racemic epi

[AZCEP]

Good tip there, thanks Doc.

I've only used the racemic epi in the most dire of situations. Peds with epiglottitis and adults with upper airway edema, and got good results from them. These patients were probably not going to be walking out of the ER anyway, but it is good to know they will be there a while.

[ERDoc]

Good tip there, thanks Doc.

I've only used the racemic epi in the most dire of situations. Peds with epiglottitis and adults with upper airway edema, and got good results from them. These patients were probably not going to be walking out of the ER anyway, but it is good to know they will be there a while.

You'd be surprised how well people do with RE. People can make a full 180 turn and are able to walk out of the ER with close followup.

[kevkei]

ERDoc, after the use of either RE or epi, don't you guys add a steroid like PO Dex?

That is the standard of care here, either they get Dex alone (mild-mild/moderate croup score) or after RE then are discharged moderate-severe). I thought there were studies that were able to defunct idea of the rebound effet with the added use of Dex.

[ERDoc]

ERDoc, after the use of either RE or epi, don't you guys add a steroid like PO Dex?

That is the standard of care here, either they get Dex alone (mild-mild/moderate croup score) or after RE then are discharged moderate-severe). I thought there were studies that were able to defunct idea of the rebound effet with the added use of Dex.

Yeah, we use steroids. I don't know about the studies, but the steroids take as long as 4 hours to work, so you may not be covered. Also in the letiginous world called the United States, you need to CYA and standard of care at this point is observation.

[bryan20w]

What about nebulizing MgSO4 with saline, There has been quite a bit of research in to it and it has had approx. the same success as albuterol, so i might make a good alternative if refractory to albuterol.

[VentMedic]

What about nebulizing MgSO4 with saline, There has been quite a bit of research in to it and it has had approx. the same success as albuterol, so i might make a good alternative if refractory to albuterol.

MgSO4, the results have not given significant results to warrant the off label policies even in the hospital.

http://www.merginet.com/index.cfm?pg=airwa...n=magsulfasthma

The big problem is the inability to get into the airway passages due to inflammation and constriction well enough for good depositon. Some of this patients may require Heliox either by mask or ventilator for several days. It is rare you'll break thru truly inflamed airways in the field. In the hospital we are capable of giving high doses of albuterol up to 25 mg undiluted with a BAN to assure minimal medication loss. This is also how we treat high K+ levels until definitive treatment. High dose nebs are not to be confused with what a hospital calls "continous" nebs nor when you dump a bunch of albuterol unit doses into a neb to get it to run continously.

Regular acorn nebs are not recommended for off label nebulization. Remember your nebs in the field are only delivering about 10% of the medication on a really good day. Since most hang face masks for convenience, you may get 5% or < after the nose filters the particles. The other issue is the safety of the crew and bystanders when off label use meds are nebulized. Our nebs can have filters and we use a scavenger if the patient is not isolated.

Racemic Epi is used frequently in RSV or bronchiolitis season in infants. We rotate Racemic Epi with Albuterol given at 2 hour intervals. The Racemic Epi may reduce the swelling of the inflamed airways just long enough to get some albuterol or steroid into the lungs with better depositon. We can also initiate a continuous Racemic Epi in a hood if necessary. That is a low dose given continously.

The 4 hours in the ED as ERdoc stated is to see what happens after the airways rebound to previous status if definitive therapy such as steroids or long acting bronchodilators don't work as planned.

Nebulized lidocaine 4% is also used to reduce "spastic" asthma with severe coughing.

Depending on the etiology of the wheezing, don't always expect miraculous results in the field.

All that wheezes is not always asthma and not all asthma always wheezes.

[AnthonyM83]

When you guys say racemic epi, do you say that just because it's the formal name or do you guys also carry a separated non-racemic mixture? What's the difference between the racemic and separated enantiomer forms?

[MSDeltaFlt]

In my career I've only handled 3 different epi's

1:100 (Racemic)

1:1000 (multi-dose)

1:10,000 (bristo-jet)

[tniuqs]

MgSO4, the results have not given significant results to warrant the off label policies even in the hospital.

http://www.merginet.com/index.cfm?pg=airwa...n=magsulfasthma

<snip>

Nebulized lidocaine 4% is also used to reduce "spastic" asthma with severe coughing.

Depending on the etiology of the wheezing, don't always expect miraculous results in the field. All that wheezes is not always asthma and not all asthma always wheezes.

More evidence based medicine from Ventmedic/ ERdoc / Kevkie, we are lucky to have thier input and take the time to "explain" as racemic epi as this has great potential for rebound, and restricted to post extubation stridor where I have worked, seldom sucessful usually a stopgap anecdotally.

Nebulised lido, is far to under-utilised in EMS, IMHO. Have used it many times with good results, but it has raised eyebrows .

I have never located ANY studies on Mag Sulfate for nebulised or IV. for the asthmatic in-the-field delivery, I believe just another EMS urban Myth.

Mag sulfate does work well for soaking of sore feet after a forced march ..... just in passing.

cheers

[bryan20w]

Whether it is helpful of not here is one such study, it is a european study however it is also sited in the Emergency medical Journal

Nebulized magnesium sulphate versus nebulized salbutamol in acute bronchial asthma: a clinical trial

HS Mangat, GA D'Souza, and MS Jacob

Intravenous magnesium sulphate (MgSO4) has successfully been used in the treatment of acute asthma. The present study investigated the efficacy of nebulized MgSO4 as a bronchodilator in acute asthma as compared to nebulized salbutamol. This was a randomized, double-blind, controlled clinical trial. Asthmatics aged 12-60 yrs in acute exacerbation, with a peak expiratory flow (PEF) <300 L x min(-1), not having taken bronchodilators and not requiring assisted ventilation were included. Patients were randomized to receive treatment with serial nebulizations of either 3 mL (3.2% solution, 95 mg) MgSO4 solution or 3 mL (2.5 mg) salbutamol solution. All patients were also given 100 mg hydrocortisone i.v., and were monitored continuously for 2 h after which they were given supplemental treatment (if and when needed) and either discharged or admitted. Fischl index, PEF improvements (in % predicted) and admission rates were the outcome variables. Thirty-three patients were studied. Fischl score improvement was comparable and significant in both groups (4.31 to 0.43 in the MgSO4 group and 4.29 to 0.76 in the salbutamol group). The increase in PEF was statistically significant and comparable in both groups (by 35% pred in the MgSO4 and by 42% pred in the salbutamol group). Two patients warranted admission in the salbutamol group and one in the MgSO4 group. Nebulized MgSO4 had a significant bronchodilatory effect in acute asthma. This effect was not significantly different from that of nebulized salbutamol.