Epinephrine auto injectors

Anaphylactic Reaction Protocol Changes

Aaron J. Katz, AEMT-P, CIC

Overview

Not just “Any allergic reaction”! Once you see it – you’ll never

forget it! Reactions tend to worsen with

each “exposure” You have a responsibility to

educate patients and families

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”

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 don’t know why allergies are increasing

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?

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

Goals

Early recognition of anaphylaxis Early BLS intervention Early ALS intervention Administration of Epinephrine

using the Epi-Pen Auto injector

Allergic reaction – immune response to any substance.

Reaction can be localized or severe and life threatening (anaphylaxis)

Allergen – substance that causes the immune response

Anaphylaxis

Common allergens

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

fragrances Latex

Patient Assessment

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

Skin

Respiratory system Tightness to throat and chest Cough Tachypnea Labored breathing Hoarseness Noisy breathing – stridor or

wheezing bronchoconstriction

Cardiovascular system

Tachycardia Vasodilation Hypotension Poor cardiac output!

Other systems

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

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)

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

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

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

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:

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

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

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

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

Pharmacology - Epinephrine

Medication name:

Generic – Epinephrine

Trade – Adrenalin

Pharmacology – Epinephrine cont

Properties Bronchodilation Vasoconstriction

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

Contraindications

None when used to treat anaphylaxis

Medication form

Liquid contained in an auto injector needle and syringe system

Dosage

Adult- one adult auto injector (0.3 mg)

Infant and Child- one auto injector (infant/child) 0.15 mg

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

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

Actions

Dilates the bronchioles Constricts blood vessels

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

Reassessment

Continually assess ABC’S for signs of worsening patient condition such as:

Mental status change Increased respiratory rate Decreasing B/P

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

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

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.

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