A patient comes in to the urgent care center and states that she has been stung by a bee. She complains of shortness of breath and dizziness. She is pale and loses consciousness in the waiting room. The receptionist screams for help and calls 911. The nurses recognizes that which of the following medications should be considered first?
A.) Diphenhydramine (Benadryl)
B.) Phenytoin (Dilatin)
C.) Epinephrine IV
D.) Epinephrine IM
It looks like an emergency situation to me, so naturally I would go with IV for fastest route, but the issue here is, does she have an IV site? If not I go with IM.
Specializes in Complex pedi to LTC/SA & now a manager.
Well, as we know, IM is the answer. I just hope to high heaven that the patient isn't allergic to epinephrine, because you know, lots of people are!
I had a friend allergic to EpiPens. It was the sulfite preservative. The vials didn't contain sulfite so she carried a kit with a vial, syringe and IM needle.
The preferred route for this is IM. If the patient becomes dead... then the preferred route is IV. Back when I worked in the field, we'd draw and give just 0.3 mg of Epi. This is an emergency situation and unless you're amazingly good at starting IV lines and drawing meds up fast, you just can't get Epi on board faster than through the IM route. The other thing to remember about giving it this way is because of the absorption rate, the entire dose of epi isn't going to race through the system and cause lots of havoc.
What would I have done?
1) Have someone call 911
2) Draw up 0.3mg Epi, administer IM
3) Start an IV line or saline lock
4) Draw and administer 50mg diphenhydramine IV.
5) As soon as possible, get patient on monitor, administer oxygen...
6) Look for stinger if you remember
By that time, EMS should be on scene and they can take over.
IM. She's in urgent care and has no IV access established. Fastest route to prevent anaphylaxis is IM. Hence why patients with known allergies are given Rx for self administered IM epi (epi pen, auviq)
Plus don't you have to be ACLS certified to push epi IV?
It is probably department policy. ACLS isn't a licensing situation. it doesn't expand your scope of practice. It does educate you and show you have additional training for an emergent code situation. However, it does not expand your scope and anyone can take ACLS. I took it as a paramedic student. I know nursing students that will take it. I know physicians are supposed to take it but most skip out on it (not sure how ethical that is).
Oh that is right. I loved the idea of AuviQ especially for children and for people that are just generally unsure of how to handle the situation. I like the fact that it talked you through the process. Hopefully they work out the kinks and get it back to market
Specializes in OR, Nursing Professional Development.
Plus don't you have to be ACLS certified to push epi IV?
It is probably department policy. ACLS isn't a licensing situation. it doesn't expand your scope of practice. It does educate you and show you have additional training for an emergent code situation. However, it does not expand your scope and anyone can take ACLS. I took it as a paramedic student. I know nursing students that will take it. I know physicians are supposed to take it but most skip out on it (not sure how ethical that is).
The way it works in many facilities is that those who are ACLS certified are covered by standing orders for code drugs.
It is kind of interesting that while sq epinephrine is not covered by ACLS protocol and anaphylaxis as condition is not mentioned in ACLS books, if patient arrests, the situation technically becomes one covered by ACLS. If patient develios SVT or any other unstable tachycardia due to EpiPen, then it is also under ACLS coverage.
P.S. i lived 20+ years with only IV adrenaline available for anaphylaxis. Couple of times it went wrong way but still worked all right. In Europe, in similar situations with no iv access there is a practice of injecting into thickness of tongue (1 inch back from the tip of mentum by midline, 90 degrees up and 1.5 inch deep). It is a zone of very active circulation supplued by several big arteries and blood from there bypasses first pass through liver. It works really good for emergencies, I have no idea why this trick is virtually not known in the USA.
The only epinephrine you should EVER really be pushing IV is the 1mg for cardiac arrest, and in my facility, this is only if you are trained in BLS and ACLS. 0.3mg epinephrine IM is the preferred drug of choice for severe anaphylaxis. Then, as another poster stated, initiate IV and fluids for Benadryl, Zantac, Solu-Medrol, etc.
It is kind of interesting that while sq epinephrine is not covered by ACLS protocol and anaphylaxis as condition is not mentioned in ACLS books, if patient arrests, the situation technically becomes one covered by ACLS. If patient develios SVT or any other unstable tachycardia due to EpiPen, then it is also under ACLS coverage.
P.S. i lived 20+ years with only IV adrenaline available for anaphylaxis. Couple of times it went wrong way but still worked all right. In Europe, in similar situations with no iv access there is a practice of injecting into thickness of tongue (1 inch back from the tip of mentum by midline, 90 degrees up and 1.5 inch deep). It is a zone of very active circulation supplued by several big arteries and blood from there bypasses first pass through liver. It works really good for emergencies, I have no idea why this trick is virtually not known in the USA.
Interesting. I will keep this in the back of my mind.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I have to say I have never seen nor heard of "injecting" into the tongue.....however I do know heroin addicts will use this spot due to the vascular nature of the area.
People are NOT allergic to epinephrine. They may be sensitive to the added preservatives but not the Epi itself. Many people report an allergy because their heat raced after dosing or they felt jittery or their mouth was dry....the is NOT an allergic response. You do need to be cautious in the elderly as they make have angina or a MI with the increased workload on the heart but they are dying from the allergic reaction and need something so they won't die.
JustBeachyNurse, LPN
13,957 Posts
I had a friend allergic to EpiPens. It was the sulfite preservative. The vials didn't contain sulfite so she carried a kit with a vial, syringe and IM needle.