At what point do you use epinephrine?

Posted on: Tue, 01/08/2002 - 10:58pm
booandbrimom's picture
Joined: 08/23/2000 - 09:00

Thanks to one of you who mentioned it in another thread, I called FAAN and asked them to fax me an article I had been trying to get for some time: the 1992 Sampson NEJM article where they profiled 7 children who died and 6 who did not.

What struck me about all the cases was that, if I was the mother, I would not have given epinephrine properly, and I still don't know what that entails. The kids who had uniphasic, immediate reactions mostly received epinephrine and survived. It was the biphasic half that had the most trouble.
Basically, this group had a mild reaction that was treated with Benedryl or not treated and then they suddenly experienced respiratory or cardiac failure several hours later.

So here's the question... If you give epinephrine at the beginning of a reaction (which only works 20 minutes), how does this prevent the respiratory or cardiac problems several hours down the road? The article basically said that they don't know why this type of anaphylaxis happens.

We dealt with many reactions (my son has MANY allergies as well as possibly idiopathic anaphylaxis) and have always given Benedryl first and watched and waited for the first hour to see if an Epi was necessary. If he doesn't get better in twenty minutes and/or he starts wheezing we give him a shot and take him to the hospital.

I was just curious if the shot is at all "protective" against the later bi-phasic reaction. He's had a couple of these and they're very think everything's o.k. and then the reaction returns and escalates. However, we've never given the Epi at the beginning of one of these biphasic ones because the initial reaction is so mild.

Has anyone ever had an initial reaction where an Epi was given and then experienced a biphasic return of the reaction anyway? Does the initial Epi help or make no difference?

Posted on: Tue, 01/08/2002 - 11:56pm
joeybeth's picture
Joined: 09/01/2006 - 09:00

I am interested to read the responses to your post. We have never ourselves given the epinephrine (the doctors have given the meds at the ER) and never had a second phase of the reaction occur. I really do fear this happening. Our PA daughters usually react immediately and very obviously (hives, swollen faces, eyes, lips, quick coughing, etc..) but have never had the second type of reaction you have mentioned; where the signs are less obvious and sudden and where there is a lot going on internally later. I would like to learn more about this type of reaction, if anyone has more info. Which PA people is this type of reaction more common for? Or, can it happen at anytime for anyone who is PA? Are people that have this second phase sort of reaction prone to doing so more often than others who usually have the other kind of reaction? I have read somewhere on here that the slower, less obvious reactions are sometimes more dangerous but I don't know much about it. I feel like I should know so I don't consider a reaction "done and over" one day when it hasn't really run its course. Joey

Posted on: Wed, 01/09/2002 - 1:48am
Carefulmom's picture
Joined: 01/03/2002 - 09:00

Everything I have read says that a biphasic reaction can happen any time, so after you give the Epi and get to the ER, you should stay there at least four hours to wait and see if the second phase will occur. If they send you home before the four hours, it is recommended to sit in the parking lot until the four hours are up.
Joeybeth, I was wondering what the doctors say about your kids having swollen lip, face, eyes, coughing, and hives and you not using the Epipen. I don`t think I would have the nerve to do that. The article I read on which people with anaphylaxis died and which ones didn`t said the ones who died were the ones where Epipen was used late. If the blood pressure has already dropped (and you can`t see the blood pressure dropping the way you can see hives), the leg doesn`t get circulation going to it, and the Epipen may not get into the system. Do the ER doctors think it is okay with your childrens` symptoms that you mentioned to give Benadryl and head for the ER instead of giving the Epipen? I would be afraid to do that.
[This message has been edited by Carefulmom (edited January 09, 2002).]

Posted on: Wed, 01/09/2002 - 2:23am
Boone's picture
Joined: 08/24/2001 - 09:00

When my son had his one and only (knock wood) reaction 5 years ago we sat in the ER with him for a little over four hours. As soon as the ambulance pulled up, he was given Benedryl - he had epi enroute. They monitored him for the standard four hour period and instucted us to give him Benedryl every 6 hours for the next 72 hours. Of course, we left with a script for Epi's.
That is why is it so imperative to go to the ER via ambulance if there is a reaction. You or your child will be monitored with an EKG readout during the trip and they have advanced life saving equipment onboard. I am absolutly amazed when people give an Epi and don't follow up with a trip to the ER.

Posted on: Wed, 01/09/2002 - 2:36am
joeybeth's picture
Joined: 09/01/2006 - 09:00

CarefulMom: Both serious reactions were in the beginning of our first child having been diagnosed as PA. The first one, of course we didn't know it was PA and didn't have an epipen in our possession. We did have benadryl in the house and gave it, realizing it helps with swelling. The second time I was too afraid to give the epipen, even though I did have it with me. (I did give the benadryl on the way to the hospital)I was blasted by the doctor who saw her in the ER that night. He said I should have definitley given the epipen. (by the way, this was the night she inhaled steam or something as we sat near an Oriental restaurant in a mall or came into contact with some peanut residue on the chair- I wasn't even sure it was a peanut reaction since there was apparently no "ingestion" involved) I will give it without hesitation if this ever happens again. You are right that it is risky to let a reaction progress like that without administering the epinephrine. I was less educated then (and I'm a work in progress still but feeling much more confident if I ever have to face a similar situation again). I am not afraid to give the pen now that I understand what it does and what it doesn't do. Joey

Posted on: Wed, 01/09/2002 - 4:04am
nopeanuts's picture
Joined: 06/20/2001 - 09:00

My son has luckily only had hive reactions up to this point. Should I plan on giving him the epi-pen if there is even one more symptom, like swelling? I planned on giving it with respiratory distress or when the benedryl didn't stop the hives, but I never thought about the in between symtpoms. Does anyone know?

Posted on: Wed, 01/09/2002 - 7:58am
Carefulmom's picture
Joined: 01/03/2002 - 09:00

The only time my daughter had egg, she developed hives and swelling around the eyes. I had read if two or more organ systems are affected to use it, so I did. Her allergist said I did the right thing. He said that often they have wheezing you can hear with a stethoscope, but not with your ears.He said that the airways have to be closed down fifty percent before you can hear wheezing without a stethoscope. If her airways were closed down forty percent I wouldn`t have been able to hear wheezing. So, he said she could have been wheezing or her blood pressure could have been dropping, there was no way to know. However, I also think that different children are higher or lower risk than my child. Some children the reactions progress really quickly. Also, the same child can have different reactions progress differently, depending how much exposure, was it eaten or simply contact, etc. And the person can become more or less sensitive (usually more sensitive) with time.
Another time, I ate a may contain product (my daughter was not known to be allergic to peanuts then), we were in the car so I didn`t wash my hands, and she wanted her juice box. I used my unwashed hands to touch her straw and put it in the juice box. Then she drank the juice. When we got home she was scratching like crazy. I undressed her, and she had a red splotchy rash. It wasn`t actually hives. That time I considered using the Epi, but didn`t. However, I was ready, and would have used it if I saw anything else. The whole thing was just so strange, because I didn`t know that she was allergic to peanuts. I also wanted to know if the reaction would go away on its own. I really wanted to know how sensitive she was to what I had eaten. Anyhow, the rash only lasted about twenty minutes and then went away.
I think since each child is different you should ask your allergist if you should use the Epi if you only see hives. If the child has a history of really severe reactions, probably you should. Or if you are the nervous type, like me. I`d much rather give my daughter a shot than watch her die. That was my motivator the one time that I did use the Epipen. My rule for myself is two or more organ systems affected I would use it. Another thing is how far are you from medical care. I live in a big city. But last summer we went on vacation to rural Tennessee, and out there I would have done it for hives only.
[This message has been edited by Carefulmom (edited January 09, 2002).]

Posted on: Wed, 01/09/2002 - 8:37am
Kim M's picture
Joined: 06/09/2001 - 09:00

I asked our first allergist how I could tell when to give Benadryl and when to use the Epipen. He said if there were only hives, give Benadryl. But if there was ANY swelling at all, use the Epipen. It's interesting, though, that the EMT's who came for my daughter's first (and only) reaction, which consisted of hives and severe swelling of the face -- eyes, lips, tongue -- said they didn't use epinephrine until someone started having breathing difficulty, which she never did. The ER gave Benadryl and Prednisone, no epi, and kept us for two or three hours to see if the reaction got any worse.

Posted on: Sat, 01/12/2002 - 3:35am
dad's picture
Joined: 08/16/2000 - 09:00

I think I'm missing something in this discussion. Is there a risk I'm unaware of in using the epi-pen that should make me hesitant to use it if my son starts to have a reaction to peanuts (even if the exposure is only suspected)? What are the dangers of giving the epi-pen. I'm unfortunately well acquanted with the dangers of the peanuts.
And if the epi-pen's bad effects are mild, why would I even hesitate to use it?

Posted on: Sat, 01/12/2002 - 6:42am
PeanutKate's picture
Joined: 05/24/2000 - 09:00

There is no harm to using the pen and there is risk of serious harm, even death, if it is not used. My doctor and all of the recent medical research that I have seen says use it--don't hesitate. Some doctors thinking/education about this is way out of date and based on old science {my opinion only of course} and they give out outdated advice. Use the pen whenever there is a reaction. It will not hurt and can save a life.

Posted on: Sat, 01/12/2002 - 6:50am
boobrinamom's picture
Joined: 09/08/2001 - 09:00

In our case, our son is allergic to many common foods including milk and soy, and even though we try very hard, we generally have one or two full-out reactions a year.
In addition, we probably have an incident a month that may be cross-contamination or idiopathic anaphylaxis, where he'll have a very mild possible reaction that won't progress (just itchy mouth or throat and a tummy ache).
Additionally, because his reactions no longer involve hives but do involve a respiratory response, an asthma attack can look a lot like a food reaction.
If you take this all together, we have the potential to give an Epi about 40 times a year.
If your child is only allergic to peanuts and has an obvious reaction pattern you don't have this issue. However, I *can't* give an Epi every time so this topic is always of interest to me. Additionally, my son has had two very mild reactions and then serious bi-phasic reactions 2-6 hours later.
Epinephrine is normally a pretty safe medication, but some kids do die from it. (They usually are kids with medical issues but not always.) Additionally, there are people who die from epinephrine overdose because they overreact with multiple shots.
All that aside, my original question was whether giving epinephrine at the beginning of a reaction would do anything to mediate the bi-phasic reaction that actually killed any of these kids. In other words, even if you give the epinephrine, it only works for 20 minutes. How does this prevent children from dying from bi-phasic reactions?


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