Epi Early and Often


Sitting next to my son, who is rather red-cheeked with his current fever, consuming a herculean amount of cartoons, I was reminded of one of my favorite shows when I was young: GI JOE.  “Knowing is half the battle,” was imprinted within my being at an early age.  The Morsels have addressed many topics that hopefully augmented everyone’s “knowing.”  One topic that deserves some attention is Anaphylaxis.

{Yes, we just went from my febrile son, to GI JOE, to Anaphylaxis.  That is the transitive property of Morsel writing.}

Anaphylaxis: More Common than you Think

  • The incidence has increased with the implementation of the broader definition.
  • The incidence ranges from 100,000 to 500,000 per year in the USA.
  • Two-thirds of the annual cases are new cases.
  • Almost 1% of cases are fatal.
  • The incidence in food-related allergies has been increasing, so it is expected that anaphylaxis will also increase.
  • Estimated that a food-induced anaphylaxis presents to the ED every 6 minutes in the USA.


Anaphylaxis: The Criteria

  • The National Institute of Allergy and Infectious Diseases define anaphylaxis as a “serious allergic reaction that is rapid in onset and may cause death” and typically involves two or more organ systems.
  • Anaphylaxis is highly likely when ANY of the following criteria are met:
    • Acute Onset with involvement of skin, mucosal surfaces, or both AND
      1. Respiratory Compromise and/or
      2. Reduced BP or symptoms of end-organ dysfunction
    • Two or more of the following that occur rapidly after exposure to a likely allergen:
      1. Skin/Mucosal tissue involvement
      2. Respiratory Compromise
      3. Reduced BP or symptoms of end-organ dysfunction
      4. Persistent GastroIntestinal symptoms (ex, crampy pain, vomiting)
    • Rapid reduction in BP after exposure to known allergen.


Anaphylaxis: Important Points

  • The severity of an anaphylactic reaction cannot be predicted based on past reactions or risk factors.
  • Young children are tricky!
    • As with most conditions, the very young can be more difficult to diagnose.
    • The preverbal may not be able to express their symptoms clearly.
  • GastroIntestinal Symptoms are important to consider!
    • They are often under appreciated.
    • They have been found in over 50% of cases.
  • BiPhasic Reactions:
    • Occur in about 6% – 11% of children.
    • Usually manifest within the first 8 hours after exposure, but may be delayed up to 72 hours.
  • Treatment:
    • Epinephrine is the preferred 1st line therapy.
    • Antihistamines (H1 and H2 blockers) are useful for urticaria, nasal, and ocular symptoms, but not other symptoms.
    • Steroids have too slow of an onset to matter in the acute phase.


Anaphylaxis: “Epi Early and Often!”

  • Epi Early!
    • Epinephrine is the 1st line therapy for acute anaphylaxis.
    • Delayed administration of epinephrine has been associated with increased morbidity and mortality.
      • Unfortunately, several studies indicate that Epinephrine is either given in a delayed fashion or not at all during the acute phase.
      • This is true for patients/parents, EMS providers, as well as physicians.
    • Dose:
      • 0.01 mg/kg of the 1:1,000 solution; Max of 0.3 mg in children (0.5 mg in adults).
      • Autoinjectors: 0.15 mg dose for pts < 25kg; 0.3 mg for pts < 25 kg.
      • Exact dose is preferred for small infants and children.
    • Route Matters!
      • Intramuscular (IM) administration into the mid-anterolateral thigh is preferred.
      • IM provides faster rise in plasma and tissue concentrations than does the subcutaneous route.
  • Epi Often!
    • Epinephrine has a short half-life.
    • May need to repeat dose after 5 minutes.
    • Up to 20% of patients require more than one dose!
    • It is important to ensure patients have at least 2 doses of self-administered Epinephrine available to them in different environments (So prescribe 2 for home, 2 for school, etc).
  • There are no absolute contraindications to Epinephrine in this clinical setting.
    • Often concerns over adverse effects of epinephrine can delay it being given.
    • Appropriate doses of epinephrine rarely cause severe adverse reactions.


Moral of the Morsel: Epi Early and Often

  • Keep the broader criteria of Anaphylaxis on your radar screen.
  • Ask specifically about GI symptoms.
  • If the patient meets criteria, give Epi without Delay and consider additional dose in 5 minutes if not improving.
  • Get access and give IVF.
  • Other meds like antihistamines should not be given instead of Epinephrine.  They can be used as adjuncts, but do not let them distract the team from getting the Epinephrine in!
  • Patients then will require either prolonged observation (no standard, but often recommended to be 4-6 hrs) or hospitalization.



Chipps BE. Update in pediatric anaphylaxis: a systematic review. Clin Pediatr (Phila). 2013 May;52(5):451-61. PMID: 23393309. [PubMed] [Read by QxMD]

Tiyyagura GK1, Arnold L, Cone DC, Langhan M. Pediatric anaphylaxis management in the prehospital setting. Prehosp Emerg Care. 2014 Jan-Mar;18(1):46-51. PMID: 24028748. [PubMed] [Read by QxMD]

Benkelfat R1, Gouin S, Larose G, Bailey B. Medication errors in the management of anaphylaxis in a pediatric emergency department. J Emerg Med. 2013 Sep;45(3):419-25. PMID: 23478178. [PubMed] [Read by QxMD]

Grossman SL1, Baumann BM, Garcia Peña BM, Linares MY, Greenberg B, Hernandez-Trujillo VP. Anaphylaxis knowledge and practice preferences of pediatric emergency medicine physicians: a national survey. J Pediatr. 2013 Sep;163(3):841-6. PMID: 23566384. [PubMed] [Read by QxMD]

Lieberman P1, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, Bernstein JA, Burks AW, Feldweg AM, Fink JN, Greenberger PA, Golden DB, James JM, Kemp SF, Ledford DK, Lieberman P, Sheffer AL, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol. 2010 Sep;126(3):477-80. PMID: 20692689. [PubMed] [Read by QxMD]

Sampson HA1, Muñoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, Brown SG, Camargo CA Jr, Cydulka R, Galli SJ, Gidudu J, Gruchalla RS, Harlor AD Jr, Hepner DL, Lewis LM, Lieberman PL, Metcalfe DD, O’Connor R, Muraro A, Rudman A, Schmitt C, Scherrer D, Simons FE, Thomas S, Wood JP, Decker WW. Second symposium on the definition and management of anaphylaxis: summary report–second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Ann Emerg Med. 2006 Apr;47(4):373-80. PMID: 16546624. [PubMed] [Read by QxMD]

The post Anaphylaxis appeared first on Pediatric EM Morsels.

MEdIC Series | The Case of the Debriefing Debacle

Welcome back again this week to the Medical Education in Cases series.  Last month we had a record breaking number of people join us for the case discussion, and we hope you will come back and share your thoughts with this one.

This month’s case centers upon Dr. Berner and his student Melanie as they both go through a Cardiac Arrest case. Consider their story and think about how you might approach this case.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Debriefing Debacle

by Dr. Joanna Bostwick

“Excuse me Dr. Berner. One of the nurses came to ask me if we were aware that there is a 20 year old guy in the Resuscitation Room with a heart rate of 200,” said Melanie nervously, a third year medical student who had just started her Emergency Medicine (EM) rotation.

“What? I didn’t hear about that. Let’s go over right away.”

Dr. Berner sprinted ahead as Melanie grabbed her stethoscope. As Dr. Berner entered the Resus Bay he saw a young slender male who did not appear well with vomitus running down his cheek. He looked sonorous and diaphoretic and the monitor showed a heart rate now of 220 bpm. Two nurses were hard at work attempting to establish an IV and draw bloodwork.

“Can anyone tell me about this patient?” Dr. Berner demanded.

“He was found slumped over at a house party tonight. The paramedics think he took a cocktail of drugs and alcohol,” said one of the senior nurses while she primed an IV with normal saline.

Dr. Berner turned to Melanie, “Have you ever intubated before?”

“Ummmm… A few times?” Melanie stuttered, she had intubated a couple of times in the OR but never in the ER. “But I’m not even sure what’s going on here.”

“We can talk more about what’s going on in a moment, first we need to secure the patient’s airway.”

“The O2 sats are starting to drop and I can’t wake him up,” said a nurse anxiously.

“Ok team, let’s give the naloxone and get set up to intubate.”

“The naloxone was given per protocol by EMS with no effect earlier,” stated the charge nurse.

“Alright then, I’m going to intubate right now.” Let’s get the crash cart at the bedside and page RT stat.” Dr. Berner turned to Melanie, “I will have you watch this one and you can attempt the next intubation.”

The patient was intubated successfully and Dr. Berner sighed with relief. With the patient’s airway secure, his oxygenation improved. He now turned to Melanie to ask about toxins that could cause tachycardia when suddenly the monitor started to beep as Dr. Berner looked in horror to see VFib.

“Melanie start chest compressions,” ordered Dr. Berner, “Betty, can you give 1 mg of epi? Also, Sarah can you go get Dr. Takeda and his residents over in the Quick Care area?”

Melanie had never done CPR before in real life and shuddered in horror as she felt ribs breaking beneath her hands.

Her head was spinning. What had just happened? She was beginning to feel her arms fatiguing and didn’t know how she could keep this up.

There was a fury of people who suddenly appeared to help at the bedside.

“Ok stop CPR let’s check the rhythm and pulse,” said Dr.Berner.

“Asystole,” said several in unison.

“Resume CPR,” Dr Berner said and then turned to Melanie, “you can switch off with Joe. He’s right behind you, ready to take over CPR.”

“Dr. Berner the family has arrived they would like to find out what’s happening and want to see their son,” said the social worker quietly from the doorway. I have tried to prepare them for what they are about to see.” Dr. Berner nodded his assent, and the social worker disappeared momentarily. A few minutes later, she returned with a middle-aged couple, both clinging to her for support.

“Another round of epi please, Betty?”

“How long has the code been going on?” asked Dr. Takeda as he arrived. He and Dr. Berner turned to each other to discuss the proceedings on the code, just out of Melanie’s earshot. Dr. Takeda then went over to talk to the parents of the patient, talking to them somberly for several moments.

A few moments later, the couple looked to him and said: “Please stop.”

Dr. Takeda then nodded at Joe, who had the bedside ultrasound set up, and ready to use at the next rhythm check.

“Rhythm and pulse check please,” ordered Dr. Takeda.

“No pulse… Asystole…”

“Bedside echo shows no cardiac activity.”

“Let’s call the code,” sighed Dr. Berner. “Time of death…”

There was a large wail as the patient’s mother fell to the ground. Melanie tried to hold back her own tears.

For the next few minutes, Melanie felt like she was walking through a daze. Had that really just happened? She felt like it had just been a few minutes since she had seen him arrive with the paramedics! He had groaned when she tried to do a sternal rub… He had been alive. What had happened? Maybe her compressions weren’t forceful enough? What if it was her fault?


Key Questions

  1. How do you debrief this case with Melanie?
  1. How do you address her fears that she did something wrong?
  1. What is a general approach to debriefing a medical student after a bad outcome in a young patient?
  1. What is the role of the family’s presence during a resuscitation?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts are:

  • Hans Rosenberg (@hrosenberg33) who is an emergency physician at The Ottawa Hospital and Assistant Professor at the University of Ottawa. IT Director and Social Media keener.
  • Tessa Davis (@TessaRDavis) is a pediatric emergency physician from Sydney, Australia. She is also the co-creator of the Don’t Forget the Bubbles blog.

On October 31, 2014, we will post the Expert Responses and Curated Community Commentary for the Case of the Debriefing Debacle. After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary which is released on October 31, 2014. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Author information

Teresa Chan, MD

ALiEM Associate Editor

Emergency Physician, Hamilton

Assistant Professor, McMaster University

Ontario, Canada
+ Teresa Chan

The post MEdIC Series | The Case of the Debriefing Debacle appeared first on ALiEM.

Sesiones PAC: Manejo de la patología ORL frecuente en el PAC…y más

Hoy ha sido una mañana muy intensa. Hemos comenzado con una presentación a la que su autora, Maite Valin, enfermera del PAC de Bengoetxea, ha titulado Protocolos PAC; Maite nos ha explicado un proyecto que le anda rondando por la cabeza desde hace ya un tiempo. Nos propone crear grupos de trabajo para protocolizar formas de actuación en diferentes procesos de nuestra tarea y que englobaría, segun el tema, a diferentes estamentos. Hoy ha sido una primera toma de contacto y quedamos emplazados el mismo día de la próxima sesión (25 de noviembre) para retomar el tema. En la última diapositiva hay una dirección de correo para poneros en contacto con Maite.

Luego, Igor Ostolaza, médico del PAC de Zarautz, ha vuelto a plantear el tema del triaje, o RAC, para ser más exactos en el PAC; un asunto difícil de abordar en el PAC y que muchos creemos necesario. También lo retomaremos el día 25 de noviembre; aquellos que estéis interesados en participar podéis mandar un correo a Igor, a su correo corporativo.

Y finalmente, Jaione Agirrezabal, médica de PAC,  nos ha presentado su charla sobre la patología ORL frecuente en el PAC. Lo ha hecho muy bien y creo que no nos vendrá nada mal repasar a través de su trabajo un montón de entidades que, precisamente por ser tan frecuentes, nos generan muchísimas dudas. ¡Buen trabajo, Jaione! Nos va a resultar muy práctica. Mila, mila esker!

En fin, os emplazo a que acudáis el próximo 25 de noviembre a las 10 h, primero hablaremos de los temas de Maite y del triaje, y a las 11 h a nuestra sesión habitual; nos la ofrecerá Asun Isasi, médica del PAC de Iztieta y tratará sobre un asunto que a nosotras, y supongo que a vosotros, nos preocupa mucho: Seguridad del paciente...promete, ¿no? Seguimos...

NO fever, NO bacteriaemia?

Clinical Scenario A 80 yo nursing home resident woman  is brought to the ED by ambulance. “Hypothension, cough and a hystory of heart failure ”, refers the nurse. She looks pale and...

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Early intraICU psychological intervention

Hola a tod@s, my dear friends.

Let´s focus today from the point of view of whom is lying opposite, facing up. Published in Critical Care in 2011, do echo of the article Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depression symptoms in critically ill patients.

The intervention of clinical psychologists from admission to ICU could help our patients to recover from stressful experience. A conclusion that seems obvious and that leads to ask... why psychologists are not a part of the team?. 30-60% of our patients suffer from this type of sequels, why not get them in value?.

As in other studies, the authors used questionnaires to assess levels of post-traumatic stress, anxiety and depression and quality of life (scale HADS, Impact of Event Scale-Revised, IES-R and Quality of life EQ5D questionnaire), and conducted an observational study with a control and intervention group. In the team there were three clinical psychologists, with a guaranteed daily presence from 12 to 16 p.m and available by phone during 24 hours, with an annual cost of 30,000 euros.

Anxiety and depression levels were lower in the intervention group, and the percentage of patients who needed psychiatric mediation was significantly lower in the intervention group, as well as a 41.7% compared with a 8.1% to the year's high of UCI.

I would like to repeat: where are the psychologists?.

Happy Friday,

SEMS 2014: Mok Yee Hui – Transport of the sick child

Dr Mok Yee Hui is a paediatric intensivist and transport guru who runs the KK children's hospital retrieval service. She justifies the case for a specialised paeds service as well as demonstrates the trials and tribulations of tranporting sick kids. This one is for all of the retrievalists out there!

Slides are here: