The Quicker Picker-Upper
An asthmatic man in his 20s presented to the ER in acute respiratory distress. He was immediately brought back to one of the critical care rooms, IV access was obtained, and inhaled bronchodilators were initiated while I performed a quick history and physical examination. I ordered a dose of IV steroids, and because his air movement was so restricted I also ordered 0.5 mg of epinephrine to be given subcutaneously.
There are two concentrations of epinephrine that we use in the ER. The first is 1 mg/mL (1:1,000) which is administered subcutaneously and used in cases of anaphylaxis or asthma. The second is 1 mg/10 mL (1:10,000) which is administered intravenously (IV) and used in cases of cardiac arrest. The first concentration is therefore 10 times stronger, so that it can be administered in a smaller quantity underneath the skin, typically with a tiny insulin syringe. IV epinephrine, particularly in bolus form, is rarely given to an awake patient with a heartbeat.
On that particular day, however, an ICU nurse was working an extra shift in the ER, and she happened to be caring for our patient. I was writing my note in the room when suddenly the patient exclaimed "OH MY GOD, WHAT IS HAPPENING TO ME??!!"
I looked up at the monitor and his heart rate had jumped up to 180, and he appeared frantic and wide-eyed. I immediately knew what had happened.
"Where did you give that epi shot?" I asked the nurse.
"Right there, doctor," she pointed at the IV catheter.
Oh. My. God. Apparently she had never given epinephrine subcutaneously before.
Despite the unfortunate epinephrine infusion, the patient still required intubation but made an uneventful recovery. Since then, I always overemphasize SUBCUTANEOUS when I give a similar order.
Once again, thanks to KevinMD for the link!
There are two concentrations of epinephrine that we use in the ER. The first is 1 mg/mL (1:1,000) which is administered subcutaneously and used in cases of anaphylaxis or asthma. The second is 1 mg/10 mL (1:10,000) which is administered intravenously (IV) and used in cases of cardiac arrest. The first concentration is therefore 10 times stronger, so that it can be administered in a smaller quantity underneath the skin, typically with a tiny insulin syringe. IV epinephrine, particularly in bolus form, is rarely given to an awake patient with a heartbeat.
On that particular day, however, an ICU nurse was working an extra shift in the ER, and she happened to be caring for our patient. I was writing my note in the room when suddenly the patient exclaimed "OH MY GOD, WHAT IS HAPPENING TO ME??!!"
I looked up at the monitor and his heart rate had jumped up to 180, and he appeared frantic and wide-eyed. I immediately knew what had happened.
"Where did you give that epi shot?" I asked the nurse.
"Right there, doctor," she pointed at the IV catheter.
Oh. My. God. Apparently she had never given epinephrine subcutaneously before.
Despite the unfortunate epinephrine infusion, the patient still required intubation but made an uneventful recovery. Since then, I always overemphasize SUBCUTANEOUS when I give a similar order.
Once again, thanks to KevinMD for the link!
posted by scalpel at 2:05 PM
27 Comments:
amazing. guess she never heard of the six R's of meds...right patient, right drug, right dose, right time, right route, right documentation.
i'm surprised the vessel didn't clamp from the 1:1,000 dosage IV.
good story
That poor bastard. I've given myself one of those shots several times. (I'm allergic to bee stings so I carry one around per doctors orders). Everytime I have ever used it, I have thought that I would almost rather die than use that medicine. There is nothing in the world that can make you feel worse in my opinion. I don't sleep for 2 days after taking one and I feel like crap for a week. I'm sure mine are the lower dosage. I can't imagine what that patient went through with a dosage 10 times as strong. I'd probably have died or killed myself. Man that is some nasty medicine but it keeps you breathing during a severe allergic reaction. It's saved my behind more than once.
Yikes.
I had run of SVT after receiving local anesthesia w/ epi during a dental procedure. It was rather disconcerting and thankfully brief.
Can't even imagine how awful he must have felt after that bolus.
CardioNP
So she gave a 1/2 amp of the code epi IV then? Yeesh. How do you/did you reverse that?
I couldn't think of a way to reverse it. But hopefully the versed at least made him not remember it.
sphincter pucker factor twelve out of ten on a scale of one to eight.
You know I think that has happened in every ER.
That is quite scary.
I think I had as much adrenaline coursing through my veins as he did.
You could have reversed it with an IV beta blocker, such as metoprolol 5 mg.
The real scary part is that an ICU nurse would not know one of the standard treatments for a common illness. Or, that anyone would give any medication without knowing what they were doing. It makes you wonder about how many errors occur everyday.
I laughed out loud at this post.
And it just reminds me how, when the rubber hits the road, ED nurses are irreplaceable.
"You could have reversed it with an IV beta blocker, such as metoprolol 5 mg"
Ummmm.....no.
You could have reversed it with an IV beta blocker
Beta blockers + asthma=Not good. Even I know that.
I would guess that ICU nurses wouldn't be overly familiar with standard treatments for asthma as it is not a diagnosis commonly seen there.
God, I'd hate to be that nurse right about now.
why are the concentrations not 1mg/ml and 0.1 mg/ml? the notation is really confusing
Also is it a waste of ER time to take in a 6 month baby with an inflammed circ? Any other redness would not have mattered but it's a penis...you only have one of those...Surely you'dd understand...
Just goes to show you that one nurse is not as good as another. No matter what administration thinks. Just because a nurse is skilled in another specialty doesn't mean they will be able to apply those skills to the ED (and visa versa) it would be like expecting and obstetrician to perform cardiac caths, after all - they're all doctors aren't they?
I was called code blue to CT last year and found a very distressed woman in her early 40s in for an outpt sinus CT- tachy to 140s, CP, SOB. It seems that when pt had transient hypotension after contrast injection the stud radiologist ran in and gave epi. He seemed proud of this. "How much did you give?" I asked. "1 mg IV push," he said. Even though all his signs on the walls clearly stated .3 mg SQ for anaphylactoid rxns. The lady had positive troponins on the first set of enzymes and was on 2 pressors for her iatrogenic cardiogenic shock. Turns out he gave that dose because he had just recertified in ACLS and he thought that was the dose.
Radiologists are stupid, I agree. I have a cardiologist friend who says he can read all those Cat scans and MRs better than the radiologists.
This happened to me in college at student health. The doc gave the shot because I was in a hurry to get to a presentation and had already waited an hour. I think he tried to give it SQ but he hit a vein and I said the exact same thing "oh my god -what is happening to me" I kept yelling "am I going to die?" It was the scariest thing. Needless to say I didn't make it to my presentation and they made me stay for observation all day. I remember a hell of a headache afterwards.
Nitro prusside perhaps?
Medical student here so don't treat me to bad, but isn't metoprolol cardioselective? What is the mechanistic reason for not using in this case... I'm sure I'm missing something.
Metoprolol is relatively cardioselective, but still has the potential to increase bronchoconstriction by blocking some of the beta 2 receptors.
Nitroprusside is a vasodilator which would lower the blood pressure but would likely increase the tachycardia. Besides, by the time the Nipride bag was mixed, the epi would have probably have worn off, since the half-life is only a few minutes when given IV. I don't remember what the blood pressure was after the epi, but it wasn't bad enough for me to want to do anything about it.
It's important to weigh the risks and benefits of any interventions. First, one has to decide what the problem is. In this case, I decided that the bad feeling the patient experienced was likely going to be relatively transient and hopefully erased from memory by the versed I used to intubate him. The tachycardia wasn't causing hemodynamic instability or ischemia, so I left it alone. I certainly didn't want to give him anything that might have compromised his breathing further, since that was the most pressing problem.
And people wonder why I'm so wary of ERs...
It did seem odd to me that someone was trying to give me an IV during anaphylaxis once (blood pressure non-existent in a patient who normally has no good veins). I even had an epi pen with me, but since I was in and out of consciousness, couldn't really use it on myself...
Is this why so many ER physicians are hesitant to use epinephrine? The nurses and staff don't know how to administer it?
Who could possibly need an IV more than someone with nonexistent blood pressure? It's as simple as ABC.
The only time I'm hesitant to use epi is in people over age 40.
Who could possibly need an IV more than someone with nonexistent blood pressure?
Hey now, Scalpel, I treat acute low blood pressure by placing a scary mask over my face and jumping in the room suddenly from behind the curtain without warning. If it's below 60/40, I yell ARGHHHHHHHHHHHHHH!!! in a vicious tone of voice. If it's merely 80/40, I just yell "boo" once. ARGHHHHH is a powerful vasoconstrictor.
IVs thwart creativity.
I don't disagree scalpel, it's just if there is no viable vein, and there is a clear history of anaphylaxis, it seems that you might want to use intramuscular epi instead of attempting to get a vein in someone who normally has no good veins? Just a thought.
You know this is a pet peeve of mine. Mostly because I really am not fond of the idea of dying due to not getting epi in time. The research is on my side that too often ED folks don't administer and patients die. Now, I haven't seen studies that showed how many patients have died due to wrongly administered epinephrine...
Now anyone who thinks someone wants to take an epi shot is well, nuts. (Of course, drug seekers are nuts in my mind.) I'll never forget the time I had to have 3 shots of epi to counteract a reaction - not fun. I slept for a full weekend afterwards.
"...it seems that you might want to use intramuscular epi instead of attempting to get a vein in someone who normally has no good veins?"
In fact, I would probably want to do both. ER nurses laugh at people who claim they don't have good veins. Admittedly some folks are more challenging than others, but most of the time people who warn us that they have no veins really just aren't good at holding still and keeping quiet while the nurse does his/her job.
Besides, if you're sick enough to need epi I'm going to want to give you IV steroids, benadryl, and pepcid too.
Current recommendations state that Epinephrine for anaphylaxis/ anaphylactoid reactions be given intramuscularly, not subcutaneously for better absorption. I refer you to the B.E. SAFE program at:
http://www.acaai.org/Member/Be_SAFE_Physician_Home.htm
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