Epi subcu or IM?

[12R34Y]

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I was reading in an ACEP CME that was mailed to me the other day on allergy/immunology and the treatment of anaphylaxis and such.............basically it said that the treatment for anaphylaxis is duh.......epi, diphenhydryamine, steroids etc.....however, it stated .3cc of epi 1:1,000 IM and NOT subcutaneous?

as a medic we were always taught subQ epi for asthma and anaphylaxis and not IM....is this right?

later

 

[DrMom]

well, my daughter's epi pen is definitely IM.

 

[Samoa]

It can be given either way in an adult. Dr. Mom, the recommended dose for children is 0.01mg/kg SQ for two doses 15 minutes apart, and then every four hours as needed.

 

[southerndoc]

Either way, but IM is absorbed faster.

You have to consider that if the patient is truly anaphylactic with a BP in the 80's, he/she might have peripheral vasoconstriction, which will limit the ability of the vessels to absorb the epi... plus, the epi itself is a vasoconstrictor, which will further decrease absorption.

 

[DrMom]

Originally posted by Samoa
Dr. Mom, the recommended dose for children is 0.01mg/kg SQ for two doses 15 minutes apart, and then every four hours as needed.

The children's version of the epi pen is IM. I have no experience with what's done in the ED, though, since the epi pen is intended to give her enough time to make it there.

 

[Samoa]

Dr. Mom, I checked the labeling for Epi-Pen, and you're right--it does say IM. The location it says to use is usually SQ, but I guess it depends on the length of the needle. I didn't think they were that long, but I couldn't find that particular piece of info. I have no idea what the rationale is for IM over SQ--the FDA doesn't generally think the lay public can handle IM injections, but it probably has to do with lengthening the duration of action to allow time to get to the ER.

Anyway, the rec above is from the Drug Information Handbook 2003 edition, which is usually pretty exhaustive in regard to acceptable routes, schedules and dosages.

 

[12R34Y]

thanks for the responses.

I just know that I have always in the field given SQ epi as have all of my colleagues where i work and back home where I train. Geekmedic's response makes perfect sense and I have wondered why we don't give it IM as well..............I guess either way works.

thanks

 

[DrMom]

Originally posted by Samoa
Dr. Mom, I checked the labeling for Epi-Pen, and you're right--it does say IM. The location it says to use is usually SQ, but I guess it depends on the length of the needle. I didn't think they were that long, but I couldn't find that particular piece of info. I have no idea what the rationale is for IM over SQ--the FDA doesn't generally think the lay public can handle IM injections, but it probably has to do with lengthening the duration of action to allow time to get to the ER.

The needle is about 1 1/4" long, if I remember correctly. I don't know the gauge, but it is one big needle. I was told that they made it large & thick walled so that it could even go through jeans. It is an autoinjector so that (in theory) any idiot could use it. I'm not so sure about that & always end up going through quite an educational session with her teachers to make sure they have some idea how to use the thing if they ever have to (no, I'm not implying teachers are idiots 😉 ).

In an emergency, I really think that the IM would be easier for the "average person" to use. I would imagine that duration of action also comes into play, too.

 

[Febrifuge]

In my state, it's within the scope of an EMT to assist a patient in administering their own Epi-Pen (and for Paramedics here, Epi is among the drugs that can be administered in the field). I believe that pen is an IM needle. The mechanics of administration are consistent with IM, as well: prepare the pen, push down on the lateral thigh until it clicks, meaning the spring-loaded needle is activated, (and the trigger is more than slight pressure) and hold for 10 seconds. When you pull back, the needle retracts.

I give myself SQ injections a couple times a week. There's no way it's the same kind of needle. As Dr. Mom says, the pen is meant to go through clothing. It's a big honkin' needle, though if you handle the pens safely you'd never actually see one. 😀

 

[DocWagner]

The answer is such...

In the face of TRUE anaphylactic shock, decreased sub cutaneous circulation should logically lead to decreased sub cutaneous medication absorbtion. IM medication in this case would be the method of choice.
It the whole "end organ" definition of shock, exactly as Geek Medic described...though I doubt in the absense of shock IM is truly absorbed faster than SubQ making for any clinically significant result.

 

[DrQuinn]

Originally posted by DocWagner
The answer is such...

In the face of TRUE anaphylactic shock, decreased sub cutaneous circulation should logically lead to decreased sub cutaneous medication absorbtion. IM medication in this case would be the method of choice.
It the whole "end organ" definition of shock, exactly as Geek Medic described...though I doubt in the absense of shock IM is truly absorbed faster than SubQ making for any clinically significant result.

Agreed. Its kind of like in DKA, you need to give the insulin IV instead of SQ, because the patient is so dehydrated that the absoption will be markedly decreased (and when they are rehydrated they may overshoot).

Q, DO

 

[ERMudPhud]

Originally posted by DrMom
It is an autoinjector so that (in theory) any idiot could use it.

I've seen three people in the last 5 years who held the pen upside down and injected their thumb!

I doubt SQ vs IM makes much difference but remember if you are going to be giving IV epi for true anaphylactic shock(not ACLS) that you better be sure of what you are doing. The patient should be really really sick, and probably have failed SubQ/IM treatment. Then make sure you have the right dose. 0.3mg or god forbid 1.0mg of epi IV push can kill people. (I've seen it). The usual recommendation is 1:10000 epi given .1mg(1.0 cc) or less at a time. Titrate for effect. Enough IV epi could make a dead horse win the kentucky derby or kill you patient

 

[southerndoc]

Originally posted by ERMudPhud
The usual recommendation is 1:10000 epi given .1mg(1.0 cc) or less at a time. Titrate for effect. Enough IV epi could make a dead horse win the kentucky derby or kill you patient

There are some that argue that you should use epi 1:100,000 and not 1:10,000.

 

[DrMom]

Originally posted by Febrifuge
When you pull back, the needle retracts...It's a big honkin' needle, though if you handle the pens safely you'd never actually see one. 😀

Hmm. I've never had to use one on Little Miss DrMom, but I have shot off a couple of expired epi-pens into apples so that I could see what they were like. I've never had a needle retract on one.

 

[12R34Y]

Back in my street medic days our protocol was for subQ epi .3mg 1:1000 for anaphylaxis up to 3 doses 15 minutes apart.

However, we used to do 2 mg of epi in a liter of NS and run it wide open for anaphylactic shock.......i believe it was like 2mcg/kg/min or something like that.

Last I heard they stopped doing the IV wide open with epi in it and started giving IV slow push (very slow) .3mg 1:10,000 epi for severe shock.

 

[DrDre']

Our protocols were 2-10 mcg/min (no kg!) for anaphylaxis refractory to sq epi. I can't imagine any med director advocating wide open!
Only needed to hang epi once anyway

 

[vtach]

During my days as a medic we had 2 doses of epi, SQ and IV. .3 of 1:1000 SQ and .3 of 1:10,000 IV over 3 min. No more than 1cc per min. I forgot this once on a frequent status asmaticus, who usually required intubation and multiple bagged albuterol tx's prior to hospital arrival......Well to make a long story short, I pushed the 3cc of 1:10,000, the pt had a 10 sec run of v-tach, took a deep breath and then said, in clear voice, that she felt much better as I was sitting with the paddles in my hands.

 

[southerndoc]

Take 0.1 mg of 1:10,000 epi (1 cc) and dilute it in 9 cc of normal saline... 1:100,000 epi. Perfect for IV use.

 

[12R34Y]

sorry about the /kg thing.......don't know what i was thinking about, but obviously something different.

our protocol in the field was 2mcg/cc WIDE OPEN! this was the protocol and the only time I heard of it done at my service was a guy who got stung by a bee and was in tru anaphylactic shock and they gave it..........he developed chest pain (duh) and ST elevation on his 12 lead........they called medcontrol and they said stop the epi drip...........they did............he got hypotensive and back into anaphylaxis he goes.........they give epi and get his pressure up..........ST segments elevate and on and on and on......

turns out the guy was having epi induced ischemia, but was saving his life from the anaphylaxis.

wierd call

later

 

[Febrifuge]

Originally posted by DrMom
Hmm. I've never had to use one on Little Miss DrMom, but I have shot off a couple of expired epi-pens into apples so that I could see what they were like. I've never had a needle retract on one.

Yikes! I reckon the expired pen I got to play with in class was of a different brand, then.

How long and what gague would you say the needle is on yours?

 

[FoughtFyr]

FYI - my paramedic protocols (Loyola Univ. EMS Sysytem, Maywood, IL - IL EMS Region 8) call for 1mg epi 1:10,000 IV or sub-lingual injection for "unstable anaphalaxis"...

No, I never gave it that way, but the PMD stated that was route of better absortion than IM or SQ in a crisis. Just a thought.

- H

 

[DrDre']

We had the SL orders for narcan in opioid OD. Despite occasional burn out, I never could do that to someone!

 

[DrMom]

Originally posted by Febrifuge
Yikes! I reckon the expired pen I got to play with in class was of a different brand, then.

How long and what gague would you say the needle is on yours?

Okay, I just shot of a really old one so that I could give a decent answer.

I guess I was mis-remembering the length, because this is about 3/4". The needle is very tough & sharp, but isn't a huge gauge. Maybe 20 or 22. It takes a bit of work to bend the needle so that I can get it back into its storage tube to dispose of it.

 

[Febrifuge]

Hmm. So it'll go through denim jeans, but maybe not the little-kid, can't-lower-your-arms snow suit.

And hey, 20 gague is plenty big to a wuss like me. Your basic IV is 18, after all...

(I am not thinking about SL injection...)