Bendaryl vs. Epi ... help!

[CMdeux]

John, you might need to read the thread again-- nowhere does anyone suggest that diphenhydramine is harmful.  There are also a physician, a pharmacist, and a research pharmacologist who have all weighed in just in this thread alone.  (wow-- I just realized that there MUST be a punchline in there somewhere, surely...   )  I'm very confident that the latter individual and most likely both of the former probably possesses at least as good a basic understanding of histamine and receptor blockade as you have. 

I think that in practical terms, physicians often go with "no benadryl" in emergency action plans because otherwise, there is a very real fear that laypersons in charge of management (before people like you ever even get there) may DELAY administration of epinephrine too long.

Think about it-- it's just you, and a bottle of benadryl and two autoinjectors.  What do you do when you see grade II symptoms?

Better think fast.

Wait and see?  Give benadryl, maybe see if that helps?  Peak concentrations there are about 15-20 minutes out, yeah?  So you won't see maximal benefit until then... probably okay to wait and see if it resolves then, right?  At least if you don't see OTHER worrisome symptoms developing, right?


Er--

no, actually. Tragically, I might add.


YES, most anaphylaxis is self-resolving.  Most anaphylaxis is a steady slow-moving freight train of clear symptoms.  But not always.  Getting it wrong means that a loved one, often one's own child-- dies.

So yeah, the physicians that care for patients who are at extreme risk for anaphylaxis do often tell parents (and other caregivers) to be trigger-happy with epinephrine, and to leave the benadryl out of the equation, which is complicated enough with only epinephrine under consideration.

http://www.the-clarkes.org/stuff/ana.html

Having a clear yes/no decision tree is essential for parents and school personnel.

This is a matter of simplifying instructions for those who may lack training-- and almost always lack additional resuscitative ability/equipment.   Fine for those who have the ability and expertise to conduct their own volumetric resuscitation if they turn out to be WRONG in the end, but for most of us, that is going to be game over unless it happens in an ER setting.

[maeve]

I'm a layperson, but I'll relay what we've been told by our allergist at Johns Hopkins. Benedryl is not a life-saving medication with anaphylaxisis. It can treat symptoms (hives, itchiness, nausea), but it does not stop the reaction. The only medication that can stop anaphylaxsis is epinepherine. I'll also concur with twinturbo, that as a parent I am following the action plan developed by my child's allergist. Now we also have a comorbid condition: asthma. Having asthma makes it much more likely that my DD will have a quickly progressing anaphylactic reaction. We will never hesitate to give her the EpiPen right away and have instructed her caregivers to do the same.

[Macabre]

Neither my son nor I have had Benadryl administered at the ER after using the EpiPen or en route (he's had Epi 4 times? Maybe more.  A I had it most recently December 2012). I had a second dose if epinephrine, pred, and Zantac given to me. Or wait--Zantac was prescribed by my allergist after rather than given in the ER.

I did get the sense that not all emergency responders treat anaphylaxis uniformly in transport. And I have experienced very different treatments of it the ER over the years.

It would be great if there were a consistent standard of care. 

[LinksEtc]

I'm just going to put this link in here ...


http://allergicliving.com/index.php/2013/08/22/lessons-from-a-teen-food-allergy-tragedy/


Dr. Wood:

Antihistamine is a useful medication for some relief of symptoms such as a few hives, but has no capacity whatsoever to prevent or control more serious allergic reactions. If a reaction is going to progress, the administration of Benadryl will not help to prevent any real progression.

Dr. Waserman:

In Canada's guidelines, we don't support the use of Benadryl if symptoms are developing in response to the accidental ingestion of food. However, some allergists will disagree with me.

[John]

This is not advising people to not use an Epi-Pen! I think you are misunderstanding me. The first thing you should do is call 911 and give an Epinephrine shot. Antihistamines are considered adjunct therapy but they are not without their place when understanding severe allergies and the way the body reacts.

Again, my goal here is not to advise people not to follow an action plan. My goal here is to educate people on why Benadryl can be an important drug in your arsenal. You should absolutely follow an action plan and your doctors orders. What I'm advising people is to read up on anaphylaxis treatments and why certain things are done.

As always, the emergency room is always the first priority. If you are camping with your kids in the woods and you only have an Epi-Pen on you, I highly recommend people to also have some liquid benadryl, that's all I'm saying. Some people, many actually, may disagree with that and that's fine.

The reason why there are so many different types of treatments given are because most parents are extremely cautious (which is fine by me) but the first sign of their kid with a red bump and they are reaching for the epi-pen. What parents need to do is learn how to watch their kids for signs of progression rather than giving their kid an injection any time they sneeze.

I know some people adhere to the "better safe than sorry" guidelines, but if you are quick to act when you see their status deteriorating, then you will never be sorry. The key is to read, watch somebody for signs of progressions and more importantly keep a calm head.

I read about the food allergy tragedy link you posted LinksEtc and yes, that can happen. But the other thing you have to remember is that only 100 people or so die every year from food allergy anaphylaxis. It's rare. Yes, it's good to be safe than sorry, but part of living life is risk. You can die from walking across the street but it doesn't stop you from taking the chance.

[twinturbo]

Red bump and sneeze? Can we use more precise terms as per anaphylaxis grading? Let's come off the silliness. And surely you're not giving medical advice to people over the internet.

I want to make the next statement very carefully worded. You as an EMT are here to explain carrying and administering epinephrine to children is the result of "extremely cautious" parents. And you, EMT on the internet, know better about allergies than the researcher immunologists whose patients we are (or are children are), and whose publications we read in peer-reviewed medical journals.

Way too many personal feelings you have in regard to judging when these are no patients of yours. I highly suggest taking some time out to query either AAAI.org to send in some questions regarding patient EAPs, or spend some time in the office of a good board certified pediatric allergist.

Does your boss know you're doing this?

[LinksEtc]

But the other thing you have to remember is that only 100 people or so die every year from food allergy anaphylaxis. It's rare. Yes, it's good to be safe than sorry, but part of living life is risk. You can die from walking across the street but it doesn't stop you from taking the chance.

We've had discussions about this here also.


Let's talk about anxiety

"If food allergy deaths in food-allergic individuals are rare, do we change our ways?"
http://foodallergysleuth.blogspot.com/2013/12/if-food-allergy-deaths-in-food-allergic.html

The study authors certainly have noble intentions of this study reducing the anxiety faced by food allergic individuals or their caregivers.

"FOOD ALLERGY: A LOT IS RIDING ON OUR TIRES"
http://www.allergyhome.org/blogger/food-allergy-a-lot-is-riding-on-our-tires/

For me, their findings convey the unlikelihood of a fatal anaphylactic reaction if appropriate management strategies are implemented, and provide me with some reassurance.

(FWIW, I liked the way he framed this.)

----------------------------------------------------------------------

Also, ana itself does not appear to be rare:
"ANAPHYLAXIS IN AMERICA"
http://www.aafa.org/display.cfm?id=6&sub=110&cont=882

According to the peer-reviewed study, anaphylaxis very likely occurs in nearly 1-in-50 Americans (1.6%), and the rate is probably higher, close to 1-in-20 (5.1%).

[twinturbo]

I'm printing John's posts out for the next appointment with allergist showing in the words of an EMT what he thinks of the EAP, carrying and administration of epinephrine. Then I'll finally get that letter on practice letterhead from allergist to give to EMTs I've been asking about. He didn't believe me that rift between allergist and EMT exists. Got proof now!

Saving for the record to use at appointments, school meetings, what have you. Voluntary, written, first person, on a public forum.

[spoiler]

I am an EMT and have a lot of knowlege on food allergies and thought I would clear up some confusion in here.

If you go to the ER for Anaphylaxis, you will get Epinephrine as primary treatment but you will also get IV Benadryl as well, because your body is having a "histamine dump" and the only thing that can stop it is the Benadryl. From the people talking on this board, it seems people think that Benadryl has no place in Anaphylaxis treatment and nothing could be further from the truth. Benadryl is exactly what gets you out of Anaphylaxis. Usual treatment in an emergency room is Epinephrine followed by an IV of Benedryl plus Ranitidine.

My recommendation to those of you with loved ones with allergies, you need to brush up on how histamines work and what works best. If you suspect an Anaphylaxis, then giving them the Epi-Pen is recommended, however, Benadryl cannot HURT your child (unless they are choking and can't swallow). It is specifically what they are going to give to your child after they Epi-Pen them. The Epi-Pen is used to treat the airway constriction and low blood pressure which can lead to death. But the Benadryl is what is used for long term treatment to stop the histamine dump and keep the anaphylaxis from continuing.

If they can swallow, the liquid Benadryl on top of the Epi-Pen give them the best chance at survival (if it's progressing to an Anaphylactic episode). And for what it's worth, the reason Benadryl isn't given as first line is because it takes about 20 to 30 minutes to start working whereas the Epi-Pen is instant.

By giving your child Benadryl, you are not hurting them (just make sure their airway/esophagus isn't constricted). You can only help their situation by counteracting the histamine dump. This doesn't mean you shouldn't also use the Epi-Pen if you need to use it. I know this can be confusing, but it's crazy to hear people talking about Benadryl as if it has no place in Anaphylaxis. It is used in every Anaphylactic episode in the ER - of course it's good for you.

This is not advising people to not use an Epi-Pen! I think you are misunderstanding me. The first thing you should do is call 911 and give an Epinephrine shot. Antihistamines are considered adjunct therapy but they are not without their place when understanding severe allergies and the way the body reacts.

Again, my goal here is not to advise people not to follow an action plan. My goal here is to educate people on why Benadryl can be an important drug in your arsenal. You should absolutely follow an action plan and your doctors orders. What I'm advising people is to read up on anaphylaxis treatments and why certain things are done.

As always, the emergency room is always the first priority. If you are camping with your kids in the woods and you only have an Epi-Pen on you, I highly recommend people to also have some liquid benadryl, that's all I'm saying. Some people, many actually, may disagree with that and that's fine.

The reason why there are so many different types of treatments given are because most parents are extremely cautious (which is fine by me) but the first sign of their kid with a red bump and they are reaching for the epi-pen. What parents need to do is learn how to watch their kids for signs of progression rather than giving their kid an injection any time they sneeze.

I know some people adhere to the "better safe than sorry" guidelines, but if you are quick to act when you see their status deteriorating, then you will never be sorry. The key is to read, watch somebody for signs of progressions and more importantly keep a calm head.

I read about the food allergy tragedy link you posted LinksEtc and yes, that can happen. But the other thing you have to remember is that only 100 people or so die every year from food allergy anaphylaxis. It's rare. Yes, it's good to be safe than sorry, but part of living life is risk. You can die from walking across the street but it doesn't stop you from taking the chance.

Thanks CMDEUX, just read it. This is what stood out to me like big red neon letters which pretty much covers the mentality of many at this board.

"Fortunately, food-allergy induced fatalities remain rare, although fear of fatal reactions contributes to the anxiety that exists in families with a food-allergic child."

Somebody mentioned loony earlier and I wouldn't be so quick to discount that. Just because you keep jabbing your kid with an Epi-Pen it doesn't mean that you are keeping them safe. Did your allergist also talk with you about the risks involved? Oh wait let me guess, the risks outweigh the potential for death right?

Food allergy obsessed people are just the second coming of "fever phobia" people who throw their kids in ice baths when they have 102 fever. Just as febrile seizure is rare, so is death from a food allergy. But hey, keep giving your kid an epinephrine shot every time he gets a perfectly normal rash.

I'm sure his/her heart will be in great condition once they reach 21 from dosing on Epi-Pen 52 times a year.

In the U.S. 16 people got bit by sharks in 2005.

51 people are killed by lightning every year in the US.

Are you going to force your kids to stay indoors when it's raining for the rest of their lives?

You guys are unreal.

[/spoiler]

[LinksEtc]

The reason why there are so many different types of treatments given are because most parents are extremely cautious (which is fine by me) but the first sign of their kid with a red bump and they are reaching for the epi-pen. What parents need to do is learn how to watch their kids for signs of progression rather than giving their kid an injection any time they sneeze.

I know some people adhere to the "better safe than sorry" guidelines, but if you are quick to act when you see their status deteriorating, then you will never be sorry. The key is to read, watch somebody for signs of progressions and more importantly keep a calm head.

Most of us on this board see very good allergists and we usually just follow their instructions as written on our allergy plans.  Depending on factors such as reaction history, whether asthma is a factor, the allergen (ex - peanut), etc. .... they advise us how we should treat symptoms such as hives.

[CMdeux]

The reason why there are so many different types of treatments given are because most parents are extremely cautious (which is fine by me) but the first sign of their kid with a red bump and they are reaching for the epi-pen. What parents need to do is learn how to watch their kids for signs of progression rather than giving their kid an injection any time they sneeze.

Patronizing, much?

Thanks, but most of us here have gotten this SAME nasty attitude from friends and family.  Make that former friends and estranged family.  We really aren't totally loony.  A fair number of us see physicians who are leaders in the research associated with this field clinically, by the way. 

How many times have you WITNESSED food anaphylaxis from start to finish?  Not many, I'm guessing.

Now I'll report to you what MY allergist has had to say on the subject of early epinephrine and first responders such as yourself:  basically, I should know better, since YOU most likely won't have a clue if my child isn't COVERED in hives and struggling to breathe.  At least not until she arrests, and even then you'll most likely be arguing with me about how with no cutaneous symptoms, this can't possibly be anaphylaxis...  in other words, don't waste time arguing when time is brain function-- preempt the entire conversation with DIY before they show up.

If you'd read the link about Natalie Giorgi's fatality, you'd know that her father was treating her on the scene-- her father being a PHYSICIAN.  Wait and see is dangerous.

The vast majority of parents and adults who post here have experienced anaphylaxis firsthand, often more than once, and more than a few of us have been LUCKY to survive grade IV-V reactions.  With all due respect, our risk here is a little bit higher than that "enjoyed" by most people just crossing the street.  My teenaged daughter can probably (best case scenario) expect to experience another 8 to 14 episodes of anaphylaxis in her life. Statistically speaking, I mean.  Given her history, her odds of experiencing a  life-threatening reaction that requires a 911 call are... almost inevitable.

Some additional enlightening reading on this subject:

No, actually-- epinephrine "over-use" is not really a thing.

Dr. Jacobsen's team surveyed 3500 nationally registered paramedics in the United States and found that 36.2% of responders felt there were contraindications to the administration of epinephrine for a patient in anaphylactic shock.

"They also had challenges in the recognition of atypical presentations of anaphylaxis and determining the correct location and route of epinephrine administration," he said.

Only 2.9% correctly identified the atypical presentation, 46.2% identified epinephrine as the initial drug of choice, 38.9% chose the intramuscular route of administration, and 60.6% identified the deltoid as the preferred location (11.6% identified the thigh).

We have the same issues in the United States that were found in the Canadian study.


"Our study also revealed that 40% of paramedics believed that diphenhydramine was the first-line medication for a patient suffering from anaphylactic shock," added Dr. Jacobsen.

Well, well. Now perhaps it is clear why my own allergist feels the way that s/he does about first responders and atypical presentation, eh?  It's ON US as patients/parents to treat with epinephrine before an EMT rolls up, because the odds are far too high that they WON'T.  Until it's too late, I mean.

No, over-use  really isn't a thing-- I promise.

Underutilization most assuredly IS, however.

I'm printing John's posts out for the next appointment with allergist showing in the words of an EMT what he thinks of the EAP, carrying and administration of epinephrine. Then I'll finally get that letter on practice letterhead from allergist to give to EMTs I've been asking about. He didn't believe me that rift between allergist and EMT exists. Got proof now!

Indeed.  Well, he knows.  He just overestimates the ability of mere mortals to GET THROUGH TO THEM, because he happens to actually have those magical letters "M.D." behind his name, and forgets that it matters, even if he's acting in the capacity as "dad" at the time.  But it's why he's given me the advice that he has.  Epi early and often-- before the "pros" show up and dismiss everything that you know (that they don't).






John-- PLEASE consider carefully reading the following:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096462/

[CMdeux]

This has several highly instructive entries, with nice citations and commentary throughout:

http://certifiedallergysa.com/wordpress/tag/epipen/?wpmp_switcher=desktop


I really recommend that to everyone. 

[John]

John-- PLEASE consider carefully reading the following:

ncbi.nlm.nih.gov/pmc/articles/PMC3096462/
[/quote]

Thanks CMDEUX, just read it. This is what stood out to me like big red neon letters which pretty much covers the mentality of many at this board.

"Fortunately, food-allergy induced fatalities remain rare, although fear of fatal reactions contributes to the anxiety that exists in families with a food-allergic child."

Somebody mentioned loony earlier and I wouldn't be so quick to discount that. Just because you keep jabbing your kid with an Epi-Pen it doesn't mean that you are keeping them safe. Did your allergist also talk with you about the risks involved? Oh wait let me guess, the risks outweigh the potential for death right?

Food allergy obsessed people are just the second coming of "fever phobia" people who throw their kids in ice baths when they have 102 fever. Just as febrile seizure is rare, so is death from a food allergy. But hey, keep giving your kid an epinephrine shot every time he gets a perfectly normal rash.

I'm sure his/her heart will be in great condition once they reach 21 from dosing on Epi-Pen 52 times a year.

[John]

Only 11 people died from food allergies in 2005. Previous reports of 150 people dying per year are miscalculated (please see article at Huffington Post entitled "Food Allergy Deaths: Less Common than you Think."

To put in in perspective: 250 kids drown in swimming pools in 2004.

In the U.S. 16 people got bit by sharks in 2005.

51 people are killed by lightning every year in the US.

Are you going to force your kids to stay indoors when it's raining for the rest of their lives?

[John]

I'm printing John's posts out for the next appointment with allergist showing in the words of an EMT what he thinks of the EAP, carrying and administration of epinephrine. Then I'll finally get that letter on practice letterhead from allergist to give to EMTs I've been asking about. He didn't believe me that rift between allergist and EMT exists. Got proof now!

Saving for the record to use at appointments, school meetings, what have you. Voluntary, written, first person, on a public forum.

------------------------------------------------------------------------------------

For the record, I never said anything about not dosing epinephrine. I stated that Benadryl has its place in the treatment of any allergic reactions up to and including anaphylaxis. With Epi-Pen being the primary treatment before anything else (besides calling 911).

You guys are unreal.

[twinturbo]

Do you think you should calm down a bit before coming back to this?