A consideration for austere management of anaphylaxisAnaphylaxis can be a scary encounter even when 911 is a few minutes away. In Austere medicine, where patient evacuation is delayed, not on it's way, or you are the medical professional sitting on this patient, a serious situation just became worse. When you give your initial intramuscular injection for anaphylaxis, there is about a 20% chance you patient may need another dose, but you only had one Epi-pen... What now?
Step 1.) Loosening the shell.We're starting from the point where you've already removed the blue safety and administered the first dose. Your clinical judgement has led you to decide you need to administer another dose. You can use a knife, multi-tool, pliers or what you have on hand to loosen/pry the four corners around the core, as you keep the orange tip away from you to prevent accidental 'stick' with the used needle. You are loosening the transparent case from the white core for the next step.
Step 2.) Pulling the white core out of the transparent sheatheNow that the outside is loosened, pulling the internal parts of the Epi-pen out will be easier. It may take a couple minutes and some wriggling back and forth. When on it's way out, the spring may cause the white core you're grabbing to spring out. To avoid parts going all over the place you can pull down with the orange tip facing up. After the spring comes out, the only thing left inside should be the syringe of epi and it's needle. [gallery size="medium" ids="1747,1749,1750"]
Step 3.) Identify and prepare needle and syringe:The only thing left inside the epi-pen should be the syringe and needle. You can see for yourself how many doses are left. It's important to note that the needle is covered in a gray sheathe and to avoid sticking yourself. You will want to remove the gray sheathe carefully. The 'plunger' is opposite the needle and will be used to draw air into the vial of epi as well as push more epinephrine into the anaphylaxis patient in the next step. [gallery size="medium" ids="1752,1753,1758"]
Step 4.) Administering a dose:The plunger should come already pushed down to the stopper due to the initial dose given to the patient. Point the needle up in the air and draw air into the needle until the rubber part of the plunger is near the back of the vial that holds the epinephrine. CAUTION, if you pull the rubber part of the plunger back too far, you could pull the plunger out of the vial and leak the precious epinephrine out of the back! Once you have air drawn in to the syringe, you will administer the second intramuscular dose to the patient. The air is mainly to replace pressure, because the plunger has the stopper and can not be depressed past that point, so you need to draw the air in, in order to push more epinephrine out. This can be repeated 3-4 more times depending on how you measure it. Pushing the epinephrine out is easy. After each dose, the needle will become more dull and possibly increase the pain of the insertion.[/caption] Between doses when you need to move the casualty for patient transport, as well as when all the doses are used up, place the syringe and needle back in the case for safe transport. Continue evacuation, as mentioned in the article: The Scary Reality of Casualty Evacuation to a higher level of care
References: Epi-pens Website, Reference and Videos - https://www.epipen.com/en/hcp/about-epipen/dosage-and-administration Biphasic Anaphylaxis - http://www.medscape.org/viewarticle/583328_7
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