Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Schools and Asthma/Anaphylaxis

The Asthma and Allergy Foundation of America (AAFA) has recently released its report on school health policies,[1] specifically focusing on asthma and anaphylaxis. Anaphylaxis is the fancy word for life threatening allergic reaction. Not the rash. Not the itching. Not the minor complaints.

Life threatening.

Dramatically lower blood pressure and/or significant difficulty breathing. These may never have happened before in this person. My favorite questions to ask are:

1. Has this ever happened before.

2. If so, what happened then?

3. What seemed to help?

4. What didn’t seem to help?

5. How does this feel compared to previous episodes? Better? Worse?

One of the nice things about anaphylaxis is that you can usually diagnose it from across the room. This is not a subtle presentation.

Their report shows a lot of good information about how schools are handling the ability of children to treat themselves. There is no good reason for a child to have to wait for a teacher to determine that they are sick enough to go to the school nurse to get their EpiPen.[2] What if the school nurse is not available? On 911 calls there is often no school nurse on the premises, since the nurse may be assigned to cover several schools at the same time.

This change in the approach to self-medication by children with chronic, but potentially life threatening, illnesses is a good thing.

I responded to a middle school that did not allow children to carry their medication. A child was having a severe asthma attack. Fortunately, the school nurse was authorized to administer an EpiPen injection. When I arrived, he was looking as if he was ready to stop breathing. Uh oh! The number one get your BVM and intubation kit out indicator. The school nurse had just given him an injection from a pediatric EpiPen (or EpiPen Jr). He was stating that he felt that his breathing was improving. Time to reassess and provide some oxygen and decide between albuterol and benign neglect. If I remember correctly, he received benign neglect, since his breathing was good. He actually was soon complaining more about the side effects, than the respiratory distress. Respiratory distress that almost ended with him intubated, or even in cardiac arrest. The difference can be just a matter of a couple of minutes. And some epinephrine.


Photo credit

Here is a video on using an EpiPen. I looked at a bunch of videos. Most had something good about them, but none were great. This seemed like the best one.

EpiPen now appear to be sold in packs of 2, so that you have another on hand if the anaphylaxis or asthma does not respond to one dose, or if EMS is not readily available.

Here are a couple of other descriptions of the use of EpiPens in life threatening situations. The CNN article states that it is only for anaphylaxis. No. An EpiPen is appropriate for severe asthma, too. Of course, I have pointed out that CNN needs a medical correspondent, who does a responsible job of vetting medical news, or even responding to complaints about completely false information. The LA Times article is by a professor of medicine.[3] The CNN article does not list any medical qualifications.[4] Why include the CNN article? Stories help us to understand what presentations might be like, to anticipate variations in these emergencies.

I have been dispatched to plenty of patients, who had used EpiPens. I have not yet had to treat any of them. Sometimes medical command insists that the patient receive diphenhydramine (Benadryl) and/or fluids, but not because the patient needs it, because it is in the protocol.

There is also a video about FDNY BLS ambulances finally being issued EpiPens.[5] This should not be news. Fire Commissioner Nicholas Scoppetta demonstrates a horrible lack of understanding of math. He states:

At a price tag of more than $96,000, Scoppetta says it will be money well spent.

“This is a terrific investment. If you save the life of one child who goes into shock, it pays for itself 1,000 times over,” said Scoppetta.

One life = $96,000 a thousand times over? Easy math. That is $96 million per save. 2 full time EMTs combined make less in a year than the cost of the whole program $96 thousand.

At a price of $96 million per life saved, even NYC would not be able to afford to keep this program running. Or, this might explain why their resuscitation rate is so low./

Footnotes:

1 2009 State Honor Roll
Annual Report of State Asthma and Allergy Policies for Schools
– Updated Report Features New “Honorable Mention” States that Made Progress in 2009
www.StateHonorRoll.com
The Asthma and Allergy Foundation of America (AAFA)
Web Page with links to plenty of resources.

2 EpiPen® and EpiPen® Jr (0.3 and 0.15 mg epinephrine) Auto-Injectors
DEY®
Web page.

3 The highly allergic should keep an epinephrine shot close by
For some, a bee sting can be fatal, so learning to self-administer the injections — and having one on hand when traveling — can be a life saver.
Los Angeles Times
In Practice
By Claire Panosian Dunavan
September 7, 2009
Article

4 Allergy injectors are ‘liberating and daunting’
By Elizabeth Landau
CNN
updated 9:11 a.m. EDT, Fri September 4, 2009
Article

5 All FDNY Life Support Units To Carry Epi Pens
04/04/2009 01:11 PM
By: NY1 News
Article and Video

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PediCap Product Recall


Also posted over at Paramedicine 101. Go check out the rest of what is there.

This is the Pedi-Cap.

For comparison, here is the Pedi-Cap next to its big brother/sister, the Easy Cap II.

It is tiny. To give you another idea of the size, here it is being used on an itty-bitty baby, who could fit in my hand.


Photo credit

This device is a simple piece of litmus paper. CO2 (Carbon diOxide) is acidic. In the presence of CO2, this paper will change from Purple to Yellow. The concentration of CO2 determines how yellow the paper becomes.[1]

Some of the problems with this are due to it being nothing more than a piece of litmus paper with a supposedly airtight plastic cover, airtight except for the connections. When litmus paper becomes moist, it does not do what we want it to do in the presence of CO2. It does not tell us if there is any CO2 present.

We are looking for the CO2 because that indicates that the tube is connected with a place that either has a reservoir of CO2, or to a place that is capable of exchanging CO2 for O2 (Oxygen).

If you have been providing mouth-to-mouth ventilation, but have been filling the belly, rather than the lungs, that would be one source of a CO2 reservoir at the end of the esophagus. After a while, the CO2 should be removed. In the mean time, you may be misled into leaving the tube in the esophagus and ventilating the stomach. This may not turn out well.

Contraindications
• Not to be used for detection of hypercarbia.
• Not to be used to detect main stem bronchial intubation.
• Not to be used during mouth-to-tube ventilation.
• Should not be used to detect oropharyngeal tube placement.
Standard clinical assessment must be used.[2]

This is a description of a problem with the Pedi-Cap.

Began ventilating patient with pedi-cap and peds ambubag. Patient began to desaturate immediately. Could not force air thru ambu with Pedicap on. Removed pedi cap and ventilation was accomplished. O2 sats improved. Manufacturer response (as per reporter) for CO2 detector, Pedi-Cap “size of the paper in the detector was dimensioned incorrectly causing the device to have a higher flow resistance.” Testing other lots to see if same problem exists.[3]

Let’s look at this step-by-step.

Began ventilating patient with pedi-cap and peds ambubag.

No problem, yet.

Patient began to desaturate immediately.

Not a good sign. PALS (Pediatric Advanced Life Support) teaches a 4 step assessment for sudden deterioration of an intubated patient using the mnemonic DOPE (not something to say out loud in front of family). D = Dislodged; O = Obstructed; P = Pneumothorax; E = Equipment failure.

Could not force air thru ambu with Pedicap on.

That would be D for Dislodged. E does not really apply, since that is supposed to be for patients on a ventilator, but use whatever works.

Removed pedi cap and ventilation was accomplished.

Problem solved, but I am guessing that the reason for the assessment of CO2 has not been addressed.

O2 sats improved.

I’m assuming that the CO2 was evaluated in some way. Maybe they just kept ventilating and figured that the response to ventilation with bagging was confirmation enough. The immediate improvement in oxygen saturation is unlikely to be a false positive.

Manufacturer response (as per reporter) for CO2 detector, Pedi-Cap “size of the paper in the detector was dimensioned incorrectly causing the device to have a higher flow resistance.” Testing other lots to see if same problem exists.


Image modified from the Nellcor product manual.

Nice work by the person ventilating the patient in quickly recognizing a problem and reacting appropriately.

August 14, 2009

Dear Valued Customer,

We are informing you of an urgent voluntary medical device recall regarding the PediCap End-Tidal CO2 Detector (PediCap and PediCap 6).

We have received a customer report in which they experienced difficulty manually ventilating an intubated patient through the PediCap. While we continue to investigate, we believe that a recent modification to the PediCap End-Tidal CO2 Detector may result in increased resistance to airflow through the PediCap. This could result in ineffective ventilation of the patient and/or inadequate detection of CO2 levels, so that the indicator paper will not change color.

Although we have received no reports of patient injury, we have determined that all PediCap and PediCap 6 End-Tidal CO2 Detectors from the lots listed below must be returned. We are requesting your assistance in conducting this activity. Please review your inventory and segregate any product with the affected lot numbers and return affected product according to the directions below[4]

Likewise, it is nice to see a company responding with a recall, rather than waiting for a patient to be injured. Only one week between the FDA notice and the company recall. While it could be faster, some companies will keep denying problems even after there are a bunch of dead bodies from their product.

Footnotes:

^ 1 CO2 detection sheet
Nellcor
Free PDF

^ 2 Pediatric End-Tidal CO2 Detector PediCap®
Nellcor
Free PDF

^ 3 FDA Medical Product Safety Report
FDA
08/07/2009
I cannot get Blogger to accept the html for a link to the FDA page. Cut and paste this link:

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/medsun/medsun_details.cfm?ID=%25″-O%3D%25_X%20%0A

^ 4 URGENT MEDICAL DEVICE RECALL for PediCap™ End-Tidal CO2 Detectors
Covidien (owner of Nellcor)
August 14, 2009
Free PDF

All necessary information, to contact the company, is in the pdf. Also included are the numbers of all of the lots involved.

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