ONLY an EpiPen for anaphylactic shock?

Listen to Zenheretic (an experienced pharmacist by profession) and D25 (obviously an experienced paramedic). They are dispensing professional advice.
 
Thomas,
Here are excerpts from information that may be of interest to you on the subject of anaphlaxsis, including this working definition accepted by the medical community. Please note!!! this is NOT medical advice, just information.

From Current Opinion in Allergy and Clinical Immunology
"Understanding the Mechanisms of Anaphylaxis"

Posted 09/22/2008

Author Information:
Richard D. Peavy and Dean D. Metcalfe, Laboratory of Allergic Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA

[Anaphylaxis and insect allergy: Edited by Theodore Freeman, Jacobs, Ramirez, and Freeman Allergy & Immunology Associates and Alessandro Fiocchi]

"With the initiative of the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network, representatives from several organizations in the United States and abroad met in symposia in 2004 and 2005 to debate and seek consensus on a universally accepted definition and clinical criteria for identification of anaphylaxis. The outcomes of these symposia were published in two reports in the Journal of Allergy and Clinical Immunology.[2,3] In seeking a definition both useful and accessible to the lay public, the participants proposed simply that, 'Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death.' Even more significant for emergency response and treatment, the participants established a set of three diagnostic criteria for anaphylaxis to include observations of skin and mucosal tissue symptoms, respiratory distress, reduced blood pressure, and/or gastrointestinal symptoms over a time course of minutes to hours after exposure to allergen.[2,3]"


"The most frequently identified triggers for anaphylaxis include foods (especially peanuts and tree nuts), drugs (antibiotics, vaccines, medications, and anesthetics), insect venoms, latex, and allergen immunotherapy injections.[3,14] There is also a significant number of anaphylaxis cases reported for which there is no cause identified (idiopathic anaphylaxis).[15,16]'

Self-Injectable Epinephrine for Initial Management of Anaphylaxis in Children

Posted 09/09/2008

Marcia L. Buck, Pharm.D., FCCP; Kristi N. Hofer, Pharm.D.; Michelle W. McCarthy, Pharm.D.

"It has been estimated that 1 to 2% of the population is at risk for anaphylaxis.[1,2] Intramuscular (IM) administration of epinephrine is the primary therapy in the emergency management of anaphylaxis resulting from insect bites or stings, foods, drugs, latex, or other allergic triggers. Its efficacy lies in prompt administration after allergen exposure. Self-injectable epinephrine products have been designed for administration within minutes of the onset of symptoms. In children, these products may be administered by a parent or other trained personnel. This issue of Pediatric Pharmacotherapy will review of the role epinephrine in anaphylaxis and highlight current recommendations on the use of self or caregiver-administered epinephrine in children."...................from the same article:

"Position Statements and Practice Guidelines"

In 2002, the American Academy of Allergy, Asthma, and Immunology (AAAAI) published an updated position statement on the use of epinephrine in the treatment of anaphylaxis.[8] This statement included the following recommendations:

* Prescribers need to be aware of patients' previous allergic reactions. Self-injectable epinephrine should be considered in all patients with a previous history of anaphylaxis or a serious reaction to an allergen. Patients and/or caregivers should be provided with detailed instructions regarding methods for identification and avoidance of allergens, as well as a treatment plan.

* If the patient is not capable of self-administration, epinephrine should be given by any individual recognizing the presence of an emergency need. The Academy supports authorization of trained personnel to administer epinephrine, including lifeguards, teachers, and camp counselors.

* Paramedics should receive training in the recognition and treatment of anaphylaxis. They should be certified to administer epinephrine, based on individual state requirements.

* Intramuscular epinephrine should be included in emergency medical kits in all public facilities.

* It is recommended that epinephrine be available in all schools for use by nurses or other trained staff.

Similar recommendations were published last year by the European Academy of Allergology and Clinical Immunology.[9] Like the AAAAI recommendations, this group supported the use of IM epinephrine as a first-line therapy in children. The group called for the development of anaphylaxis management plans tailored to the individual child, based on previous allergic reactions, other medical conditions, and social circumstances. They recommend that self-injectable epinephrine be prescribed for all children with prior cardiorespiratory reactions, exercise-induced anaphylaxis, idiopathic anaphylaxis, and persistent asthma in children with food allergies.

In March 2007, the American Academy of Pediatrics published a clinical practice guideline on the use of self-injectable epinephrine.[3] This document provides a thorough review of the literature and addresses some of the controversies in the care of pediatric patients, including symptom identification and epinephrine dosing in children weighing less than 15 kg, for whom standard auto-injectors may provide an excessive dose.".......................

"Drug Interactions

Epinephrine should used with caution in patients taking digoxin, quinidine, diuretics, or other alpha or beta-adrenergic agonists, as concomitant administration may lead to arrhythmias or hypertension. The effects of epinephrine may be increased when given with antihistamines, furazolidone, levothyroxine, methyldopa, reserpine, tricyclic antidepressants, or monoamine oxidase inhibitors.[4-6]
 
Last edited:
Most of the advice I have located on the Internet implictily assumes or expressly states that "immediate" "professional medical care" is to followup injection of epinepherine.

Where professional care is many hours or even several days away, should oral antihistamines be administered as an adjunct to injectable epinepherine?

I conclude that the answer is, "Yes."

Dissent?
 
Thomas,

I would also conclude "YES". I have never seen any evidence to suggest that administering antihistamines to someone suffering from a reaction will cause harm or worsen the situation. The question is how much good it will do, but in my mind it is the only thing that may buy you enough time to get to help or prevent the worst case scenario.

I do know that the epi-pen alone wasn't enough to get me better. The hospital administered IV drugs (antihistamine can't remember what, and O2) that made me feel better in about an hour. Mac
 
Don't know if its been mentioned but there have been a couple of recalls on "twin-ject" epi-pens, the two shot ones. different failures, pretty much any and everything that can go wrong has. so for now I'd recommend sticking to the single shot ones
http://www.epipen.com/ for some really good resources including free "trainer" pens
 
This has been a particularly interesting thread for me. My 3 year old Grand Daughter has been recently diagnosed with allergies to anything peanut related. An epi pen goes everywhere she goes, the doctors instructions were simple, epi pen and 911. Something not brought up in this thread is the use of a Practice Pen for proper administration. It took me a couple of tries to get it right, in a real emergency you only have one shot at it.
 
do you guys in the USA need prescriptions for Epipens? we do in BC, makes it hard to stock the FAK for the woods
 
Bushman5 said:
do you guys in the USA need prescriptions for Epipens? we do in BC, makes it hard to stock the FAK for the woods
Click to expand...

Yes, you have to have a prescription.

When I was a kid, I had an allergy test done and was allergic to dust mites and the hickory family of trees. I had another one done a few years ago and was allergic to literally everything they test for, save one thing (I forget what the one thing was). So, I carry an EpiPen with me everywhere. :)

For the practice pen, I have a couple, but I can't remember if they came with the prescription or from my allergy doctor. My doctor showed me how to properly use an EpiPen as soon as he wrote the prescription, so I'm thinking it came from him. Either way, I'm sure a pharmacist or doctor can point you in the right direction.

I used to have some severe problems with allergies and chronic sinusitis. Still do, but I've had a few surgeries, am on allergy shots, and take Zyrtec-D twice a day, everyday, so I stay problem free for most of the year, with only a few sinus infections a year. I take antihistamine BEFORE I start a hike just to avoid any sort of allergy problems, just be aware of the potential side effects. I have never had problems with drowsiness with Zyrtec-D, but I have had dizziness issues with Clarinex-D after exerting myself (like on a hike). From what my doctor tells me, Zyrtec-D is the strongest stuff on the market.
 
Thomas Linton said:
Wilderness first aid issue.

What do you think of advice for anaphylactic shock that only discusses use of an EpiPen? It was my impression that giving/taking antihistamines was also critical? Did the conventional wisdom change when I wasn't lookin'? :confused:
Click to expand...


In the hospital in case of shock epi . You can give antihistamines as well afterwards. The reason that you don't give antihistamines oral route is that its not potent enough and it takes 30 minutes before it starts working. Even giving someone epi pen is not an automatic cure. I had a patient who was stung by a bee his mom gave him epi shot right away, and did a tracheotomy young man still died. Part of your emergency pack should be glucose tabs, antihistamines , and an inhaler even if you aren't an ashamtic.

Also keep in mind that antihistamines can cause some serious heart related issues.
 
Last edited:
HLS careful what you pack, and make sure that its appropriate, Soy allergies are getting more common, and ipotropium Brominde (atrovent) will react badly with those people. Some places are making the EPI-jr pens available OTC. not sure if thats a good idea or not.
Most people I've talked to, (ER nurses, Medics etc) say that anytime you are in a +7minute ambulance responce area, any antihistamine is better than none. remember if you are dealing with a true anaphilactic emergency, they are dead if you do nothing, so you can't much make it worse. but everyone has a different opinion. and its hard to find advice that isn't tainted by liability issues
 
DaveinNY said:
Something not brought up in this thread is the use of a Practice Pen for proper administration. It took me a couple of tries to get it right, in a real emergency you only have one shot at it.
Click to expand...

What are some of the 'mistakes' that you were able to learn to prevent with the practice pen?
 
I once had a discussion about this with one of the MDs who started the Haight-Ashbury Clinic in San Francisco. I suspect he had to deal with quite a few people with severe allergic reactions and anaphylaxis during Grateful Dead shows. Anyway, one of the things he extolled was the use of over the counter asthma inhalers (pure epinephrine) before things got too bad. Each dose is tiny, but while your lungs are still functioning okay, it the epinephrine gets into your bloodstream very rapidly. He would combine it with Benadryl and got good results.

I'm not (and he did not) advocating OTC asthma inhalers as a replacement for Epi pens, but they can be of significant benefit if you don't have an Epi pen with you and you need it. They also don't need a prescription, so you can keep a couple in your kit.

Also, after reading about the concerns of overdosing with multiple pen injections, I wonder if use of an inhaler might be a little safer if the initial pen shot wears off before help arrives or the person gets to help. Small doses from repeated puffs as needed could really help and OD would be less likely.

Just thinkin' out loud on the last part.
 
annr said:
What are some of the 'mistakes' that you were able to learn to prevent with the practice pen?
Click to expand...

He is referring to how often people jab the wrong end into their thigh, getting a needle through the thumb and epinephrine squirting into the air.
 
gadgetgeek said:
HLS careful what you pack, and make sure that its appropriate, Soy allergies are getting more common, and ipotropium Brominde (atrovent) will react badly with those people. Some places are making the EPI-jr pens available OTC. not sure if thats a good idea or not.
Most people I've talked to, (ER nurses, Medics etc) say that anytime you are in a +7minute ambulance responce area, any antihistamine is better than none. remember if you are dealing with a true anaphilactic emergency, they are dead if you do nothing, so you can't much make it worse. but everyone has a different opinion. and its hard to find advice that isn't tainted by liability issues
Click to expand...

Urghhh I happen to be in the medical profession, if you read my posting it does not recommend any particular inhaler or medication. Any medication can have an adverse reaction with certain patient whether it be simple aspirin or PCN As I mentioned in my original posting antihistamine oral route is notthe ideal if you have epi, I did not disregard it. We are talking about shock here right not just mild reaction. I was giving potential adverse reaction for cardiac patient ,as there is a tendency to over medicate not discounting antihistamine. With respect to inhalers, did I mention any particular name brand with respect to any medication ? I don't believe I did, you can go out get otc and get epinephrine inhalers, how about albertol,? With respect to atrovent, you are right about the potential warning for those RARE instances where people have severe adverse reaction to soy I would hope that anyone who carries medication with them read warning labels that goes for epi as well. In most instances signs and symptoms of soy allergies are are mild you can find more adverse reaction in other food allergies like shell fish and nuts. Also keep in mind that most soy issues occur in infants and young children, most of which will eventually outgrow them. With your reference to growing number of soy allergies what percentage are you talking about. I wasn't exactly sure what the numbers were and I didn't want to just make blanket statements so if you look a the following link its gives 1 % of u.s. pop and some info about soy allergies and the majority of those people have mild symptoms, so we are talking about a very small percentage of people that that life threatening reaction. This is in no way to down play those individuals that have life threatening reaction to soy base products. Also keep in mind that when it comes to allergic reaction there also a load dose to consider "not always but potential" I.E. some people may be allergic to cats but they may require having two or more cats to trigger symptoms while one doesn't do anything to them. Also keep in mind that food allergies are relatively rare and that peanuts are the number one food allergy associated with the lethal allergies. One death in about 800,000 cases among children.

http://www.mayoclinic.com/health/soy-allergy/DS00970
 
Last edited:
Would there be any benefit to crushing up an antihistamine pill and 'snorting' it? Would that make for a quicker absorption of the drug as opposed to ingesting it and waiting for it to dissolve? May not be pleasant, but would it work and be beneficial in such a situation where you wanted quick relief?
 
statius said:
Would there be any benefit to crushing up an antihistamine pill and 'snorting' it? Would that make for a quicker absorption of the drug as opposed to ingesting it and waiting for it to dissolve? May not be pleasant, but would it work and be beneficial in such a situation where you wanted quick relief?
Click to expand...

Not that is is any sort of advice potentially it can be effective if you can get it in very powder form. One of the problems you may come up with is the potential risk of aspiration " foreign matter in lungs in this case stomach contents" , since unpleasant sensation may induce gag reflex. Further complicating things depending on the level of shock they may not be able to snort. Lots of things can change how quickly a drug is absorbed. Most drugs are absorbed in the small intestine not in the stomach as many people may believe. So if you are on various medication or had a big lunch it can dramatically slow down absorption rate. You may try rectal and sublilngual route as well.
 
Sorry about that HLS but I can never be sure what someone is refering to when they say "inhaler" to me that can be any of three styles of MDI, with any number of drugs, combos and doses. I meant to add clarity to the situation, not frustrate you.

What part of the medical profession are you a part of if you don't mind my asking. I only ask as some people have different biases. As an emergency first responder I would never even think of a heart condition when dealing with anaphylactic shock, as the person is dead if I do nothing, so if their heart can't handle the epi- or antihistamines, thats just tough.

As for the rarity of allergies, every where I work, regardless of the size of group, I can nearly guarantee that there will be a child with some allergy severe enough to require epi. the rate of death may be low-ish, but the risk is still there.

also I do not believe that MDIs with epinephrine are available in canada, I've never heard of anyone mention it.

So am I correct in stating that you disagree with the antihistamine with epi, where as I believe and have been taught that if epi is warranted then the antihistamines are as well? although I think that antihistamines should be given as soon as a reaction happens that is either, near the mouth/nose, stronger than normal, or covering a moderate area of the body, to act against what you called the load dose, and keep then below the danger threshold. but that is besides the point
 
You must log in or register to reply here.
Back
Top