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Would the three children described by Mark Levy et al1 and many others who died have survived if they’d had multiple epinephrine (adrenaline) intramuscular (IM) injections? Former President Obama legislated in 2013 for epinephrine auto-injectors in educational establishments for acute asthma attacks, as well as anaphylaxis,2 with a Good Samaritan clause. The National Review of Asthma Deaths recommended auto-injectors for asthmatics who survived a first life-threatening attack. In the thunderstorm epidemic in Victoria, Australia, in November 2016, paramedics gave IM epinephrine repeatedly to enable patients to survive until hospital arrival. UK paramedics will also give IM epinephrine to life-threatened patients with asthma.3
Available auto-injectors are EpiPen®, Jext® (same manufacturer), and Emerade®; the former have doses and needle lengths of 0.15 mg (13 mm) and 0.3 mg (16 mm). After firing EpiPen, 1.85 mg (ml) and 1.7 mg (ml) remain in the internal syringe. A YouTube EpiPen wilderness medicine technique demonstrates obtaining additional doses. Emerade has 0.15 (16 mm), 0.3, and 0.5 mg (23 mm), the largest dose and length; no drug remains after firing. Natasha Ednan-Laperouse, who died after eating a baguette containing an allergen, received two EpiPen 0.3 mg injections to no avail (auto-injectors were invented for low-thigh fat astronauts) and her coroner4 asked for longer needles, larger doses, and wondered if use-by dates could be extended (confirmed years ago).5
Other manoeuvres for life-threatened patients with asthma and anaphylaxis sufferers are mouth-to-mouth breathing, cardiac compressions, and speedy hospital delivery, but with no guarantee of survival. For patients with asthma in hospital, a combination of intravenous (IV) magnesium sulfate, IV salbutamol, and IV epinephrine (titrated carefully), may avoid tracheal intubation and lung ventilation.6 In many hospitals in the Netherlands, the selective phosphodiesterase inhibitor and smooth muscle relaxant IV enoximone, is successfully used in status asthmaticus.7 When evidence to treat is not available, common sense, case reports, and experience must guide therapy.
- © British Journal of General Practice 2019