By Kevin Crocker, LP; Ashton Herring, EMT-P; Dickson Robert, M.D.
Anaphylaxis is a potentially life-threatening disease process that is commonly encountered and treated in the pre-hospital environment. The front line treatment for anaphylaxis of all causes is epinephrine. Without the quick administration of epinephrine, the patient could further deteriorate into respiratory arrest or cardiovascular collapse.
However, the numbers for deployment of the drug are grim.
One study found that of all the anaphylaxis fatalities within their study group, only 20 percent of them received epinephrine during the course of their treatment. The good news is that with appropriate treatment, the fatality rates drop significantly. An emergency department case review from 2006 to 2009 within the United States revealed that the fatality rate of patients treated in the ED was only 0.3 percent.
How should pre-hospital systems deploy epinephrine to get this lifesaving drug into the right hands?
Making epinephrine available to first responders in Montgomery County, Texas
Montgomery County Hospital District (MCHD) is the sole 911 ambulance provider for Montgomery County, Texas. It is a suburb county of Houston and, according to the 2016 census, is the 17th fastest growing county in the country. Montgomery County spans more than 1,100 square miles and is a mix of urban, suburban and rural populations. MCHD is an MICU-capable ambulance service which uses a strategic deployment of ambulances throughout the county to meet the needs of the community, based on population and historical data. MCHD also partners with eleven fire departments within Montgomery County that provide BLS first response to high priority calls based off the EMD determinates.
Typical to other agencies around the country that use a deployment model similar to this, the first responder fire departments often arrive on scene before the ALS providers. A retrospective look at MCHD’s pre-hospital ambulance care showed that epinephrine is administered up to 40 times for anaphylaxis each year. Given the rapid onset and severity of anaphylaxis, MCHD decided that placing epinephrine in the hands of fire department first responders was more beneficial than waiting on an ALS provider to arrive on scene. By providing this life saving drug to those first on the scene, it was found that first responders could effectively decrease the time to treatment for patients suffering from anaphylaxis.
Creating cost-effective epinephrine kits
After the decision was made to deploy epinephrine to the first responders, there were several obstacles to overcome regarding cost and training. With the price of epinephrine auto injectors increasing to an average of $450 each, it was cost prohibitive to deploy them across an entire county. MCHD decided to build their own anaphylaxis kits (Figures 1 and 2). These kits consisted of 2 ampules of epinephrine 1:1,000, 4- 1cc syringes, 4-22g 1-inch needles, alcohol wipes and adhesive bandages. Each of these kits were built for under $30.
In addition to the actual supplies in the kit, there is a quick reference card secured to the inside of the lid. This reference guide provides information about anaphylaxis, indications for treatment, adult and pediatric dose references and an image of what the syringe should look like with the proper dose (Figure 3). The contents of the kits, the reference guide and the doses were all approved by the Medical Director, Robert L. Dickson, M.D. For this deployment, 130 units were needed to place one in each medical bag of participating departments. The cost savings between the MCHD anaphylaxis kits and epinephrine auto injectors was over $100,000 to get the same amount of epinephrine on each apparatus.
Each fire department in Montgomery County has a different shift schedule, which makes scheduling training a unique process that took several months. Anaphylaxis and Epinephrine Administration CE is two hours long and includes background information of anaphylaxis, proper treatment, epinephrine pharmacology and hands on practice. Each firefighter was supplied with ample practice time to learn the basics of withdrawing and administering the proper doses of epinephrine. At the end of the class, it was verified by the instructor that all students could successfully draw up the proper dose of epinephrine and administer using appropriate technique for intramuscular injection.
Successful epinephrine deployment leads to better patient care
Since the deployment of the new anaphylaxis kits, first responders administered epinephrine four times in the first two months. Each of these cases were reviewed through the MCHD quality review process and the treatment was found to be appropriate in each case. These patients were exhibiting signs of anaphylactic shock prior to the epinephrine administration and showed signs of improvement in their condition prior to arrival of ALS providers. There have been no inappropriate uses thus far, and no complications to date.
The deployment of epinephrine into the hands of those first to make patient contact in these fragile and rapidly deteriorating patients has already improved patient outcomes. The development of the anaphylaxis kits proved to be simple to build and economical to deploy. The training for the first responders was well received and we feel sufficient for these first responders to successfully treat anaphylaxis. Ultimately, we feel that by putting epinephrine where it belongs, in the hands of those first on scene, will prove to be a lifesaving choice for our community.