Moderator EMEDPA Posted July 20, 2013 Moderator Share Posted July 20, 2013 Recently saw a bounce back seen by one of my FM colleagues. 52 yr old guy with a significant allergic reaction to a food product(basically anaphylaxis). itching all over, tight throat, swollen lips, etc. Quick look in his mouth shows a malampatti 4 airway. When they were initially seen they got benadryl, steroids, and pepcid and transiently improved and were discharged. They presented back on night shift with increasing throat tightness/ lip and tongue swelling/etc. I repeated the above treatments and added epi. The pt improved rapidly, was offered obs admission and declined. Epi was not given initially by the FM provider due to a fear of side effects in this guy > 50 yrs old with a hx of htn. Now the philosophy bit. EM folks know that both of the following are true: 1.You need to give yourself permission to do the difficult thing if you think it is the right thing. 2. when there is only one choice it is the right choice. This guy had the potential to go down fast. I was already thinking about how to manage his airway and was thinking ahead as far as a crich as I think an oral intubation in this guy would have been difficult at best(would have tried but would have had crich set at bedside). Take home message: don't worry about the side effects of a treatment if not using the treatment would result in a worse outcome than the treatment itself. I used to work with an old ER doc whose " 1st law" was "treat the patient, not the diagnosis." very true and a philosophy that still guides me to this day. the diagnosis can be wrong. the patient presenation is not wrong although our interpretation of it may be. Link to comment Share on other sites More sharing options...
rcdavis Posted July 20, 2013 Share Posted July 20, 2013 Epi and susphrine ( do they still make that??!) EXCELLANT choice. The other leg to start down was IV heparin. Btw, Ihave started reverting to the old two fingers down the throat method for the malampatti 4s.. Sticking my left index and middle fingers down over base of tongue, trying to feel epiglottis, and squirilling the tube inbetween the fingers under the epiglottis and thru the cords blindly. Had a malapatti 3/4 come in who had had radiation and surgical tx for throat cancer... Could open his mouth only about 17 mm due to the fibrosis... as cirico tray being set up, tried that and worked ... Sweet. The other main problem with FM in ED is their hesitancy to Adequately open something which needs to be surgically drained.. Or to make a mere nick in the skin in trying to get a deep abscess... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 20, 2013 Author Moderator Share Posted July 20, 2013 SUSPHRINE(I remember it too) was taken off the market probably 15 years ago. it was felt pts rebounded from it more than regular short acting epi and were likely to do so outside of the dept. I remember when we used to give LOTS OF IT to asthmatics. Link to comment Share on other sites More sharing options...
rcdavis Posted July 20, 2013 Share Posted July 20, 2013 Then, too, was the propensity of docs and/or nurses to overdose... Had one 3y/o lost kidneys due to 100xnormal dosing.. ( she forgot those were decimals... Link to comment Share on other sites More sharing options...
Moderator ventana Posted July 20, 2013 Moderator Share Posted July 20, 2013 from the FM perspective, if they are that sick they need to be in the ER - I would not prescribe EPI as an out patient for an acute issue - and in fact ALWAYS tell patients if they use an epi pen the MUST go to the ER! If they are that sick they deserve to be in the ER - unlike the 70% of patients that could be seen in the office Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 20, 2013 Author Moderator Share Posted July 20, 2013 from the FM perspective, if they are that sick they need to be in the ER - I would not prescribe EPI as an out patient for an acute issue - and in fact ALWAYS tell patients if they use an epi pen the MUST go to the ER! If they are that sick they deserve to be in the ER - unlike the 70% of patients that could be seen in the office This was an er pt seen by an fm trained provider. they probably should have gotten epi the first time. difficulty swallowing/tongue swelling/etc gets my pucker factor going.... Link to comment Share on other sites More sharing options...
PM2PA Posted July 20, 2013 Share Posted July 20, 2013 Life before limb, airway before everything else (usually). Link to comment Share on other sites More sharing options...
Moderator ventana Posted July 20, 2013 Moderator Share Posted July 20, 2013 Life before limb, airway before everything else (usually). ahhhhemmmmm - scene safety before all else - I am getting in my car and driving home at the end of the night.... (sorry tanget there..) Link to comment Share on other sites More sharing options...
HMtoPA Posted July 20, 2013 Share Posted July 20, 2013 Right or wrong, I've always sort of considered Epi first-line Tx for anaphylaxis. Benadryl and everything else are more of adjunctive therapies, and I can't imagine going to them (if I was at all worried about an airway) before Epi. In fact, right before I was in PA school, I worked in an allergy clinic, and we (as Corpsmen) basically had standing orders to administer Epi in clinic at first suspicion of anaphylaxis, THEN get the supervising doc. The patient would then be quickly transported to the (very close by) ED for the rest of the Tx (Benadryl, O2, additional Epi, etc.). Prior to that, as a field Corpsman, I always carried Epi on exercises and deployments, and given the often austere conditions and delayed transits to higher echelons of care, developed a pretty low threshold for using it. I never had to, but maybe all those experiences influence my judgment now. Perioral or palatal tingling in the right context would be anaphylaxis until proven otherwise, and (if I was an ED provider) I would likely use Epi right away. In the FM environment I would hesitate a little...probably have it ready, but arrange for the patient to get to an ED for proper definitive care preferentially. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted July 21, 2013 Administrator Share Posted July 21, 2013 This was an er pt seen by an fm trained provider. they probably should have gotten epi the first time. difficulty swallowing/tongue swelling/etc gets my pucker factor going.... If I had seen an allergic reaction with airway involvement in MY FP setting, they would have gotten epinephrine. I would have probably code blue'd them to get the crash cart there faster if they looked really bad. Crash cart is kept in urgent care, which is a good distance, but at least on the same floor. Link to comment Share on other sites More sharing options...
Just Steve Posted July 21, 2013 Share Posted July 21, 2013 Have a Glide Scope down there on the coast? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 21, 2013 Author Moderator Share Posted July 21, 2013 Have a Glide Scope down there on the coast? yup. I actually like the king vision better which is what they have at my other rural job. the screen is right on the handle. Link to comment Share on other sites More sharing options...
cbrsmurf Posted July 21, 2013 Share Posted July 21, 2013 I don't think we even have Epi on hand at the FP clinic I work at... is it a requirement for FP clinics to have it in stock? Link to comment Share on other sites More sharing options...
rcdavis Posted July 21, 2013 Share Posted July 21, 2013 I don't think we even have Epi on hand at the FP clinic I work at... is it a requirement for FP clinics to have it in stock? Do you have a crash cart? I do not think it is a "requirement" per se. But, if you are injecting any materials , giving any vaccines, repairing any lacerations, removing any foreign bodies, giving any medications, evaluating any allergic conditions.. Then it is a requirement... So, it whether or not it is a requirement depends on what you are doing in the clinic. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted July 21, 2013 Administrator Share Posted July 21, 2013 An FP "crash cart" might just be an EpiPen, BVM, OPAs, and AED, but every practice should have *something* handy for an emergency. Because people NEVER go to their doctor for chest pain instead of calling 911... Link to comment Share on other sites More sharing options...
CByersPAC Posted July 21, 2013 Share Posted July 21, 2013 @cbrsmurf: Personally I wouldn't work without some emergency basics such as epi, regardless of the legal requirement situation. I've never had to use the epi at my practice sites, but I make sure I know where it is and have the acute management for anaphylaxis prominently posted. Just as I've never had to use the AED, but I know where it is and (hopefully) how to use it. I *have* had to use the ASA, NTG and oxygen, which I guess is peculiar since, as rev ronin has already pointed out, people never drive themselves to a clinic for chest pain instead of calling 911. Gotta say, as an FM weinie, I never wanna have to use that stuff and have certainly been guilty of dabbing gingerly at an abcess with the tip of my scalpel instead of sailing in there with EM aplomb and incising widely. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 21, 2013 Author Moderator Share Posted July 21, 2013 I quit a former per diem job at an urgent care center when they took away the crash cart. Their philosophy changed from "stabilize and transfer" to "call 911 for emergencies". not ok. my license is worth more than seeing potentially emergent pts without adequate supplies available. even at $75/hr 3 yrs ago it wasn't worth the risk. Link to comment Share on other sites More sharing options...
G. Davenport Posted July 21, 2013 Share Posted July 21, 2013 EDEMPA. I quit that job too. Seems like this is a topic that crosses all boundaries. Any provider who injects, dispenses, or touches a patient should be ready to treat an adverse reaction. And ready to treat it aggressively and correctly. Calling 911 and waiting for transport can be a fatal approach. IMHO. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 21, 2013 Author Moderator Share Posted July 21, 2013 yup, a few months later the manager who made all the chnages got fired for running the place into the ground. a few of our colleagues still work there now but it has basically turned into an after hrs fp ambulatory care center. nothing "urgent" about it any more. we used to run codes in the hallway there when it was run by the dept of em....switrching it to the control of fm was a huge mistake. it used to be 24/7/365. now it's only open 6-10pm m-f and all day on weekends. what a joke. Link to comment Share on other sites More sharing options...
Moderator ventana Posted July 22, 2013 Moderator Share Posted July 22, 2013 This was an er pt seen by an fm trained provider. they probably should have gotten epi the first time. difficulty swallowing/tongue swelling/etc gets my pucker factor going.... Whoops, my bad. Yes this is alarming that airway issues did not get epi. While working in Er a few years ago this into a very good emrap presentation that epi is really is the only treatment, everything else is just fluff. Link to comment Share on other sites More sharing options...
cbrsmurf Posted July 22, 2013 Share Posted July 22, 2013 Guess I will push for some Epi in the office. We have salumedrol, but I guess that probably wouldn't be enough if the pt is already in shock. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 22, 2013 Author Moderator Share Posted July 22, 2013 Solumedrol works in hours, not minutes.... Link to comment Share on other sites More sharing options...
sk732 Posted July 24, 2013 Share Posted July 24, 2013 I work in a rural area - my Regional Health Authority started taking back the crash cart as the place really isn't a functioning ER and we don't want people thinking it is, but I drew the line at the anaphylaxis meds, since myself and the public health nurse do immunize patients, I do minor procedures and sometimes will give IM/IV antibiotics. Even though the amubulance station is literally a 45 second drive away, if they're on another call and not covered, I still have to manage long enough for transport to arrive. My epi, Benadryl and Solu-Cortef stayed...and I've made sure I have some extra airway equipment handy in case all ends up in the sewer. Any of my patients with Epi Pens now get an Rx for TwinJects instead - bigger bang for the buck and they have that extra dose handy due to travel distances in case of a relapse...man I miss the old AnaKits. SK Link to comment Share on other sites More sharing options...
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