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As reported in, JEMS, newspapers, magazines and medical journals across the country:

Standing Order Subcutaneous Epinephrine
Fatality suggests caution...

When a 39 year old man in respiratory distress called 911 for assistance, an ambulance was dispatched as routine and normal. What happened after the crew arrived will and has changed the lives of many individuals forever.

A fatal error or a missed diagnosis?

The medics evaluated the patient and determined his distress was the direct cause of an allergic reaction/anaphylaxis from one of his medications. This due to the findings from a field exam and a subjective evaluation from the patient. With this history, an objective secondary survey and a quick consult between themselves, the crew decided to administer 0.5 mg of epinephrine via subcutaneously.

Standing orders:

The medics using existing standing orders, administered the drug and complicated the more serious problem; decompensated Congestive Heart Failure... The patient was suffering from a mild reaction to a new medication, but he also was suffering from left heart failure. The epinephrine causing periferal vasoconstriction further compromised the decompensated CHF by increasing the afterload. The heart failed further.

A more thorough secondary or a detailed differential diagnosis might have led the medics to more accurately treat their patient. The correct diagnosis would have been made if the whole picture was taken into consideration. The patient had pitting edema and an unusually elevated blood pressure, common in acute pulmonary edema. Warning flags should have been easily spotted. The question now is, would the paramedics been given the order to administer the drug by the base station? If these subtle signs, but obviously important facts were relayed to the doctor on the radio, the oder for epi would have been with held.

"Paramedic Misjudgment"

In a report filed by B. Zane Horowitz, MD. from the University of California-Dvais Medical Center and published in the December isuue of The Annals of Emergency Medicine. It suugests that EMS systems reconsider the use of Epinephrine as a standing order drug. However, this is the only known documented case of a fatality associated with the administration of subcutaneous epinephrine in the field.

Contact Doctor Horowitz for further information at:
Division of Emergency Medicine,
University of California-Davis medical Center
Professional Services Support Bldg.,
4150 V St.,
Sacramento, CA. 95817

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