A couple of weeks ago, I did the primer episode on Ben McKenzie's amazing AMAX4 protocol. Today, we have the explosion episode where we go in-depth on the intricacies and dive deeper.
See the show notes for that previous episode for information and links on the protocol.
BVM use during Bronchospasm
Squeeze Hard but Not Big
Different Types of Anaphylaxis
Food Allergy
Slower onset so the pt may arrive by car rather than ambulance
Huge co-incidence of asthma/atopy
Death is from bronchospasm or airway edema
This is how deadly asthma will be seen in 2023-
Insects
Will prevent with hypotension or vascular collapse unless the pt also has asthma
Drugs
Low BP with some bronchospasm
Epi Routes
Subcut
Way, way too slow; won't even discuss it
IM
5-8 minutes for peak onset but at least in healthy controls, the dose also has a 2nd peak at 30 min and effects are gone at 60 minutes–so how much is patient actually getting at any point in the hour–who knows
IV
If they are sick consider giving 10-20 mcg IV Push and then 10-20 mcg/min infusion
If unconscious or crashing, 50-100 mcg by grabbing cardiac epi and giving 1-2 mls for adults. In peds, 1 mcg/kg
Other Things Mentioned during the Discussion
Errors of commission vs. errors of omission
EMCrit Wee – Errors of Commission vs. Errors of Omission
Additional New Information
More on EMCrit
EMCrit 355 – AMAX4 for Crashing Anaphylaxis and Asthma – Part I Primer
EMCrit 306 – Critically Ill and Severe Anaphylaxis
Additional Resources
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
Would you consider nebulized epi through the ET tube? Or just albuterol?
i would stick with albuterol–epi has only shown benefits for laryngeal edema at the airway level
I just want to say thank you for these episodes. 2 days ago I had a nightmare anaphylaxis. 16M with a peanut allergy. Despite the EpiPen from mom he came in in extremis and the additional IM epi, albuterol, AND IV epi were not helping. Ultimately I intubated him with my trauma attending standing right at his neck thanks to a well-timed concurrent trauma alert. I gave A LOT of IV epinephrine which I’m sure was instrumental in eventually being able to actually place this poor kid on the ventilator instead of bagging him and squeezing his chest only to… Read more »