Epinephrine auto injectors

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Epinephrine auto injectors

• Anaphylactic Reaction
• Protocol Changes
• Aaron J. Katz, AEMT-P, CIC

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Overview

• Not just Any allergic reaction!
• Once you see it youll never forget it!
• Reactions tend to worsen with each exposure
• You have a responsibility to educate patients and
  families

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Some interesting cases

• Post Dental Visit
• Bee Sting (2 cases)
• Cookies with hidden nuts
• Milk 6 month old
• Milk 2 year old
• Touched the fish
• Penicillin shots
• Allergy injections
• The cheese danish
• Neighborhood X

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Introduction

• Anaphylactic shock is a potentially life
  threatening emergency
• This condition has a high mortality rate when not
  recognized and treated early
• With allergies increasing, mortality has also
  increased
• We dont know why allergies are increasing

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Introduction Cont.

• Hatzoloh responds to approximately 400 calls per
  year for anaphylaxis of which 15 are of patients
  with true anaphylactic shock
• Patients in anaphylactic shock are those that
  benefit from epinephrine injections
• ALS units are not always readily available
• More of a problem for FDNY/EMS?

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Introduction

• Many studies have shown that the use of an EPI-
  PEN can be safely administered by an EMT
• The EMT must be appropriately trained

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Goals

• Early recognition of anaphylaxis
• Early BLS intervention
• Early ALS intervention
• Administration of Epinephrine using the Epi-Pen
  Auto injector

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Anaphylaxis

• Allergic reaction immune response to any
  substance.
• Reaction can be localized or severe and life
  threatening (anaphylaxis)
• Allergen substance that causes the immune
  response

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Common allergens

• Insects bees, wasps
• Food nuts, fish, milk, chocolate
• Plants poison ivy, oak
• Medications antibiotics
• Other outdoor allergens, fragrances
• Latex

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Patient Assessment
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Skin

• Swelling to face, neck, hands, feet, tongue and
  periorbitally
• Urticaria hives
• Itching
• Erythema redness
• Flushed skin
• Warm tingling feeling to face, mouth, chest, feet
  and hands

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Respiratory system

• Tightness to throat and chest
• Cough
• Tachypnea
• Labored breathing
• Hoarseness
• Noisy breathing stridor or wheezing
• bronchoconstriction

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Cardiovascular system

• Tachycardia
• Vasodilation
• Hypotension
• ? Poor cardiac output!

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Other systems

• Itchy, watery eyes
• Headache
• Sense of impending doom
• Runny nose, nasal congestion
• Decreased mental status
• Abdominal distress

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Critical Point

• Findings that reveal hypoperfusion (shock), or
  respiratory distress (upper airway obstruction,
  lower airway disease, severe bronchospasm ) may
  indicate the presence of a severe allergic
  reaction (anaphylaxis)

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Past Treatment Protocol

• Perform initial assessment
• Perform focused history and physical exam,
  including
• History of allergies
• What was patient exposed to
• How were they exposed
• Effects
• Time of onset
• Progression
• interventions

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Past Treatment Cont.

• Assess baseline vital signs and SAMPLE history
• Administer high concentration oxygen
• Monitor breathing for adequacy
• Request ALS assistance
• Assist the patient with self-administration of
  their own prescribed Epinephrine
• Loosen restrictive clothing or jewelry
• Assess for shock and treat if appropriate

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New Treatment Protocolpatients over age 9 or
weighing over 30 kilos

• Determine that patients history includes past
  history of anaphylaxis, severe allergic
  reactions, and/or recent exposure to an allergen
• Administer high concentration oxygen
• Request ALS assistance
• Assess the cardiac and respiratory status of the
  patient

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Continued

• If both the cardiac respiratory status of the
  patient are normal, initiate transport
• If either the cardiac or respiratory status of
  the patient is abnormal, proceed as follows

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Continued

• If the patient has severe respiratory distress or
  shock and has a prescribed Epi-Pen assist the
  patient in administration
• If the auto injector is not available or expired
  and the EMS agency carries one, administer (0.3
  mg.) as authorized by the agency medical
  directors
• If the patient does not have a prescribed
  Epi-Pen, begin transport and contact medical
  control for authorization to administer 0.3 mg
  via auto injector

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Note

• If unable to make contact with on-line medical
  control and the patient is under 35 years old,
  you may administer 0.3 mg epinephrine via an
  auto-injector if indicated.
• The incident should be reported to medical
  control or your medical director as soon as
  possible

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Protocol cont.

• Contact medical control for authorization to
  administer a second dose if needed
• Refer to other protocols as needed (resp
  distress/failure, obstructed airway, shock)
• If patient arrests treat as per the non-traumatic
  cardiac arrest protocol

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Pediatric differences

• The age for pediatrics in this protocol is
  patients under 9 years old or weighing less than
  30 kg (66 lbs)
• The dose of epinephrine is 0.15 mg
• It can not be given without medical control
  authorization

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Pharmacology - Epinephrine

• Medication name
• Generic Epinephrine
• Trade Adrenalin

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Pharmacology Epinephrine cont

• Properties
• Bronchodilation
• Vasoconstriction

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Indications

• Must meet the following three criteria
• Patient must exhibit findings of severe allergic
  reaction (anaphylaxis)
• Medication is prescribed for this patient by
  their physician, direction by medical control, or
  inability to contact medical control and
  epinephrine is indicated
• Administration of medication is authorized by
  REMAC or a physician

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Contraindications

• None when used to treat anaphylaxis

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Medication form

• Liquid contained in an auto injector needle and
  syringe system

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Dosage

• Adult- one adult auto injector (0.3 mg)
• Infant and Child- one auto injector
  (infant/child) 0.15 mg

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Administration

• Obtain order from medical control either on line
  or as per protocol
• Obtain patients prescribed unit if available
• Ensure prescription is written for patient
• Ensure medication is not discolored
• Remove safety cap from device

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Administration cont.

• Place tip of device against the patients thigh
• Use lateral portion of thigh midway between the
  waist and knee
• Push firmly until the injector activates
• Keep in contact for 10-15 seconds
• Record activity and time
• Dispose of injector in appropriate container
• Can be administered through patients clothes

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Actions

• Dilates the bronchioles
• Constricts blood vessels

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Side effects

• Increased heart rate
• Pallor
• Dizziness
• Chest pain/ sudden death
• Headache
• Nausea/ vomiting
• Excitability, anxiousness

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Reassessment

• Continually assess ABCS for signs of worsening
  patient condition such as
• Mental status change
• Increased respiratory rate
• Decreasing B/P

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Reassessment

• Be prepared to initiate BCLS measures if
  indicated including CPR, AED, ALS intercept
• Treat for shock
• As the drug lasts in the system 10-20 minutes, be
  prepared for a potential return of the
  anaphylactic reaction

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Reassessment

• As many as 25 of those having an anaphylactic
  reaction will have a recurrence of life
  threatening symptoms within hours of the first
  attack

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Transportation Decision

• Any patient who received Epinephrine should be
  transported to an Emergency Room for evaluation
• On-Line Medical Control must be contacted for any
  patient refusing treatment or transportation
  after treatment with Epi.

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Special Consideration

• A BLS crew may encourage an authorized layperson
  to administer an Epi-Pen to a patient if all of
  the following conditions are met
• The BLS unit is not equipped with an Epi-Pen
• The Patient is having an anaphylactic reaction
  where Epi-Pen is indicated
• ALS assistance is not readily available
• An authorized layperson is present with an
  Epi-Pen and in the clinical judgment of the EMTs
  it is in the best interests of the patient to
  allow the authorized layperson to administer the
  Epi-Pen