Instructional video by Peter Antevy reviewing updated allergy and anaphylaxis protocol. Emphasis is on earlier and appropriate use of epinephrine (epinephrine is the definitive treatment; no absolute contraindications), switching from subcutaneous to intramuscular administration (lateral thigh preferred), and a conservative IV-epinephrine dilution/infusion technique for patients with very low blood pressure. Other supportive treatments (diphenhydramine, albuterol, fluids) are mentioned as unchanged; pediatrics protocol is referenced but covered separately.
Questions this video answers
About 90%.
Lateral thigh.
Changed away from subcutaneous (sub-Q) because skin blood flow decreases during shock, making subcutaneous absorption unreliable; intramuscular (IM) is preferred.
When systolic blood pressure is less than 90 (or when radial pulses are lost/around the 80s).
Squeeze out nine CCs from the 1:10,000 amp, replace with nine CCs saline — yielding 0.1 mg (0.1 milligrams) in the ampoule; push slowly over a couple of minutes and reassess; repeat with additional similarly diluted amps if needed.
Chapters
We're going to go over our allergy and anaphylaxis protocol. There's some changes in the epinephrine dose and how we handle giving epinephrine. So first step of this allergic reaction gives you a variety of symptoms. Almost always you'll see some sort of skin reaction. Sometimes, almost always there'll be a rash, an itchy rash at that, and that'll be in about 90% of the cases. So when you've got an allergic reaction, you should see some sort of either urticaria, hives on the skin, and then the severity of whether you call it just an allergic reaction or an anaphylaxis depends on what else is involved. So if you're dealing with an allergic reaction, it's a little bit unpredictable whether you're going to progress to anaphylactic shock and subsequent death, or whether it's just going to stay as a relatively mild allergy. The number one cause of death, of preventable death with allergic reactions in this country is failure to give epinephrine in a timely manner. So I want everybody to understand that Benadryl is not the cure for allergic reactions. Epinephrine is the cure for allergic reactions and for anaphylaxis. So don't be so afraid to give epinephrine. There are no absolute contraindications. So if we're going to be giving an intramuscular shot of the epinephrine instead of the sub Q, there are various locations you can give. The preferred location is in the lateral thigh because it's usually good muscle mass. Even in small debilitated folks, you usually still have a good fair amount of muscle mass in that area. So let's use the lateral thigh as our preferred location when possible. There are some people you want to be cautious on. If they've had a stroke, if they've got very high blood pressure, if they have a history of heart disease, those folks can get into trouble if we give them epinephrine. However, if they are showing signs of anaphylactic shock, which I'm going to define in a moment here, give them the epinephrine. If you delay, it may be too late to give them epinephrine. They can die from it. So allergic reaction starts off with more mild symptoms. They're itchy, they might be sneezing. That's just allergy for those folks. You can still give the epinephrine, you can give the Benadryl. But if we're going to give the epinephrine, we're going to give it im, and that's a change to what you had before. You were giving it subcutaneously. The problem with subcutaneously is as you progress from allergy to allergic to anaphylactic shock, you start decreasing the blood supply to the skin. All forms of shock do that, which is why you start getting cool skin. And since the blood supply to the skin gets diminished, the absorption of subcutaneous medications becomes unreliable. So you really want to get intramuscular for these type of medications. So we're going to give the epinephrine IM for those that still have an okay blood pressure. Once you get to the point where the blood pressure is really severely low, either you're losing radial pulses or the systolic blood pressure is getting less than 90, or they're in 80 range. Now you really have to consider giving them intravenous epinephrine. But you have to recognize that intravenous epinephrine actually can be quite dangerous. So we're going to be changing the way we give it to be a much more conservative way, yet still enough to save the patient. The process is going to be like this. You're going to take one of our one to 10,000 epi amps. You're going to squeeze out nine CCs, and then you're going to replace nine cc's with saline. So now you've basically taken your epi amp and you've diluted it. You've taken one milligram of that amp, and now you've got 0.1 milligrams. That's our dose. So now that amp is now the dose for anaphylactic shock. But now you've got enough volume where you can push that medication in slowly. And when I say slowly, there's no set time frame. We're just talking about not squeezing it all in one second. So you want to push it over like maybe a couple of minutes. And as you're pushing it in, you're looking to see what the patient's response is. Typically, you'll see results within a minute, within 60 seconds or 120 seconds. If you end up needing more, you can repeat that process with two other amps. With going through the same dilution process, we're going to have a similar sort of protocol for Pediatrics that Dr. Anteby will go over, but this will at least cover what we're doing for the adults. The rest of the protocol is pretty much what you're used to in terms of the Benadryl and the albuterol and the fluid status. So. And these videos that I give, I'm mostly going to be talking about the changes that you'll be seeing compared to what you're used to. So if I don't mention something in future videos, it's really. It's because you're already covering that stuff.
