Page 14 - Journal of Special Operations Medicine - Winter 2014

previously described in a field environment of a patient Table 2 Suggested Field Management
on a jungle expedition who demonstrated resistance to 1. Lie patient supine if respiratory status allows.
repeated IM epinephrine doses. 19
2. Administer 0.5mg IM epinephrine (into lateral thigh,
Bolus IV administration of epinephrine has historically if possible).
been considered a high-risk activity and has not been 3. Repeat 0.5mg IM if no improvement within 10 minutes.
recommended. It has been suggested that outside of a 4. Obtain IV access.
fully equipped resuscitation environment with monitor- 5. If systolic BP <100mmHg and/or additional signs of
ing facilities, IV epinephrine is not appropriate. 20 poor perfusion, administer 1000–2000mL of normal
saline (if available).
The authors have personal experience with the use of 6. If deteriorating despite IM epinephrine, consider
a dilute epinephrine infusion without invasive monitor- 1:1,000,000 infusion (1mg into 1000mL normal saline
ing, central line access, or a syringe driver in the place of or 0.5mg into 500mL or 0.25mg into 250mL):
bolus administration with no apparent loss of efficacy i. Administer at 1–2mL/min titrated up to achieve a
or increase in side effects. While this has not been sub- clinical effect or the occurrence of side effects such
jected to a randomized trial, there is good observational as new onset tachycardia or hypertension.
evidence of efficacy and safety. In an emergency out-of- ii. Infusion can be increased up to “wide open” if
3
required. Side effects with a 1:1,000,000 solution
hospital where there has been failure to respond to in- are very uncommon even when given through a
tramuscular dose(s), this option is supported by clinical wide-open line.
guidelines produced by both the Therapeutic Guidelines
group (Australia) and the Australasian Society for Clini-
cal Immunology and Allergy. 21,22 but field medics need to be aware of these options,
should evacuation to a nearby emergency center or hos-
Fluid therapy is the second mainstay of resuscitation, af- pital be feasible.
ter epinephrine. Large volumes of fluid may be required.
The majority of patients will respond to IV fluids and
epinephrine, especially where the cause is venom related, Summary
and this is most commonly seen in a field environment. 3,23 Anaphylaxis is a relatively common resuscitative emer-
gency. In some patients, it can be difficult to manage
Insertion of an IV line is now a common skill, and ad- with intramuscular epinephrine. The consequence is
ministration of fluid resuscitation is usually available to that it can be a potential operational threat and require
vocational medics or medically trained operators. It is a medical evacuation. We suggest that the field care
not a complicated step to use a dilute epinephrine infu- can be optimized with the addition of a dilute epineph-
sion in field settings, and any risks are likely to be ac- rine infusion for cases not responsive to intramuscular
ceptable if the alternative is death before medical care. epinephrine.

We recommend the field treatment regimen outlined in
Table 2. The primary focus needs to continue to be on Disclosures
early IM administration of epinephrine but also recogni- The authors have nothing to disclose. The authors
tion that there will be a small number of nonresponders have no financial or other conflicts of interest in the
who may require aggressive IV fluid resuscitation and manuscript or the topics discussed as per our ICMJE
IV epinephrine. In an operational environment, a dilute statements.
infusion can be administered safely and efficaciously
and is a viable option and potentially mission saving.
Unit medical officers and those involved in standard set- References
ting and education for medics should consider this as 1. Sampson HA, Munoz-Furlong A, Campbell RL, et al. Sec-
an option. ond symposium on the definition and management of ana-
phylaxis: summary report—second National Institute of
Other Measures Allergy and Infectious Disease/Food Allergy and Anaphy-
Some cases of very severe anaphylaxis appear to be re- laxis Network symposium. Ann Emerg Med. 2006;47(4):
373–380.
sistant to epinephrine and fluids. Advanced procedures 2. Brown SGA. Clinical features and severity grading of ana-
including intubation/ventilation, potent vasoconstric- phylaxis. J Allergy Clin Immunol. 2004;114(2):371–376.
tors (e.g., vasopressin, metaraminol), and mechanical 3. Brown SGA, Blackman KE, Stenlake V, et al. Insect sting
cardiac support (intra-aortic balloon pump) have been anaphylaxis; prospective evaluation of treatment with in-
reported as necessary to prevent death. These will be travenous adrenaline and volume resuscitation. Emerg
outside the scope of practice for most operational units, Med J. 2004;21(2):149–154.

4 Journal of Special Operations Medicine Volume 14, Edition 4/Winter 2014