October 2022

Approach to the Critical Patient

Allergies and Anaphylaxis7 Chapters

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Paul Z. -

It was stated that epi should be given in the anterolateral thigh because it is absorbed faster than in the deltoid. That surprised me, so I checked the reference. The paper that supposedly supports this was primarily comparing the  intramuscular route with the subcutaneous route. I do not think this paper supports for the contention that the anterolateral thigh is superior to the deltoid when comparing intramuscular epi administration. Pharmacologically, this does not make sense to me. What does Brian Hayes think?
Other points:#1: the anterolateral thigh is usually recommended because the EpiPen brand of auto injector comes out as a long forceful needle that can penetrate jeans -- and impale the humerus if given in the deltoid. (It can shoot a stream of epi 6' through the air - I've tried it!)  So I agree with the manufacturer's recommendation on that basis.
#2: in our children’s emergency room we draw up the epi - both because it is less expensive, but more importantly, it allows for more accurate dosing. The standard doses of either 0.15 or 0.3 mg mean that most children will be either underdosed or overdosed. (We then give it IM - but usually in the deltoid.)
Summary: The focus on the anterolateral thigh as the only place to administer epi intramuscularly has appeared previously in EM:RAP (March 2021). If you want to push this site because that is the only place to give a commercial Epi-pen, that is understandable -- but you should at least mention that other intramuscular sites, such as the deltoid, are acceptable rather than create another medical myth that will need to be busted one day.
End of this rant. I have other pediatric rants if you want them.

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Allergies and Anaphylaxis Full episode audio for MD edition 61:58 min - 68 MB - M4A