Anaphylaxis

[island emt]

The scope of practice for Advanced EMT's does not have benydryl in it.

They do have IM or SubQ epi for anaphylaxis with orders.

The national scope of practice model was produced by our good friends at NHTSA as a plan to make all providers in the U.S. work to the same standard.

However it is in my opinion working to the lowest common denominator instead of forcing states behind the curve to increase their education standards and allow the providers to excel in prehospital care.

here is some light reading for you.

http://www.ems.gov/education/EMSScope.pdf

Edited April 22, 2014 by island emt

[systemet]

@ Cadaceus; re: Benadryl [still can't get the quote function to work on my win8 machine].

The reason that the EMTs can't give Benadryl is primarily political. Originally the EMT was conceived as a level that did not administer any medications. Over time, there's been a movement to recognise that paramedics are not always available in a timely manner, and to introduce some medications into the EMT scope. Generally these are medications that are either low-risk, or have a very high potential benefit. ASA, ventolin, and epinephrine certainly all fall into this category.

Depending on the region, other medications, such as glucagon, D50W, narcan, Tylenol, atrovent, etc., might be included in this scope as well.

The reason Benadryl probably isn't in most EMT scopes, is that the benefit is relatively small. It's considered an "adjunctive" medication, compared to IM epinephrine, which is life-saving, and the treatment of choice for anaphylaxis.

In this situation, po Benadryl would be a poor choice. The patient is quite tachypneic and dyspneic, and may have a significant amount of airway edema. It may not be particularly practical, or comfortable for them to take a po elixir of Benadryl. They're quite distressed, and going to be breathing through a NEB or NRB mask. In addition, oral medications are poorly absorbed in shock states. The body shunts blood flow away from the digestive tract and towards the heart, lungs and brain, delaying absorption. Orally-administered meds are slowly absorbed, even under ideal conditions, and are subject to a lot of break down by the liver ("First-pass metabolism").

As a paramedic, this patient would get a dose of Benadryl and a dose of a corticosteroid, probably dexamethasone, IV. This wouldn't be a first priority, but would get done once some other things were taken care of.

Many of the EMT scopes restrict medication use to specific routes, e.g. IM epinephrine, but not IV epinephrine, or for specific conditions, i.e. "You may give NTG SL to a patient with suspected ACS, with a prior prescription for NTG SL", but prohibit it's use in other conditions, e.g. congestive heart failure. Sometimes these restrictions don't make sense, as in the example of NTG for ACS (negligible benefit), versus NTG for CHF (large potential benefit, but greater risk of harm through inappropriate use). A lot of regions have a scope of practice that restricts EMTs from given meds via the IV route.

A lot of these restrictions seem very arbitrary. For example, my local BLS can place a king LT tube, which has a small benefit in most circumstances, but can't use a CPAP device for CHF/COPD, which has a large benefit. It's just a reflection of the way scope of practice develops, which is often fragmented and may even require changes in the language of specific laws. As an EMT, this used to frustrate me, often.

There are two competing ideas here. The first is that there are a large number of skills within the paramedic scope that could be performed by an EMT, an EMR, a first responder, a first aider, or a random member of the public. We have certainly seen many of these shifts where the skill has been performed by people with less and less training, e.g. public access defibrillation, dispatch prearrival instructions for ASA, epi-pens, narcan autoinjectors, etc. If you consider EMS, the whole history is a sequence of events whereby physicians realise that they can extend care into the community by delegating certain tasks to EMTs or Paramedics. There is often a period of resistance to change, and a concern that a lesser educated provider may cause harm. We have seen this result in changes where the skill has been withdrawn, e.g. RSI for paramedics is currently being greatly curtailed, or increased, e.g. cathlab bypass or field thrombolysis, ketamine, adult intraosseus initiation.

As a paramedic, or as an EMT, the second idea, is that we are attempting to develop a profession of skilled out of hospital health care providers. That the patient is not going to receive the same level of expertise in a prehospital setting as they would from a board certified EM physician, but that we are going to try and move incrementally closer in that direction. This is part of the driving force behind developing Bachelor degree paramedic programs, and even graduate degrees in some countries. The educational training requirements in North America are woefully inadequate at both the BLS and ALS level. As a paramedic, a concern for me, is that if I lack sufficient education for what I am doing, and I believe strongly that my training programs were inadequate -- then passing on the skills that I can perform to someone with even less education runs the risk that we decrease the training standards further. Most of what I do could be done by a fairly experienced EMT, almost as well. But this is not the way to build a profession.

So, it would be easy to add a lot more skills to the EMT scope. They could have antihistamines and corticosteroids. They could have antiemetics, opiod pain control, narcan, an anti-convulsant, etc. But given EMT training in my region is about 250-300 hours of didactic, with another 160 hours of ambulance practicum and 40 hours in the hospital, I think the training time would be inadequate to do this well. Just as my training level often lets me down when I need it. I think EMT training in many regions in the US is substantially shorter.

Sorry if this constitutes a derail. I just want to add that I very much value my EMT colleagues, without whom nothing would get done. We are a team. This does not prevent me from wanting us to collectively increase our level of training and education.

[Caduceus]

@Island Thank you for that link. I have put it on my ereader so I can read it without the net distracting me. It does seem like the US has a bad habit of setting the standards so the state's citizens can pass tests rather than making them raise their test scores. This happens with everything and not just EMS. The state tests for high schoolers in Washington dropped their standards two years ago because "too many students were failing". Nope, not a word about our school programs. Nothing at all.

@ Systemet It seems that all over the US there are too many differences in EMT training programs. They are all over the charts, I really feel like the US needs to just set solid guidelines that say "EMTs can do this, AEMTs can do this, and Paramedics can do this." We shouldn't have differentiation between states because that just confuses things. Also, once a national standard is set and held people will see EMS as a profession like nursing. Thank you for giving me such a long response, I do appreciate it and find it interesting.

And if this derails it's mostly my fault ^_^" Sorry.

[jwiley40]

Diphenhydramine (Benadryl) when given by a medic is in IV form, not a syrup like you find at home. Yup, it'll make you sleepy, but it stops the histamine release. Epinephren 1:1000 given subcutaneously is the first line medication in anaphylaxis, as it relaxes the smooth muscles. The two meds working together will bring relief to the patient.

[HellsBells]

Interesting, this is not a pt I would like to have to try and intubate. I'm actually thinking that this may be a case where digital intubation might be a reasonable option.