenaline

7. Draw up .3mg (.3ml)

8. Change needles

9. Prepare skin with an alcohol prep

10. Inject drug

.... wouldn't it be easier to pop the cap of your epi-pen, hold against the thigh and click the button?

First off the use of a “filter” needle is debatable. Can you say increased needle-stick injury risk (amongst other issues)? Where I work in BC “safety engineered” sharps are mandatory by OH&S regulation. It isn’t even possible to use a filter needle with some of these syringes.

But that costs $120 .... and a syringe, two needles and a vial of adrenaline costs like $1 is what I will be told from the bean counters

You mean it actually costs less to use educated professionals in some instances? Sounds like an opportunity to use the bean-counters own logic against them. Just giving you a bit of a hard time really. I know the Kiwi’s are excellent proponents for improved educational standards.

Edited March 16, 2010 by rock_shoes

[1EMT-P]

QUOTE (mobey)But aside from that Epipen's are pretty safe, although the EMT's should have to take extra education in recognizing anaphylaxis.

Seriously. The 40hr First Responders I train can recognize anaphylaxis pretty quick and thanks to Sabrina's law are expected to be able to get a patient their own epi-pen if the patient is unable to. If an EMT-Basic isn't already qualified to use this piece of equipment, then let's drop all the pretenses and call them Ambulance drivers. I know Basic education sucks, but I'd expect that giving them the epi autoinjector to use should not be a huge deal.

All EMT-Basics in the US are taught the signs & symptoms of shock & how to treat it. They are also taught how to assist patients with their own life saving medications. If an EMT can assist a patient with his or her own medications then why should they not be allowed to carry & administer those same medications during a life threatening emergencies when ALS is not available?

[JPINFV]

All EMT-Basics in the US are taught the signs & symptoms of shock & how to treat it. They are also taught how to assist patients with their own life saving medications. If an EMT can assist a patient with his or her own medications then why should they not be allowed to carry & administer those same medications during a life threatening emergencies when ALS is not available?

So you want to give EMT-Bs access to, say, nitro?