EM:RAP 2019 December SNACK

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Ian L. -

In an infant -IV is hard so if an infant has eaten peanut butter or egg give adrenalin IM EARLIER -at a sign of rash .
Even with adrenalin Img in Iml at 0.1mg / kilogram a 10 kg infant can be administered 0.05 -0.1ml in a 1 ml syringe deltoid or thigh IM
I have done this for a 6 month old baby who was brought In to a general practice by his mother soon after he ate peanut butter with a macula papiular trunchal rash and crying - the trunchal rash faded and the.Mobile Intensive care ambulance arrived.
The infant did well .

Stephen W. -

I totally agree with this and have administered in this fashion to severely anaphylactic patients. There was a relatively obscure study that looked at the maximum plasma levels of epinephrine given IV, IM, SC or by inhalation and this found that epinephrine levels reached maximum peak levels in 5 minutes with IV and 32 minutes for IM or SQ. (1). There has even been a study looking at intranasla epinephrine, which seems efficacious, biut it required doses up to 5 mg to achieve the same effects of 0.3 mg of Epinephrine.(2).

A few cavetas to mention: Lets try to use consistent language with which Epi to use. For Cardiac Arrest, making an Epi Push "Spritzer" or to mix a drip we should all use the term Epi 1:10,000. For anaphylaxis or asthma via IM route we should all use Epi 1:1000 vial. Our code cart has both and saying "cardiac epi" can be confusing to some.

Also, we all worry about the amount of epinephrine we give, for good reason as we can see tachycardia and hypertension. An important caveat to that is that the does we give result in picogram changes in concentration of serum epineprhine AND, the half life is really short - 3 minutes to 11 minutes in most studies. So, even if we do see side effects they are often short lived and the patients almost always get better and do OK. This speaks to the fact that we will OFTEN have to re-dose.

Anaphylaxis is a life-threatening disease. As ED providers we can often get IV access quickly. If we have it, use it. If we don't and can get it quickly, its probably going to again be faster and more efficacious than IM.

Great talk and well spent 8 minutes. Keep up the good work!

(1) Biopharm Drug Dispos. 1999 Nov;20(8):401-5.
(2) Asian Pac J Allergy Immunol. 2016 Mar;34(1):38-43.

Anand S. -

Thanks for the thoughts.
I think regarding doses and concentrations the language should be changed be changed completely. 1:10,000 and 1:,1000 is antiquated and far too confusing. I prefer exact doses. 10 mcg, 5 mcg etc.

Preston W. -

Dear Sir, Are you nor being unduly pedantic? As a practical matter whatever the "language" what we administer to the patient is a volume. As we administer volume we must necessarily know the concentration. To wit, 300 mcg of 1/1000 0.3ml 300mcg of 1/10000 is 3 ml

Anand S. -

It's not pedantic. Almost every med we use is dosed based on mcg, mg, gm. Epinephrine is on an old and out of dates system that breeds errors. We should be specific with our dosing and that means we should use the actual mcg/mg dosing we want as this is much more specific and less rife for error.

Preston W. -

The operative word is "ALMOST" the exception is drugs wherein there are different concentrations available... Like epinephrine. I have seen misadventures with Ketamine because there are different concentrations available. I submit that in these circumstances the focus on concentration contributes to patient safety. ie. HOW MUCH DRUG IS ACTUALLY IN THE VOLUME OF FLUID IN THAT SYRINGE BEING ADMINISTERED TO THE PATIENT. But along your line of thought. perhaps we need to standardize epinephrine concentration. Like multiple strengths of sublingual nitroglycerin tablets on the med cart has been largely eliminated.

Stephen W. -

Agreed, but I was told there would be no math.....

Stephen W. -

I think we are all speaking the same language. My point was that if you ask a nurse (or physician) for that matter to make a X mcg/mL drip, they might ask "Do I use the 1:1000 concentration or the 1:10,000 concentration to accomplish that?". Especially under stress, most people aren't going to be thinking about equations. I agree, it's an old and outdated system, but still one that many people use to differentiate between thte two drug concentrations. Having Pre-mixed drips is one answer to simplifying this and making it a safer process. Really good at-the-bedside guides with clear instructions (a recipe) are also very helpful. Ongoing education and simulation is key as well. Great conversation and I look forward to hearing about more ideas on how to simplify this and make it a safer practice.

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EM:RAP 2019 December SNACK Full episode audio for MD edition 7:25 min - 14 MB - M4A