Bendaryl vs. Epi ... help!

[Janelle205]

Two things:

1) I haven't been around here forever, but for a while.  Never have I heard one of the parents here, or adults with FA, talk about using epi for just a rash.

2) It's great that there are not a lot of FA deaths each year.  However, that statistic means a lot more to the general population than the self-selecting group here.  The people here (those with FAs themselves and parents) are associated with individuals that are WAY more likely to have severe/adverse reactions than the general population.  If this wasn't a significantly life altering (and life-threatening) condition, I would not have sought out a support group.

[Macabre]

John, I think your initial post about Benadryl was helpful to some degree.

Truthfully, practically all if us use it when appropriate (there is a concern for some Benadryl formulations for those with a dairy allergy, as they contain milk).

It may have it's place in anaphylaxis, but as you said initially it would be secondary to epinephrine. Frankly, my EAP calls for Epi then feet above heart. In certain situations (if I had it available and if I were worried emergency transport were not arriving soon enough (happened with my son), I might take a hit of Benadryl, but my allergist has expressed concern that using Benadryl could mask anaphylaxis symptoms. So I worry about that. But 99% if Benadryl is going to be used in anaphylaxis after Epi, it would be because medical personnel would administer it, not because I'm going to go against my board certified allergist's plan. And in 5 or 6 trips to the ER for anaphylaxis (my son had a biphasic rxn 8 hours later that required a second Epi and transport, so two those were in one day) neither my son nor I have been given Benadryl in the ER.

The worrisome fact is that for a great many parents of children with food allergies, they think Benadryl is sufficient. They don't carry epinephrine. I will come back and support that with data (On my phone now). If you look at deaths of FAs , the majority of them either did not have epinephrine with them or did not use it soon enough.

The peer reviewed medical literature supports using the Epi sooner rather than later. (I'll provide a lion later).

The group here is not a bunch if EpiPen happy munschausen moms. In fact, we do everything we can to prevent having to Epi. It's not a get out if death free card.

Fwiw, a study last winter found that emergency responders do not recognize anaphylaxis by and large (I will insert the link).

I found this to be the case personally. In Dec 2012 I inadvertently consumed sesame and started experiencing runny nose, hives, stomach cramping, trouble breathing (I'm asthmatic) and my Eustachian tubes swelling. Also eventually got that impending doom sense. This was anaphylaxis. I called my husband and he talked me through the injection (I had used the Epi on myself once before and my son, now 15, twice, but it is hard to convince myself sometimes).

Per my EAP, I lay down with my feet above my heart and called 911. The EMTs arrived in 5 min and took me to the hospital. I remember on the way having a difficult time forming sentences. I felt very confused.

Once I got to the ER, a biphasic reaction began to occur. The we doc gave me more epinephrine. He gave me pred as well. Upon leaving several hours later,  he told me to take Zantac and gave me a pred script.  I continued to have uterine contractions for a few days.

(BTW--no Benadryl, intravenous or otherwise, was given to me. This was one of Minneapolis' premier hospitals.)

The doctor wrote in my discharge a dx of anaphylaxis.


When my insurance company did not pay for my transport, they said because it was not medically necessary--because the EMTs wrote that I had a minor allergic reaction.

The doctor diagnosed anaphylaxis. I gVe the Epi because I had reactions from more than one body system, which indicates anaphylaxis.

So I think you'll understand if I don't simply buy what and EMT says I need to do.

[CMdeux]

I've already inserted a number of those same links, Mac!   



We do get trolls, folks.  Yes we do.     

Of course, it's only term break right now for college and high school students on SEMESTERS.  So expect more of this sort of thing come the quarter-break in March.  LOL.

[lakeswimr]

John, you started out telling us that Benadryl was an important 2nd step for the prevention of a reaction continuing and that giving it via IV is standard procedure.  People showed you the current National Institute of Health's guidelines which contract what you claim.  The guidelines say that Benadryl has no life saving capabilities and is for comfort only.  You then switch to saying that we and others dealing with food allergies are all giving the epi for minor symptoms.

You sound as though you got trained by someone who was no up to date on the most current recommendations for treating anaphylaxis and that is fairly common.  I'd recommend you take the NIH guidelines over whatever training you had.  You are not a doctor.  You are not an allergist.  You are not a specialist in food allergies.  You are someone who has a very important job and must be a generalist in knowledge.

Your posts reflect someone who is just  not up to date.

And you assume a lot.  I know that most anaphylaxis self-resolves even without treatment.  The trouble is that sometimes it does not and most of the very worst reactions start as minor.  So, when my child has food allergic reactions I watch and wait and only if warranted based on my son's emergency care plan, do I epi.  And I try to always epi if my son's plan calls for it but even then my response is to want to not have to epi.  I have failed to epi more times than I have given it. 

Thanks for your advice but I will stick to following my emergency care plan that I got from one of the top allergists in the world.  I recommend you stay open to the idea that things change and you must stay up to date in order to know how to best care for patients.

[lakeswimr]

The big change in claim from being an EMT who is pushing for the importance of Benadryl to someone trying to convince us that we are epiing too much and that the epi isn't needed as the risk of not doing so is remote also made me think troll but who knows.

[twinturbo]

Or he flipped out and lost control on his day off. It is a stressful job contributing to PTSD and depression. I don't think he's a troll I think he had all these feelings bottled up and got stuck not being able to run on sheer feeling when confronted with objective, credible information.

[CMdeux]

The big change in claim from being an EMT who is pushing for the importance of Benadryl to someone trying to convince us that we are epiing too much and that the epi isn't needed as the risk of not doing so is remote also made me think troll but who knows.

Agree-- kind of erratic, that rant-- and a large part of me HOPES troll.

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?

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

That's the wikipedia level of pharmacology here, I suppose.   I've speculated about this (IRL, not here); that first responders and ER physicians may well regard epinephrine from a pharmacy-tech level viewpoint as "oh, epinephrine...   = powerful cardiac drug!  elevates BP and pulse rate!" when that is not a very nuanced (or, as it happens, CORRECT) way of looking at that molecule in the first place.  Other pharmacologists (including cardiac pharmacologists in particular) agree with me wholeheartedly, as have many of the cardiac clinicians I know.  It's an interesting consideration which I find academically interesting-- except for the unfortunate sequelae that matter to me as a patient and mom (that being that it's NOT seen as a first-line therapy due to reluctance to let go of "drug of last resort" and "powerful").  It's interesting to note how differently EMT's, Nurses, and Physicians view drugs; they see a constellation of symptoms and up and down arrows associated with them, I think.  Pharmacologists think in feedback loops and receptor-ligand specificity and binding on/off-rates.  Just different.  So yeah-- I'm not the least bit intimidated by beta agonists.  Well, less so than other things, like muscarinics and some ion channel blockers.  LOL.     


By the way, since we're discussing benadryl?  H1 blockade is itself not without risks.   Those risks are somewhat comparable to low-dose IM epinephrine, actually.   H2 blockade is still not entirely clear, in terms of mechanistic benefit during anaphylaxis, but it doesn't seem to carry the cardiovascular risk of H1 blockade.   H1 = benadryl and H2 = ranitidine, in layman's terms.

I'm also wondering if John knows why EPI is preferred over other beta agonists in treating anaphylaxis, and about drug interactions (beta blockade comes to mind immediately, but also some cholinergics-- whoooboy, check out the fine-fine-FINE print on promethazine-- that one takes a lot of docs and pharmacists by surprise, even) that make treatment of anaphylaxis much trickier pharmacologically.   


If I'm wrong about this person being a troll, then I sincerely hope that our guest will avail himself of CME credits and get a little more education about anaphylaxis and its mediators.  Oh-- and cardiac pharmacology, since he seems to believe that epinephrine has serious risks when administered IM, and this (seems) to be a possible barrier to care, professionally, given its other uses therapeutically, where it has few substitutes.       

    I hope TT is right, and that John is just having a really really bad day-- and really, better here than unloading on some poor mom or dad while hauling their kid away.   We've all pretty much been there with a bad day, I think. 

[lakeswimr]

Oh, and I didn't see the 52 times a year thing.  Wow!

My son's allergist did talk to me about the risks of giving the epi vs not giving it and it is a topic that has been studied and written about by many top allergists and food allergy researchers and the NIH, etc. Giving the epi is regarded as much safer than not giving it in the case of a systemic allergic reaction.  The risks of the epi are very small and it is considered safe for all those except people who have heart conditions.  It used to be standard treatment for asthma and has a long history of being used.

I have had EMTs, ER nurses, etc focus on benadryl and freak out about it, "we have GOT to get this kid Benadryl!"  So, I do not think John is alone in his false belief that Benadryl has life saving capabilities.  It's unfortunate since one day one of his patients may be in need of a 2nd (or from the sound of recent posts a first) epi and he may not give it.  I sure hope not. 

[rebekahc]

I've already inserted a number of those same links, Mac!   



We do get trolls, folks.  Yes we do.     

Of course, it's only term break right now for college and high school students on SEMESTERS.  So expect more of this sort of thing come the quarter-break in March.  LOL.

I suspect "John" may be more than an ordinary troll.  I think he's out to prove to his friend/family member that she's overreacting with her child's recent anaphylactic reaction.

[PurpleCat]

John, I don't know what state you are from or who the doctor is who gave you the information.  I do know that not all EMT's or Paramedics are well trained in dealing with anaphylaxis.

Here is what my most recent experience was with an excellent Paramedic from our town.  Almost a year ago, my teen had anaphylaxis to sesame flour in a bread at home.  Her reaction started with an itchy mouth....we did not know at the time what prompted it so I gave her benedryl as she also has OAS to some fruits and vegetables and maybe this was a new one.  About 20 minutes later she threw up (which she does from cross contamination with egg) and felt much better but tired.  Then as she rested she started getting mucus in her mouth....immediately - epi and 911, both had been in my hands the whole time.  Our town's emergency response was superb - police, fire, and ambulance.  In the ambulance she got an iv and they monitored her vitals and watched her asthma.  The specific allergen, determines how anaphylaxis will progress for my child...her body behaves differently for each one.

She remained stable, at the hospital they gave her more epinephrine, predisone, and something to settle her upset stomach....I don't remember what that was.  The Paramedics stayed for a bit.

My DD got weird and I knew something was wrong, I ran out and grabbed the doctor, nurse and paramedic who were discussing DD.  By the short time they got in the room she was covered in the biggest hives I have ever seen, out of control itching and having difficulty breathing.  She looked horrid.  They did what needed to be done and she calmed after getting a breathing treatment.

A month later, the Paramedic asked me about the second reaction at the hospital.  He had never seen that and did not know that kind of reaction was possible based on the situation and how stable DD was.  He genuinely wanted to learn from what he saw and what I could tell him about how my child experiences anaphylaxis.  We had a great conversation.  I told him I had never seen hives that big on DD.....size of softballs, even on her scalp!  She looked like a horrible topical relief map.

My point to all this is if you have come to learn, you will learn much from us.  We live this everyday and we dread a reaction....but when it happens, we know how best to treat our child based on experiences and what our allergists have taught us.  It is not textbook, it is not black and white, and I think your original post should be identified as "your opinion, or your practice" but not as what every person should do.  In my opinion, without that disclaimer, it is not safe advice for some of our new parents who are looking for answers and solutions.

Welcome, join our conversations, learn and share, we are a good group of adults and parents with children dealing with allergies

[twinturbo]

Just for sake of structure and because it directly relates to who may administer (a) epinephrine to adults (b) epinephrine to pediatric patients by law per state.

EMT Basic (most common)
EMT Intermediate
EMT Advanced
Full paramedic often shorthanded as medic

The training is not the same, the knowledge and experience is not the same. In some programs one may take the EMT Basic without the actual hands on clinic but I think any of those are not allowed to apply for jobs that function as EMTs.

In my current state all EMTs may administer epinephrine even to pediatric patients as far as I know. In my previous state only full paramedics could and they were very few. Typically I find that EMT A, paramedics and ER attending physicians are more in line with NIH standards and current best practices with regard to epinephrine as it pertains to immunology, anaphylaxis and EAPs. Those are the ones that usually 'talk shop' openly.

I doubt few paramedics would identify themselves as an EMT and probably more as "medic". But that's anecdotal based on the medics I know in social circles.

[CMdeux]

 

EMT B here is:  pass knowledge exam ---> graded practicum ---> certification.


Just to clarify this point, as well-- there are no absolute contraindications to IM epinephrine for the treatment of anaphylaxis.  Not even cardiac ones. 

Concerns about epinephrine as a drug often as not revolve around IV administration, which IS much more hazardous.  IM administration is quite safe.

[twinturbo]

Again, anecdotal, but in talk with previous pediatrician who was one of the types to talk to a patient as a colleague as long as you could keep up with him we covered the difference of knowledge and use of epinephrine (specifically the fear of it within some first responders) in pediatric patients presenting with anaphylaxis.

Hashing it out we surmised it's because many first responders see so many patients with pre-existing cardiac conditions which leads them to erroneously assume if an elderly person with a weakened heart is prone to a strong beta agonist then surely a pediatric patient must be at equal or more risk not realizing it's contrary to that belief.

This is one of those areas that really FARE probably needs to gain speed on to make sure the discipline of immunology, its best practices, NIH guidelines, critical care and first responders of ALL level and training should align.

By the way it's worth mentioning that THIS thread is about epinephrine. For coverage of the wide array of antihistamines (or even prednisone for those of us who are using it post-reaction or for other reasons) then take 5 seconds to use the search function to find and read the conversations about them. Many of us are using daily antihistamines such as Zyrtec, Claritan and Allegra to use their trade names and Benadryl as part of our EAPs.

My tolerance for hyperbole, false dichotomy, straw men, ad hominem and garden variety BS without showing the least bit of professionalism and demonstrable knowledge when queried with cold hard fact from both well read individuals and/or the pharmacology professionals who can themselves mint other pharmacology professionals through PhD levl, is worn thin.

[maeve]

but the first sign of their kid with a red bump and they are reaching for the epi-pen

What a terribly dismissive statement. I have never administered the EpiPen for a "red bump" or even for an area of localized hives. Goodness a stray red bump could be anything in an atopic child who is prone to eczema as well as contact reactions. 

[maeve]

John-- PLEASE consider carefully reading the following:

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

Totally off topic.  Oh, we saw the author of that study when she was doing her fellowship with Dr. Wood.  We loved Dr. Keet. Honestly, all of Dr. Wood's fellows are top notch. Dr. Keet now does research at Hopkins. Dr. Sharma, who writes for the American Allergic Living, was also one of Dr. Wood's fellows and now heads up pediatric allergy at Children's in DC.