Final copies of the update EMS protocols have been sent to medical directors.
Why we do what we do: Einephrine in anaphylaxis. Epinephrine is the most important drug in the management of anaphylaxis. It is so important because it saves lives! This is no hyperbole. Let’s focus on the evidence behind the use of IM Epi in anaphylaxis.
What are the indications? You should rapidly admisister epinephrein for anyone with anaphylaxis. But, how do we define anaphylaxis? Do we know it when we see it? Well, Kind of. Note that 90% of cases havea skin findings with hives, itching, flushing, etc. Other symptoms symptoms generally come from at least one of the following “systems;” upper airway swelling, lower respiratory tract disease, GI symptoms and cardiovascular. There is no lab test that makes the diagnosis – it’s clinical. And, based on consensus recommendation it is any of the following three criteria:
Acute onset of illness involving the skin, mucosal tissue or both plus either/both of:
- respiratory symptoms (difficulty breathing wheezing, stridor, hypoxemia) and,
- hypotension or signs of reduced end organ perfusionTwo or more of the following acutely noted after exposure to a likely allergen (the first time eating fish):
- Skin and mucosal involvement including hives, swollen lips, tongue and/or soft palate
- Respiratory symptoms
- Adults: systolic BP <90 mmHg
- Babies <12 months: <70 mmHg
- 1-10 years < (70 + age x2) mmHg
- Persistent GI symptoms (abdominal pain, vomiting)
The individual patient response to Anaphylaxis varies. It can actually resolve spontaneously (we make our own epinephrine naturally) or it could progress to cardiovascular collapse within minutes. Death is from upper or lower airway obstruction or cardiovascular collapse. In general it is very hard to predict who will progress and how rapidly they will. So when in doubt…
administer epinephrine ASAP! In adult sized patients (>30kg) 0.3-0.5 mg/dose IM in the anterolateral thigh (you choose the leg). The Epi-Pen and Auvi-Q autoinjectors are 0.3 mg/dose. In children < 30 kg, give 0.01 mg/kg IM in the anterolateral thigh or the “Junior” autoinjectors which have a dose of 0.15mg. The dose should be repeated every 5-15 minutes as clinically warranted.
How does it work? Epi has numerous adrenergic effects. In short, the alpha-1 agonist leads to vasoconstriction, increased peripheral vascular resistance (thus increasing afterload and BP) as well as decreasing mucosal edema (especially important in the upper airway). The beta-1 adrenergic activity has cardiac effects on inotropy and chronotropy. And, the beta-2 adrenergic agonist effects lead to bronchodilation and decreased release of inflammatory cytokines from mast cells/basophils. What’s the evidence? Pumphrey, Current Opin Allergy Clin Immunology, 2004. A case series of patients with anaphylaxis that suggested that though symptom onset was rapid (<5 minutes) in the 6 fatalities, epinephrine was not administered until a mean of 93 minutes (range 25-180) after onset.
Why IM instead on subcutaneously or IV? IM is preferred over subcutaneously because it leads to a more rapid rise in plasma concentrations. Simon, et al, demonstrated as such in a small RCT in healthy adults that received either an IM, or Sub Q injection and in a prospective study of children with anaphylaxis noting that the mean maximum plasma epi concentration was at least 10% greater and achieved faster plasma concentrations by 8+/- minutes. Only use IV if the patient has circulatory collapse. The infusion rate is 2-10 mcg/min in adults and 0.1-1.0 mcg/min in children. This can be done peripherally for short periods if necessary.
Pumphrey, J Allergy Clin Immunol, 2007. This is a series of deaths from anaphylaxis in 24 patients from when I was in high school and college. Only 5 (20%) received Epi at any point. Admittedly, this was 1992-98 and Epi wasn’t as “popular” back then. Kemp, J Allergy Clin Immunol, 2002. In 164 deceased patients with anaphylaxis, only 14% received Epi before they had respiratory or cardiac arrest. 62% did get it overall, but once the patient was in arrest there was no reversal of the course towards mortality.
So, sure, there are no RCTs for anaphylaxis. It would be hard to ethically withhold it. Ultimately, though the evidence remains limited, but it is a first line treatment as recommended by experts in the field. Despite this, administration rates in the ED, though improving, are still unacceptably low.
Are there any contraindications? With Epi you get activation of the “fight or flight” response – anxiety, headache, restlessness, jittery, palpitations, and tremor. These are short lived and preferable to airway or circulatory collapse. The risk of causing ventricular arrhythmias, MI or pulmonary edema, as well as, increased BP leading to intracranial hemorrhage is theoretical and only really an issue if you give the wrong concentration (1:1000 IV for instance). It is then more likely that anaphylaxis itself would lead to these bad things rather than the Epi you just gave.
So, in summary – there are NO real contraindications to giving IM Epi in patients with anaphylaxis?
Reprinted from PEM BLOG Brief with their permission
Benefits of Yoga for Emergency Physicians, reprinted by permission from ACEP Now
Bryan Balentine, MD, FACEP
UAB, AL ACEP Board Member
Shawn Galin, PhD, Associate Professor
Fifteen minutes into my first yoga class, I (Dr. Bryan Balentine) quickly wondered what I had gotten myself into. I am a fairly open-minded individual and was looking for an alternative way to exercise. We, as emergency physicians, are all keenly aware of the stresses that are inherent to our profession, and I am not immune. What could be more relaxing than sitting around in a circle and chanting “om”? I needed a break from the surrounding clinical symphony of alarms, beeps and interruptions.
After some basic stretches, the small class stood in a circle. The instructor gestured to someone near me who responded, “Sun,” as if that was his new name. The person next to me responded, “Moon.” It was now my turn. “Uh, Bryan” was my answer. A few giggles followed in the room. Apparently, we were standing in a circle that did not allow everyone to spread their arms and then touch their toes at the same time without bumping into a neighbor. Alternating the stretch (Sun and Moon) next to your neighbor prevented ”full-contact” yoga. I smiled.
Two years later, I’ve developed a deeper appreciation for yoga, flexibility and a greater ability to simply relax in most situations, I could not remember the last time I could touch my toes, but now I can--- and grab the bottom of my feet. From a practical standpoint, my 43-year-old body can hop up from the floor easier after playing with my young children. Clinically, I am more aware of my posture while sitting at work. My chair angles at 90 degrees rather than the previous somewhat reclining position and kyphotic posture. How many patients with back pain do you see a day with surgical histories? I like my spine without scars.
Practicing yoga in an everyday setting can be as simple as noticing and observing one’s posture when seated, standing, or even lying down. For physicians, being mindful of how weighted down their white lab coats are can be a form of yoga. To lighten the lab coat and decrease the forward shoulder pull and subsequent kyphosis is, in a sense, a practicing yoga.
While I benefit from numerous yoga instructors, I spend more time with Shawn Galin, PhD. He is a course director for Endocrinology at the local medical school and an Associate Professor of Critical Care Medicine, and he enjoys a passion for yoga. I learned of his background in medical education just before joining the ACEP Well-Being Committee. After sharing my experiences with him on how yoga positively impacted me at work and home, we shared articles and research. PubMed contains almost 3,000 articles on yoga, but our goal in collaboration is to focus on a few areas that can impact you now.
The Breath and Stress
As in life, proper breathing is very important in yoga practice. In fact, the ability to breathe properly and control one’s breath can have profound effects on both the mental and physical status. When the breath is shallow, a common side effect of stress, blood is not oxygenated properly, which impairs mental function and promoted physical fatigue. Stress can cause shortness of breath and anxiety. These changes in breathing patterns are mediated through the sympathetic nervous system as part of the fight-or-flight response. As you get more anxious, your breathing muscles fatigue and cause even more shortness of breath and anxiety. Thus, stress can create a vicious, perpetuating cycle.
My yoga classes focus on breathing techniques, or pranayama, that help practitioners slow down their breath. A recent article in The Wall Street Journal titled “Breathing for Your Better Health” reports the benefits of abdominal breathing and notes that they are direct results of vagal stimulation. Slower breathing stimulates the vagus nerve, which runs from the brainstem to the abdomen. The vagus nerve, as part of the parasympathetic nervous system, is responsible for the body’s rest-and-digest activities. In contrast, rapid, shallow breathing is associated with the sympathetic nervous system. The article goes on to report that the vagus activity can cause the heart rate to decrease as we increase the length of exhalation. This is, in part, due to the vagus nerve’s release of acetylcholine, which slows down the heart rate and digestion. This highly suggests people can actually alter their physiologic responses to stress simply by altering their breathing. Take long, deep breaths with conscious observation of the length of exhalation can promote vagal stimulation, resulting in a sense of calm rather than chaos.
Although meditation and pranayama are core components to the practice, yoga is more commonly associated with asanas, or postures. There is a common misconception that people need to be flexible in order to attend a yoga class when, in fact, the opposite is true. Yoga is designed to increase both strength and flexibility by synchronizing breathing with physical movement through various postures. It is not uncommon for someone to notice and improvement in posture within weeks of starting a yoga practice.
Noticing postural habits soon becomes second nature to a yoga practitioner. Standing taller, sitting up straighter, and walking with a straight spine are all common benefits of a regular yoga practice. Practicing yoga in a everyday setting can be as simple as noticing and observing one’s posture when seated, standing or even lying down. For physicians, being mindful of how weighted down their white coats can be a form of yoga. To lighten the lab coat and decrease the forward shoulder pull and subsequent kyphosis is, in a sense, practicing yoga.
My growing Yoga practice triggered a wonderful journey, from a comical introductory class where I thought I would receive a new celestial name to networking with PhDs in Endocrinology and joining the ACEP Well-Being Committee. The ever-apparent stresses of our profession levy a remarkable toll on our wellness unless an appropriate negating response is initiated. While I do not exist in a constant calm mode at work, yoga allows me to relax more, provide better care, and extend my longevity in medicine.
Prestigious PEMSoft/EBSCO Award for Pediatric Emergency Medicine Goes to Dr. Marianne Gausche-Hill
The winner of the 2016 ACEP and PEMSoft/EBSCO Achievement Award is Dr. Marianne Gausche-Hill, Medical Director of the Los Angeles County EMS Agency and Professor of Clinical Medicine and Pediatrics at the David Geffen
School of Medicine, UCLA. “I am honored to receive the ACEP and PEMSoft/EBSCO Achievement Award for evidence-based pediatric emergency medicine," Dr. Gausche-Hill said. "I feel fortunate to have worked with so many bright minds to build the evidence that assists us in providing the best care possible."
The award is annually conferred upon an emergency physician or pediatric emergency physician who has contributed significantly to pediatric emergency evidence-based medicine. Nominees for the award need to have contributed first author publications and/or contributed to practice-changing innovations in electronic publication or technology, which have meaningfully enhanced emergency care of children. PEMSoft/EBSCO has sponsored the award since its inception.
"PEMSoft is used internationally as a comprehensive archive of evidence-based pediatric practice, and EBSCO funded the award to both recognize an exceptional academic leader and also to encourage other investigators to engage in scientific work,” observed Dr. Ron Dieckmann, long standing ACEP member and Chief Medical Officer for PEMSoft. “Marianne is a perfect recipient of the award and has distinguished herself in every category of academic leadership in pediatric emergency medicine and evidence-based practice.”
The award will be presented at the Advanced Pediatric Emergency Medicine Assembly in Orlando, Florida, March 8-10. The Advanced Pediatric Emergency Medicine Assembly, co-sponsored by ACEP and the American Academy of Pediatrics, serves as the premier annual educational meeting for pediatric emergency medicine and is the ideal venue for the award presentation. Showcasing the honoree at this meeting assures maximum visibility for the candidate and her/his contributions. It is the only national award that specifically honors scientific endeavors in pediatric emergency medicine. "I am thrilled that Dr. Gausche-Hill has won this award," said Dr. Sean Fox, Advanced Pediatric Emergency Medicine Assembly Program Chairman. "Without question, Dr. Gausche-Hill epitomizes what it means to be an academic pediatric emergency physician who strives to ensure that children receive the best possible care where ever they are managed. Not only is she a giant in our field, she is a wonderful humanitarian and I am honored to consider myself a colleague of hers."
Past winners of the award include David Jaffe, Kathleen Brown, and Nathan Kuppermann, all of whom have contributed substantially to a wide range of practice-changing articles in pediatric emergency medicine. Dr. Gausche-Hill will join this prestigious group of winners. "I went into Pediatric Emergency Medicine because of a desire to learn as much as I could so that I could care for our most vulnerable patients," she recalls. "The pursuit of knowledge through scientific inquiry drives change in medicine, which ultimately impacts the care of the patient."
With this philosophy as her guide, Dr. Marianne Gausche-Hill has built a remarkable career. She is nationally known for her work as an EMS researcher and educator, and for her leadership in the field of EMS and pediatric emergency medicine. Dr. Gausche-Hill is best known for her remarkable study of pre-hospital airway management for children
published in JAMA in 2000 and her work on the National Pediatric Readiness Project published in JAMA–Pediatrics in 2015.
Come to the Advanced Pediatric Emergency Medicine Assembly to learn from Dr. Gausche-Hill and her colleagues in person.
Point-of-Care Pelvic Ultrasound Done by Emergency Physicians Comes Under Fire
Emergency physician–performed (EP) pelvic ultrasound has been shown to save lives, expedite patient care, and improve patient satisfaction. The 2001 and 2008 ACEP Emergency Ultrasound Guidelines define pelvic ultrasound as a core application for the assessment of the first-trimester patient presenting with vaginal bleeding or abdominal pain. Despite this, AuntMinnie.com, an imaging website, recently published an interview questioning the utility of EP pelvic ultrasound.
Naloxone Nasal Spray Approved by FDA for Opioid Overdose Treatment
The U.S. Food and Drug Administration approved the first-ever nasal spray emergency treatment for opioid overdose on Nov. 18, 2015. The spray, developed by privately held Adapt Pharma Ltd, uses naloxone, a drug used to treat opioid overdose for nearly 45 years but approved only in injectable forms.
Laceration or Incised Wound: Know the Difference
August 14, 2014 - Heather V. Rozzi, MD, FACEP - 0 Comment
The Case: A 24-year-old male presents to the emergency department sustaining the wound shown in Figure 1…