If you want a 100% safe climbing experience, crack open a beer and watch Masters of Stone VXII.

Define "small chance," please. The literature I've read is undecided on the situation, but by and large, "pre-existing cardiovascular disease" is a relative contra-indication to SC Epi. That doesn't mean you should never give it (SC Epi,) to a patient with a cardiac condition. It just means that you need to be really careful and understand the potential consequences, along with evaluating and weighing the entire situation (i.e. not every allergic reaction needs SC Epi.) I thought I made that clear. If not, then my apologies.

thank you for the epi self-dose stats. where did you find that number? i definitely learned something today, and i'd like to know the source so i can pass it on.

re: your justification of discussing epi contraindiction. i stand by what i said. above you mention SC (subcutaneous) injection of epinephrine. SC delivery is an urban protocol. in the woods, most folks either have epi pens (automatic IM intramuscular delivery) or are trained to draw up epi manually, for IM delivery.

but i do know that in the real world, if you have a life threatening reaction, you shoudlnt waste a second thinking about contraindications, and doctors will back me up on that.

"May be administered in life-threatening anaphylactic reactions, even when the following relative contraindications are present: (1) coronary artery disease, (2) uncontrolled hypertension, (3) serious ventricular arrhythmias, and (4) second stage of labor"

in the woods, either the reaction is life threatening, in which case you give them epi and take it from there. or is isnt life threatening right now, in which case you give them benadryl and proceed with caution. unless you are packing a lot of EMS credentials and a lot of gear, a rare combination in the woods, you won't diddle around with SC injections, contraindications, or the like.

Epi Pens are not IM injections, but are actually SC injections (ever see the needle of an Epi Pen? Ain't long enough to go IM, unless you're overly famished and have ZERO body fat (even well conditioned athletes have a small degree of body fat... now whether they admit it or not is a different story!)

Perhaps true. Perhaps not. I know that I, as do many of my colleges, always take a moment (even if it is just a few seconds,) to think of the options. It's good medicine. Performing an intervention without considering the ramifications is a bad idea.

Since I can not possibly teach someone all they need to know about Epi in a forum such as this I am relegated to giving some broad info, and imploring the reader to do more research, including having such a discussion with their physician.

You make good points, Anthony. Thanks for the discussion.

are you *sure* epi pens are SC delivery?

right. you can continue to take a couple seconds to think about the ramifications becuase it will only take you a couple seconds. the rest of the lay public, the people who are reading this forum, will have absolutely nothing to think about except that a paramedic in a forum they read said they could do some damage by giving epi pen doses.

exactly. and the nutshell version, your 'broad' version, should not be "beware the contradindications'. it is 'give epi if it looks like they need it'. you know as well as i that asking that the reader do further research and discuss with physician will not make that happen. even if they did, the answer would be the same. normal rc.com readers who don't have prior training: if your patient, yourself, your partner, your neighbor, is having trouble breathing such that they can't talk without difficulty, and you believe it is caused by an allergic reaction, then give them a dose of epinephrine. that's how it works in the real world.

You make good points, Anthony. Thanks for the discussion.

Yep. I'm sure. The Epi Pens I've seen all say "to provide Subcutaneous injection of 0.3 mg Epinepherine, USP." or some variant of that.

What I want people to understand is that Epi is not benign, and giving it can cause side effects. A recent article (I think it was a "Tech Tip" actually,) in either Climbing or R&I suggested that giving one self an Epi Pen injection was totally safe, and made no mention of any need for follow up care. So too do your suggestions. Perhaps you don't intend to, but that's the tone you give: "Epi is safe, and you don't need to consider the side effects." And THAT is what I call B.S. on.

[regarding converting mol/l into mg]
One can't simply convert. You'll need to know the molecular weight of the substance first. Chemistry class.

ok. i pulled out an expired pen. from side of pen: "delivers 0.3mg intramuscular dose of epinephrine". unless Dey labs has changed something the manufacturer seems to agree with me.

a good point. i never explicitly said that one should seek definitive care after dosing themselves, which is certainly necessary. but i dont think reading my posts would advise otherwise. i think you are twisting my criticism of your post because the standard protocol for laymen is not to consider contraindications, it is to administer to prevent death.

Then I misunderstood your comments. But you're wrong here. The standard layman protocol (which, by itself, is an oxymoron, as the layperson has no protocol,) is to do nothing, and call 9-1-1. Anything else needs to be justified, and that justification needs to include good reasons to disregard any risks. Which is what you promote by saying that people should give Epi Pens with no regard to the consequences or exclusions. And that, sir, is where we differ.

dude, wtf? first off, this entire conversation is in the context of wilderness medicine where the do nothing, call 911 bit is never the first thing that springs to mind. second, even in an urban environment, if someone is having a life threatening allergic reaction, ie anaphylaxis, then the layman course of action is TO GIVE THEM THE FRIGGIN' EPI-PEN ALREADY. fer goodness sakes, the reason they prescribe them in those idiot proof autoinjectors is so that the average joe simpleton can self administer this life saving medication (which coincidentally has NO contraindications given a life threat).

unchecked by the voice of reason (and in this case, medical science), the layperson might read your post, and be confronted with the situation the OP described. they, worried about possible cardiac trouble, might spend a precious minute while their climbing partner breaks out into hives asking them whether they have a history of cardiac trouble. say the now wheezy climber, unable to speak in full sentences, tell them that yes, he had a heart attack four weeks ago and every person in his immediate family died before the age of 35 from massive MI, the layperson might hesitate yet further to administer epinephrine. possibly not give it at all. doctors, EMS professionals, the wilderness emergency medical schools across the nation, the manufacturers of the epipen itself, they all agree- there are no contraindications if there is a life threatening allergic reaction.

now. you can, no doubt, sense im feeling a little snippy.

Since you mention it, what are YOUR credentials? Just curious, as you have made some decent arguments. Wondering if you're medically trained and educated, or just read a lot.

read up, think through anaphylaxis in the context of climbing, maybe take a wilderness emergency medicine course, and get back to us.

Perhaps it's a difference in laws, country-wise, but I thought regular folk weren't allowed to administer epi-pens, asthma breathers, etc, to other people. Unless, of course, you're accredited for that.

If you went by generic WFR logic you should give epi and benedryl to anyone who is stung by a bee. This is not always a good idea.
In fact even as someone who IS allergic and has a prescription for Epi I would not use it everytime I get stung. IF I got stung and did not have a reaction(which is not only possible but has happened to me on 2 occasion's) I would not use my Epi. If i got stung and started showing signs of anaphlaxis i wouldn't hesitate to jam that bad boy in my thigh.

We start heading down, and I feel the anaphylactic shock symptoms arising again

There are ZERO contraindication when administering an Epi pen in a case of severe allergic reaction...such as a bee sting. ZERO.

If you went by generic WFR logic you should give epi and benedryl to anyone who is stung by a bee

Basically what you have drawn out over 20 post's(your words), is exactly what reno said in the first place.... he just went into more detail.

He never said don't give epi to someone who needs it....but he did say don't give it to someone who doesn't....you are splitting hairs.

I think the disconnect we're having here is that of street vs. wilderness protocals and ethics.

Now... As long as you meet the criteria below, you're *probably* safe taking two doses. Perhaps even three. But if I, as a paramedic, had a patient that needed more than 3 doses of Epi, I'd be thinking one of two things: This is the worst allergic reaction in the history of medicine, or this isn't an allergic reaction but something else that looks like an allergic reaction.

Anyway, the consensus, and it is a consensus, on treatment of anaphylaxis (not allergic reaction) in the backcountry is epinephrine (multi-dose vial or epi-pen) .3 mg IM, followed by 25-50mg of benadryl. More epi and benadryl as needed and evac.

it is my position, and has been from the start, that Epi Pens are beneficial in Immediate, Critical, Impending Doom, "Right the hell now or I'm gonna die!" anaphylactic reactions. I've also said, from the beginning, that while Epi is helpful, it can have side effects.

Now... As long as you meet the criteria below, you're *probably* safe taking two doses.

You ALWAYS have time to think. And for a "medical provider," especially one that purports to teach WFR/WEMT classes, to NOT acknowledge that taking a moment to think is a good thing, is quite simply scary.

this is no longer a useful thread, but that's ok. me and you are probably the only ones still reading.

as a final note, let's take that quote of yours. you followed it by saying "where in that whole post did I ever say that Epi shouldn't be given?"


well, look dude. you cant have it both ways. this quote suggests that there are times when you would not be safe taking two doses. your quote suggests that the times when you would not be safe were when you did not meet the criteria below, which was a long list of cardiac problems and irregularities. therefore, you are saying that epi shoudlnt be given, or at least sometimes shoudlnt be given, when people have cardiac issues. the context of this thread is a person who is experiencing anaphylaxis therefore you are advocating delaying, or not delivering at all, a life saving medication, and slapping a "i know what im talking about because im a medic" label on it.