Correspondence

Administration of Epinephrine by Emergency Medical Technicians

N Engl J Med 2000; 342:822March 16, 2000

Article

To the Editor:

One morning, my wife motioned to me that she felt her throat tightening and was suddenly having difficulty breathing. With progressively worsening epiglottitis, she now had severe respiratory stridor due to laryngospasm. During the next few minutes, her condition rapidly deteriorated. As she gasped for air, I telephoned our 911 emergency-response line. Within six minutes, the first responders from our town's fire and police departments arrived, as did an ambulance staffed by basic-level emergency medical technicians. Twelve minutes after I summoned help, an advanced-level ambulance arrived, staffed by paramedics. Meanwhile, I injected epinephrine from an expired EpiPen Auto-Injector (epinephrine, 0.3 mg; Dey, Napa, Calif.) into my wife's thigh. Her breathing began to normalize within a minute.

Although the first responders in my town are authorized to perform cardiopulmonary resuscitation and to use automatic external defibrillators, they are not permitted to carry or administer epinephrine. Thus, if I had not had an epinephrine auto-injector at home, my wife might have had irreversible hypoxic damage from laryngospasm.

I subsequently learned that in my town, only paramedics staffing an ambulance equipped to provide advanced cardiac life support, and not first responders, are permitted to carry and administer epinephrine. I found this shocking, because patients who have anaphylaxis for the first time ordinarily do not have access to epinephrine. Others may need more than one injection or may have misplaced or not filled a prescription for an epinephrine auto-injector.

These restrictive rules are the norm, not the exception, across the United States. First responders should be trained to recognize and treat laryngospasm and anaphylaxis. Community activists must lobby to repeal the restrictive legislation that is in place in 43 states. In the other seven states (Table 1Table 1The Seven States That Permit First Responders to Carry and Administer Epinephrine.),1 concerned citizens must ensure that first responders are trained and permitted to carry and administer epinephrine in their town, city, or county. Federal legislation should indemnify properly trained first responders throughout the United States and supersede the current maze of state, regional, and local regulations.

Virtually all physicians should carry an epinephrine auto-injector so that they can respond in emergency situations. Concerned laypersons should volunteer for training in the recognition and treatment of anaphylaxis. In certain circumstances, it would be appropriate for physicians to prescribe an epinephrine auto-injector for properly trained persons who feel a responsibility to intervene if they encounter this medical emergency. With more widespread recognition and acknowledgment that a life-threatening problem exists, community leaders, health care providers, and elected officials can design and implement constructive and pragmatic solutions.

Samuel Z. Goldhaber, M.D.
Harvard Medical School, Boston, MA 02115

1 References

1. 1

   Food Allergy Network. Emergency Medical Services epinephrine policies: a state-by-state review. Fairfax, Va.: Food Allergy Network, 1999.
   

Citing Articles (4)

Citing Articles

1. 1

   David C. Cone. (2002) S UBCUTANEOUS E PINEPHRINE FOR O UT-OF -H OSPITAL T REATMENT OF A NAPHYLAXIS. Prehospital Emergency Care 6:1, 67-68
   CrossRef

2. 2

   JERALD WINAKUR. (2002) Side Show. Prehospital Emergency Care 6:1, 68-68
   CrossRef

3. 3

   D. A. Moneret-Vautrin, G. Kanny, M. Morisset, J. Flabbee, L. Guenard, E. Beaudouin, L. Parisot. (2001) Food anaphylaxis in schools: evaluation of the management plan and the efficiency of the emergency kit. Allergy 56:11, 1071-1076
   CrossRef

4. 4

   Scott H. Sicherer. (2001) Self-injectable epinephrine: no size fits all!. Annals of Allergy, Asthma & Immunology 86:6, 597-598
   CrossRef