Hypertonic Saline given by EMS

[suckstobeme]

So, I had EMS bring in a guy.
Healthy guy, someone broke into his house and hit his head with a hammer. He was "agitated" (probably just pissed off that someone just hit him with a hammer) and had vomitted once but was otherwise conscious and talking. No sign of intoxication.

So we get the call on the radio and EMS tells us they have started 3% Saline. We told them to stop. The guy came in and he was fine. Some scalp lacs. CT negative. His Sodium was 147 (slightly hypernatremic by our reference ranges). They gave a total 125cc's of 3%.

Has anybody else ever encountered this? I remember reading about hyypertonic saline in the field research studies, but then I thought it all died out. Personally, I didn't think there's any reason to have hypertonic on the rig, but apparently they have a hypertonic protocol. Apparently they gave mannitol in the past, but a few yrs ago they switched to hypertonic.

I thought it was weird.

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[migm]

No benefit to hypertonic saline in severe TBI pre-hospital in a randomized multi-center, placebo, blinded RCT in jama 2010

Context Hypertonic fluids restore cerebral perfusion with reduced cerebral edema and modulate inflammatory response to reduce subsequent neuronal injury and thus have potential benefit in resuscitation of patients with traumatic brain injury (TBI).

Objective To determine whether out-of-hospital administration of hypertonic fluids improves neurologic outcome following severe TBI.

Design, Setting, and Participants Multicenter, double-blind, randomized, placebo-controlled clinical trial involving 114 North American emergency medical services agencies within the Resuscitation Outcomes Consortium, conducted between May 2006 and May 2009 among patients 15 years or older with blunt trauma and a prehospital Glasgow Coma Scale score of 8 or less who did not meet criteria for hypovolemic shock. Planned enrollment was 2122 patients.

Intervention A single 250-mL bolus of 7.5% saline/6% dextran 70 (hypertonic saline/dextran), 7.5% saline (hypertonic saline), or 0.9% saline (normal saline) initiated in the out-of-hospital setting.

Main Outcome Measure Six-month neurologic outcome based on the Extended Glasgow Outcome Scale (GOSE) (dichotomized as >4 or ≤4).

Results The study was terminated by the data and safety monitoring board after randomization of 1331 patients, having met prespecified futility criteria. Among the 1282 patients enrolled, 6-month outcomes data were available for 1087 (85%). Baseline characteristics of the groups were equivalent. There was no difference in 6-month neurologic outcome among groups with regard to proportions of patients with severe TBI (GOSE ≤4) (hypertonic saline/dextran vs normal saline: 53.7% vs 51.5%; difference, 2.2% [95% CI, −4.5% to 9.0%]; hypertonic saline vs normal saline: 54.3% vs 51.5%; difference, 2.9% [95% CI, −4.0% to 9.7%]; P = .67). There were no statistically significant differences in distribution of GOSE category or Disability Rating Score by treatment group. Survival at 28 days was 74.3% with hypertonic saline/dextran, 75.7% with hypertonic saline, and 75.1% with normal saline (P = .88).

Conclusion Among patients with severe TBI not in hypovolemic shock, initial resuscitation with either hypertonic saline or hypertonic saline/dextran, compared with normal saline, did not result in superior 6-month neurologic outcome or survival.

 

[Birdstrike]

Many of the things tried to reduce brain swelling in trauma over the years have ended up doing more hard than good.

Even steroids were given at on point... hypertonic saline...mannitol...hyperventilation...icp monitors...

All are "intuitive" on some level. but none are without issues.

 

[Old_Mil]

Talk to their EMS director, this is an opportunity to improve pre hospital care in future transports.

Sent from my A110 using Tapatalk 2

 

[pinipig523]

Neurosurg used to give 3% during my trauma rotations at County.

 

[Apollyon]

Neurosurg used to give 3% during my trauma rotations at County.

Yeah, NSx. When I was in the PICU 9 years ago as a resident, we did it then, too. On the ambulance, though?

 

[Zanegray]

I don't know about you guys - but there is actually not a lot of things I want EMS to actually give. We do online medical direction and they want to DO something (understandably) but I usually just want them to get to me.

Eg. Afib with RVR, rate in the 130's - Doc should I start verapamil?
Me - Is the patient hypotensive? - no
Me - Is the patient alert? - yes
ETA? 10 minutes
Just get here.
Last time the guy actually converted before he even arrived. Plus - without a 12 lead I am not always convinced of the rhythm.

Then, in another scenario - someone with anaphylaxis - I want them to get the IM epi, but instead they get benadryl and soul-medrol. I guess something is better than nothing though.

 

[medicsb]

Based on the ROC study, no EMS agency should be doing this outside of a well-planned study. The question is who is the doc that approved this to be done in the field. Best to take the issue up with the service's medical director.

 

[The White Coat Investor]

3% saline in an awake patient? Surely that's not what the protocol says. Here's what I expect from EMS:

Check the glucose and give glucose prn
Stop the bleeding
Splint the fractures
Needle the chest if indicated
Bag the patient. Maybe intubate them. Suction their mouth.
Narcan.
Zofran.
Maybe morphine.
Albuterol for asthma.
Epi for anaphylaxis.
Good compressions.
Shock V-fib and unstable V-tach.
Valium or versed for seizures.

That's about it. 3% saline? Uhhhh...no.

 

[e30ftw]

inappropriate and deserves a follow up conversation with your local EMS medical director.

Hypertonic saline for head bleeds or elevated ICP is voodoo anyway and has potential for actual morbidity as a side effect. There is really no place for it in current trauma literature outside of the decision of an ICU/trauma attending after resuscitation in the ED.

 

[deleted92121]

Just a small note from a current paramedic but I work hard to keep things simple and remember the basics. Doing this saves more lives than many advanced treatments. I may have a pretty good understanding of pathophysiology (at least more than a fair number of my fellow medics) but that comes from always asking my command physicians questions and continuously reading everything from pathophysiology and more. I take my job seriously but I know my limits. I guarantee you proper assessment, treatment, and hand-off. And if I don't know, you're getting a call.

 

[southerndoc]

As an EMS medical director, I took lactated ringer's off the ambulances. They only carry 5 liters of normal saline per truck (and a small bag of D5 to mix medications). This is more fluids than a patient will ever get in an ambulance, but they carry that many to handle back-to-back calls if needed.

I was under the impression that hypertonic saline required a central line?

My paramedics have standing orders for nearly everything (including diltiazem boluses and drips). They have 30-minute transport times, and I'm pretty aggressive with what I allow them to do. I would never put 3% saline on an ambulance unless there was clear benefit. Was it possible they got 3% saline by accident when they stocked their drug boxes?

 

[deleted92121]

The only time I've seen hypertonic solution on the truck was when we were one of the ROC study groups. I cannot figure out why they are carrying it. Out of curiosity, what state did this occur in?

 

[neusu]

inappropriate and deserves a follow up conversation with your local EMS medical director.

Hypertonic saline for head bleeds or elevated ICP is voodoo anyway and has potential for actual morbidity as a side effect. There is really no place for it in current trauma literature outside of the decision of an ICU/trauma attending after resuscitation in the ED.

Where are you getting your information? Hypertonic saline has a profound effect on reducing elevated ICP.

 

[deuist]

Where are you getting your information?

See the second comment in this thread.

Hypertonic saline has a profound effect on reducing elevated ICP.

Now your turn. Where are you getting your information that hypertonic saline reduces mortality?

 

[neusu]

See the second comment in this thread.



Now your turn. Where are you getting your information that hypertonic saline reduces mortality?

I'm neither disagreeing with that article nor stating it reduced mortality in the EMS/pre-hospital setting.

I am saying it has been shown to have a profound effect on intracranial pressure.

Brain Trauma Foundation Guidelines: Pre-hospital management
"Hypertonic resuscitation is a treatment option for TBI patients with a GCS < 8"
https://www.braintrauma.org/pdf/Prehospital_Guidelines_2nd_Edition.pdf

US Department of Health and Human Services
National Guideline Clearinghouse guidelines.gov
"Level II: Hypertonic saline should be considered for the treatment of severe pediatric TBI associated with intracranial hypertension."
http://guidelines.gov/content.aspx?id=36899&search=severe+traumatic+brain+injury

"the data suggest that HTS given as either a bolus or continuous infusion can be more effective than mannitol in reducing episodes of elevated ICP"
http://thejns.org/doi/pdf/10.3171/2011.7.JNS102142

"We found that hypertonic saline is more effective than mannitol for the treatment of elevated intracranial pressure."
http://www.ncbi.nlm.nih.gov/pubmed/21242790

"The correlation between changes in osmolality and ICP supports the hypothesis that HSS may in part decrease ICP by means of an osmotic mechanism."
http://online.liebertpub.com/doi/abs/10.1089/neu.2000.17.41

I could go on and on, but most trauma centers are switching to hypertonic saline for elevated ICP instead of mannitol.

 

[e30ftw]

Where are you getting your information? Hypertonic saline has a profound effect on reducing elevated ICP.

ya its profound effect is similar to the profound effect of hyperventilation, which is only matched by the profound effect of mannitol, which is only slightly less than the profound effect of steroids on overall m/m.

just like em gets worked up about the amazing actions of epi in ACLS, it's a real life saver..

 

[survivordo]

During my third year of med school an attending was giving us a lecture on IV fluids. He said if there is one thing I want you all to remember it is this: he then wrote 3% NS on the board and next to it drew a skull and crossbones. Still haven't forgotten it!

Survivor DO

 

[EM_Rebuilder]

I am a newer EMS director, but I sure do not see a reason for hot salt on a truck!

I have never given it in the ED either; only used it rarely in the NSICU as an intern.

Someone else mentioned it, I wonder if their was a mixup with the stocking? If there WAS a protocol for hot salt with ICP changes, this guy likely did not have ICP issues based on exam... I agree with everyone else; let your local medical director know about it. Next time, it might be YOU that has an MVC and gets some...

 

[fiznat]

I don't know about you guys - but there is actually not a lot of things I want EMS to actually give. We do online medical direction and they want to DO something (understandably) but I usually just want them to get to me.

Eg. Afib with RVR, rate in the 130's - Doc should I start verapamil?
Me - Is the patient hypotensive? - no
Me - Is the patient alert? - yes
ETA? 10 minutes
Just get here.
Last time the guy actually converted before he even arrived. Plus - without a 12 lead I am not always convinced of the rhythm.

Then, in another scenario - someone with anaphylaxis - I want them to get the IM epi, but instead they get benadryl and soul-medrol. I guess something is better than nothing though.

That's a bit dismissive, isn't it? It sounds to me that what you actually want is competent paramedics, not a change in protocol. As an EP, don't you have an opportunity to effect positive change in the paramedics that bring patients to your department?

3% saline in an awake patient? Surely that's not what the protocol says. Here's what I expect from EMS:

Check the glucose and give glucose prn
Stop the bleeding
Splint the fractures
Needle the chest if indicated
Bag the patient. Maybe intubate them. Suction their mouth.
Narcan.
Zofran.
Maybe morphine.
Albuterol for asthma.
Epi for anaphylaxis.
Good compressions.
Shock V-fib and unstable V-tach.
Valium or versed for seizures.

That's about it. 3% saline? Uhhhh...no.

Agreed with the saline of course, but what about

The rest of ACLS
12 leads
ASA/NTG
Early steroids for bad asthma (plus or minus epi or mag)
Benadryl
Fluids
Sedation for combative behavior or severe anxiety
Quality sick/not sick triage assessment
Clear radio communication with the hospital, including STEMI and CVA warnings when appropriate

And I'm sure many other things I forgot...

 

[suckstobeme]

So I had already emailed the EMS director prior to posting.
He said, basically it's what trauma and NSG at our hospital wanted on the rigs, and in this case it sounds like it was given inappropriately because the protocol is for GCS less than 8. He was going to review this case in particular, and he said I should come to the next trauma meeting to discuss the policy in general (ie if there is any reason at all to keep 3% on the rig).

I still think its a little crazy...

I guess I'll go to the next meeting....

 

[suckstobeme]

The only time I've seen hypertonic solution on the truck was when we were one of the ROC study groups. I cannot figure out why they are carrying it. Out of curiosity, what state did this occur in?

Illinois
State Motto: Malpractice Attorney Shangri-la

 

[deleted109597]

1. The rest of ACLS
2. 12 leads
3. ASA/NTG
4. Early steroids for bad asthma (plus or minus epi or mag)
5. Benadryl
6. Fluids
7. Sedation for combative behavior or severe anxiety
8. Quality sick/not sick triage assessment
9. Clear radio communication with the hospital, including STEMI and CVA warnings when appropriate

...
1. is pretty useless
2. when done right
3. ASA helps in STEMI, but not to a huge degree. The cost/benefit is strong. NTG? Helps pain, might decrease BP. Useful in CHF though.
4. How long are your transport times? How fast do you think the steroids work?
5. For emergent itching.
6. Very few patients need this
7. Reasonable
8. Laughable. Unless you have the ability to refuse transport, which can also have severely bad outcomes.
9. Also when inappropriate.

 

[Rendar5]

...
1. is pretty useless
2. when done right
3. ASA helps in STEMI, but not to a huge degree. The cost/benefit is strong. NTG? Helps pain, might decrease BP. Useful in CHF though.
4. How long are your transport times? How fast do you think the steroids work?
5. For emergent itching.
6. Very few patients need this
7. Reasonable
8. Laughable. Unless you have the ability to refuse transport, which can also have severely bad outcomes.
9. Also when inappropriate.

eh, steroids don't work right away, but it's not teh transport time, but the transport + triage + set up IV line + get the steroids out of pyxis or whatever you use + administer them. saves prolly 20-30 minutes up front, which means the steroids are kicking in on the car-ride home, not after they get their albuterol MDI from the pharmacy.

So useful for those asthmatics you d/c and those borderline ppl you can't decide if you'rekeeping yet or not (though can't remember the last time I kept an asthmatic in the dep't for 3 hours.

 

[The White Coat Investor]

Agreed with the saline of course, but what about

The rest of ACLS
12 leads
ASA/NTG
Early steroids for bad asthma (plus or minus epi or mag)
Benadryl
Fluids
Sedation for combative behavior or severe anxiety
Quality sick/not sick triage assessment
Clear radio communication with the hospital, including STEMI and CVA warnings when appropriate

And I'm sure many other things I forgot...

1) Rest of ACLS doesn't seem to do much good honestly
2) I almost always repeat the 12 lead upon arrival unless it shows a STEMI
3) You have four hours to give ASA and NTG hasn't been shown to affect morbidity or mortality
4) Hmmmm.....okay, but 10-30 minutes probably don't make a big difference
5) Not convinced
6) Medics never get enough in to make a difference. There's always 8 or 900 still in the bag they hung in the ambulance bay. I do appreciate the IV being in place though.
7) I don't see this much.
8) I see them all pretty much on arrival, sick or not sick.
9) STEMI is helpful and saves a few minutes on door to cath time. CVA, not so much.

 

[glorfindel]

... Then, in another scenario - someone with anaphylaxis - I want them to get the IM epi, but instead they get benadryl and soul-medrol. I guess something is better than nothing though.

Benadryl is not an emergency medication. If it would encourage EMS to give the epi sooner, I would have no problem taking it off the rigs entirely.

The same goes for lasix. Acute CHFers with adequate pressure get ntg prehospital. Don't waste time with the lasix.

Hypertonic saline? Not an ems medication unless in a very rural area with very long transport times.

 

[Hamhock]

...
1. is pretty useless
2. when done right
3. ASA helps in STEMI, but not to a huge degree. The cost/benefit is strong. NTG? Helps pain, might decrease BP. Useful in CHF though.
4. How long are your transport times? How fast do you think the steroids work?
5. For emergent itching.
6. Very few patients need this
7. Reasonable
8. Laughable. Unless you have the ability to refuse transport, which can also have severely bad outcomes.
9. Also when inappropriate.

Agree -- and although I am live in a city with short transport times and am a big fan of scoop-and-run, I will actually ADD something to the EMS toolkit that I have seen be useful: CPAP.

Otherwise, I agree that we need to dramatically limit EMS and transport times. (for US cities with short transport times)

HH

 

[Zanegray]

That's a bit dismissive, isn't it? It sounds to me that what you actually want is competent paramedics, not a change in protocol. As an EP, don't you have an opportunity to effect positive change in the paramedics that bring patients to your department?
...

I don't mean to sound dismissive. I think that good paramedics are vital. I just want the focus to be on things that really matter in the short term. And, medications have side effects. Hypotension, arrythmias, things that can be difficult to deal with in a fully staffed ED much less in an ambulance with one or two medics. It wouldn't matter if you had the most competent medics in the world. It is hard for anyone (including docs) to deal with this stuff in an ambulance. Granted, I live in a place where transport times are very short.

And - our medics are competent medics for the most part. No complaints there. As to effecting positive change in medics - that can be tough. Mainly they just think you're an A**h*** if you give them feedback. Anyone else have luck with this?

I agree with other commenters about the second part of your post.

 

[fiznat]

...
1. is pretty useless
2. when done right
3. ASA helps in STEMI, but not to a huge degree. The cost/benefit is strong. NTG? Helps pain, might decrease BP. Useful in CHF though.
4. How long are your transport times? How fast do you think the steroids work?
5. For emergent itching.
6. Very few patients need this
7. Reasonable
8. Laughable. Unless you have the ability to refuse transport, which can also have severely bad outcomes.
9. Also when inappropriate.

I'm not sure how reasonable you're being when you are willing to downplay the value of ASA in the management STEMI in order to make your point. Steroids are a good EMS intervention precisely because they have a long time of onset, benadryl provides comfort to many and perhaps rescues a few who might have otherwise deteriorated. Fluids can be of great utility to many different types of patients, early cardioversion can be life-saving, and laugh it off if you want, but EMS sick/not sick assessments are influencing more decisions out there than you might be willing to admit.

You're sounding pretty disdainful of your medics. Maybe they deserve it, maybe they don't.

I don't mean to sound dismissive. I think that good paramedics are vital. I just want the focus to be on things that really matter in the short term. And, medications have side effects. Hypotension, arrythmias, things that can be difficult to deal with in a fully staffed ED much less in an ambulance with one or two medics. It wouldn't matter if you had the most competent medics in the world. It is hard for anyone (including docs) to deal with this stuff in an ambulance. Granted, I live in a place where transport times are very short.

And - our medics are competent medics for the most part. No complaints there. As to effecting positive change in medics - that can be tough. Mainly they just think you're an A**h*** if you give them feedback. Anyone else have luck with this?

I agree with other commenters about the second part of your post.

That sounds reasonable. I'm sorry you haven't been getting good responses from EMS when you try to give feedback. I guess nobody likes to be told that they screwed up-- it's a tough thing to hear. Nevertheless, I met many physicians during my time as a medic who were able to do it well-- and as a result truly did have a positive impact on the systems where they worked. The common theme between those EPs was that they always made an effort to start from a place of mutual respect and understanding, consistently engaged in proactive instead of reactive intervention, and were patient with healthcare professionals that weren't quite as well educated as they were.

 

[racerwad]

I'm sorry you haven't been getting good responses from EMS when you try to give feedback. I guess nobody likes to be told that they screwed up-- it's a tough thing to hear. Nevertheless, I met many physicians during my time as a medic who were able to do it well-- and as a result truly did have a positive impact on the systems where they worked. The common theme between those EPs was that they always made an effort to start from a place of mutual respect and understanding, consistently engaged in proactive instead of reactive intervention, and were patient with healthcare professionals that weren't quite as well educated as they were.

As a former paramedic, I echo this sentiment. I always tried to adhere to best practices and stay abreast of the literature, not only as it pertained to EMS but in EM and medicine as a whole. And, more than anything, I really counted on the physicians I transported to (not just my medical control) to provide answers and guidance. I hated being wrong but I also appreciated the investment the docs made because I believed it was because they respected what I did and wanted me to improve my practice.

The ED physicians play a huge role in the quality of their EMS system whether they know it (or want it).

 

[deleted109597]

I'm not sure how reasonable you're being when you are willing to downplay the value of ASA in the management STEMI in order to make your point. Steroids are a good EMS intervention precisely because they have a long time of onset, benadryl provides comfort to many and perhaps rescues a few who might have otherwise deteriorated. Fluids can be of great utility to many different types of patients, early cardioversion can be life-saving, and laugh it off if you want, but EMS sick/not sick assessments are influencing more decisions out there than you might be willing to admit.

NNT for ASA is ~50. Not negligible but not amazing either.
Benadryl has never rescued anyone, and isn't a proven treatment for anaphylaxis. Neither are steroids. Sure, it makes allergies feel better in 6 hours, but doesn't need EMS to do it. I don't disagree about cardioversion. Again, paragod triage does little, and probably misses just as many. It's training dependant.

You're sounding pretty disdainful of your medics. Maybe they deserve it, maybe they don't.

Not at all, I just wish they would drive more and spend less time on scene. I'm data driven, and the literature just doesn't support much more than diesel.

 

[docB]

Benadryl is not an emergency medication. If it would encourage EMS to give the epi sooner, I would have no problem taking it off the rigs entirely.

The same goes for lasix. Acute CHFers with adequate pressure get ntg prehospital. Don't waste time with the lasix.

Hypertonic saline? Not an ems medication unless in a very rural area with very long transport times.

The problem with epi is that when it becomes the go to drug it bogs down the ED. Instead of the "improving allergic reaction that got benadryl" (which probably would have gotten better anyway) you now have a patient post epi you need to watch for rebound.

 

[joeDO2]

NNT for ASA is ~50. Not negligible but not amazing either.

NNT ASA 50, NNT therapeutic hypothermia = 6
what is the ratio of places giving ASA for STEMI to hypothermia post arrest? we are always lagging behind the data and this is amplified in ems.

as for my 0.02 to the OP, hypertonic saline in that circumstance is insanity IMO. the only time I could see this being reasonable in an ems setting is special event coverage for marathons, etc. where severe hyponatremia can occur and is confirmed with point of care sodium testing (as is done at the boston marathon and other various events). Should not be carried in day to day operations.

 

[ah2388]

I'm typing this from my phone, so I apologize of it isn't up to par grammatically.

I currently work as a paramedic and I hope to one day make a career out of medicine.

This thread seems to have derailed into discussion about the viability of paramedic care prehospital as a whole. Some in this thread advocate for a limit to the paramedic scope of practice, while others advocate for the benefits of certain practices performed routinely prehospital.

Let us not forget the benefit to our pts in terms of earlier analgesia and other comfort measures performed prior to arrival (splinting etc.).

I think the bottom line is that paramedic education needs to be elevated with special attention given to physical exam, anatomy, physiology, etc...or be limited significantly with regard to some of the high risk/questionable benefit practices currently employed in prehospital medicine.

For the physicians in this thread, you are in an excellent position to impact the practices of the paramedics that bring pts to your ED. My personal practice has been dramatically effected by proactive, engaging discussions I've had with ED physicians. I'd like to think for the better.

EMS needs a cultural change, and it's coming slowly but steadily in the US, but for now I believe those in this thread are in a spot to help significantly get the ball rolling at a local level.

 

[docB]

NNT ASA 50, NNT therapeutic hypothermia = 6
what is the ratio of places giving ASA for STEMI to hypothermia post arrest? we are always lagging behind the data and this is amplified in ems.

Remember that ASA is a very cheap intervention to introduce prehospital and you can do it unilaterally (it doesn't matter what the hospital does after you give an aspirin in the field). Hypothermia is very expensive and requires cooperation and capital investment on the part of a receiving hospital to create a program.

IFor the physicians in this thread, you are in an excellent position to impact the practices of the paramedics that bring pts to your ED. My personal practice has been dramatically effected by proactive, engaging discussions I've had with ED physicians. I'd like to think for the better.

The model for changing paramedic practice should not be talking over the gurney. That is an element you want in your system but the quality of the information is variable. The real way to change practice is to get involved at the medical director level and change training and protocol. While that's the real way to do it it's also slow and political.

 

[ah2388]

The model for changing paramedic practice should not be talking over the gurney. That is an element you want in your system but the quality of the information is variable. The real way to change practice is to get involved at the medical director level and change training and protocol. While that's the real way to do it it's also slow and political.

Unfortunately, the last sentence is all to true.

 

[glorfindel]

The problem with epi is that when it becomes the go to drug it bogs down the ED. Instead of the "improving allergic reaction that got benadryl" (which probably would have gotten better anyway) you now have a patient post epi you need to watch for rebound.

Respectfully I disagree.

The "rebound", as far as I'm aware, isn't dependent on the epi but on the severity of the initial anaphylactic reaction.

A severe rxn would have to be observed anyway and probably admitted.

A mild to moderate one could be d/cd based on the severity of the rxn regardless of whether epi was given.

Or are you saying that prehospital epi might make it hard for us to tell once the pt hit the door whether the rxn was severe or not?

At any rate, I'd rather EMS give an effective treatment rather than some ineffective ones. Especially in a time-dependent disease like anaphylaxis. The sooner they get the epi, the better, imo.

 

[deleted109597]

Finally someone other than me gets to tilt against windmills.

What are you watching for? Rebound itching? If they had anaphylaxis, then sure, watch for that to rebound. Anything else, who cares?