1. Epinephrine Auto-Injector Training Program
WALL FIRST AID AND RESCUE SQUAD

2. Authored and Editied by…
Ian Malik, NREMT-B, Captain, Hopewell Valley Emergency Services
Jennifer Morris, EMT-B, Mount Laurel EMS
Robin Plumer, DO; Medical Director, Mount Laurel EMS
Stephen Vetrano, DO, EMT-B; Chair, BLS Subcommittee, MICU Advisory Council

3. Disclaimer
This presentation was created to assist in the education of EMTs in epinephrine auto injector administration. This presentation is available for public use and copying/distribution is encouraged.
It is the intent that this program may serve as the lecture based portion of a BLS medical director’s epinephrine auto injector program. A practical program is also encouraged.
The creators and staff of OEMS recognize that an individual medical director may modify any or all of this presentation to serve his/her organization’s needs.
The OEMS policy may not be changed under any circumstances

4. Objectives Identify the common causes of an allergic reaction.
Review the pathophysiology of an allergic reaction.
Identify signs and symptoms of severe allergic reactions (anaphylaxis).
Review differential diagnosis of anaphylaxis.
Review pharmacology of epinephrine.
Identify protocols for administration of epinephrine auto-injector.
Identify proper storage, handling, and disposal techniques for the epinephrine auto-injector.
Review documentation and regulatory requirements.

5. What this program is… A review of pathophysiology you already know
A review of a skill you already know

6. New State Policy

7. New State Policy December 13, 2006
Epinephrine auto injectors can be stocked on approved emergency service vehicles (not required)
MUST be an EMT-B to administer
Squad Must Register with OEMS
Must have a physician medical director

9. MEDICAL PRACTICE ACT
State legislation that defines scope and role of EMS personnel
Local modifications authorized by medical oversight physician or board
Usually based on Department of Transportation (DOT) National Standard Curricula for each EMT level 2

10. No change in indications – allergic reaction & anaphylaxis
New State Policy
No change in indications –
allergic reaction & anaphylaxis
ONLY!

11. MEDICAL DIRECTION LIABILITY
Respondent superior- an individual supervising a borrowed servant is ultimately liable for the acts and omissions of the borrowed servant while that individual remains under his supervision 4

12. MEDICAL DIRECTION LIABILITY
Borrowed servant- a servant directed or permitted by his master to perform services for another may become the servant of such other in performing the service (i.e. delegated practice) 5

13. MEDICAL DIRECTION LIABILITY
Borrowed servant- a servant directed or permitted by his master to perform services for another may become the servant of such other in performing the service (i.e. delegated practice) 5

14. NJ Regulation Epinephrine Auto Injector Interim Policy
Found at policy.pdf
May be made more stringent by the Medical Director
Applicable to EMT’s
Medics and MICN’s/RN’s have the knowledge base
Should be familiar with the policy

15. Allergic Reaction
Allergic reaction – hypersensitivity to a given antigen. A reaction more pronounced than would occur in the general population.
Acquired hypersensitivity, an individual must first be exposed or sensitized to the antigen; the body forms antibodies to fight the allergen. Subsequent exposure to the antigen results in an allergic reaction.
Allergen – an antigen that results in the release of IgE, resulting in a hypersensitive reaction.
Anaphylaxis – an acute, generalized, and violent antigen-antibody reaction that can be rapidly fatal.

16. Causes of Allergic Reactions
Insects (bees, wasps)
Foods (nuts, eggs, shrimp)
Plants (poison ivy, oak, summac)
Medications (antibiotics, NSAIDS)
Other allergens (dust, chemicals, foreign proteins, hormones, preservatives, X-ray contrast)

17. Pathophysiology
Sensitization – initial exposure to an antigen (allergen). Usually asymptomatic or very mild reaction, immune system forms antibodies to recognize this antigen.
Delayed Hypersensitivity – cellular immunity that does not involve antibodies. Different from anaphylaxis. Usually occurs in hours and days post exposure and commonly manifests as a skin rash. The rash associated with poison ivy exposure is an example of delayed hypersensitivity.
Immediate Hypersensitivity – is commonly referred to by the public as an allergy.

18. Pathophysiology (cont)
When an individual who has been previously sensitized to an allergen comes in contact with that allergen the immune system responds by releasing the antibody immunoglobulin E (IgE). IgE attaches to basophiles and mast cells, when the allergen binds to IgE attached to basophiles and mast cells histamine and heparin are released (degranulation).

19. Sensitization Stage  Antigen (allergen) exposure  Plasma cells
produce IgE antibodies
against the allergen
Plasma cell
IgE
Mast cell with
fixed IgE antibodies
 IgE antibodies
attach to mast cells
and basophils
Granules containing histamine

20. Anaphylactic Reaction
 More of
same allergen
invades body
Antigen • • • • • • • • • • • • • •
 Allergen combines
with IgE attached to
mast cells and basophils,
which triggers
degranulation and release
of histamine and other
chemical mediators • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Mast cell granules release contents after antigen binds with IgE antibodies • • • • • • • • • • • • • • . • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Histamine and other mediators •

21. Pathophysiology (cont)
Histamine is the principal chemical mediator of an allergic reaction. Histamine acts on H1 and H2 receptors resulting in;
Bronchiochonstriction;
Increased intestinal mobility;
Vasodilatation;
Increased vascular permeability;
Increased secretion of gastric acids.
The action of histamine is the bodies attempt to minimize exposure to the antigen.

22. Anaphylaxis
Massive amounts of histamine and other substances are released resulting in peripheral vasodilatation as well as increased vascular permeability. Massive amounts of plasma may leak out of capillaries resulting in hypotension.
Release of slow-reacting substance of anaphylaxis (SRA) causes spasm of the smooth muscle surrounding the bronchioles resulting in an asthma like attack.

23. Clinical Presentation of Allergies and Anaphylaxis
Skin
Flushed
Itching (pruritus)
Hives (urticaria)
Swelling
Cyanosis
Respiratory System
Respiratory difficulty
Asthmatics, particularly poorly controlled, have increased risk of fatality
Sneezing, coughing
Wheezing, stridor
Laryngeal edema
Laryneospasm
Bronchospasm

24. Clinical Presentation of Allergies and Anaphylaxis
Cardiovascular System
Vasodilatation
Increased heart rate
Decreased blood pressure
Gastrointestinal System
Nausea and vomiting
Abdominal cramping
Diarrhea
Nervous System
Dizziness
Headache
Convulsions
Tearing

25. Clinical Spectrum of Allergic Reaction
Mild
Nasal Congestion
Hives
Itching
Watery & Itchy Eyes
Severe
Cardiovascular Collapse
Respiratory Failure
arrows
Some define anaphylaxis as involvement
Of at least TWO organ systems!!!

26. Common Allergens Insect Bite Reactions
Large local reactions, without SYSTEMIC hives
or other involvement of another body system
other than skin, do not raise the risk of
anaphylaxis on next exposure
Does NOT require
treatment with
Epi-Pen

27. Large Allergen Exposure
Common Allergens
Large Allergen Exposure
People who may not have pre-existing allergy,
but get an overwhelming amount of exposure
May develop anaphylaxis

28. Kissing & Peanut Allergies
Common Allergens
Kissing & Peanut Allergies
A 15 year old girl with a severe peanut allergy died
after she kissed her boyfriend, who had eaten
peanut butter
Recommended to wait up to 5 hours after eating
peanuts to be peanut-free

29. Deaths from anaphylaxis in the US
Common Allergens
Deaths from anaphylaxis in the US
Radiographic Meds -
Meds -
Food Items -
Insect Stings -
Latex -
900/yr
/yr
/yr
40-100/yr
3/yr

30. Clinical Manifestations of Anaphylaxis
Signs/symptoms Incidence (%)
Urticaria and angioedema
Upper airway edema*
Dyspnea and wheezing
Flush*
Dizziness, syncope, and hypotension
Gastrointestinal symptoms
Rhinitis*
Headache*
Substernal pain*
Itch without rash*
Seizure*
*Symptom or sign not reported in all four series 88 56 47 46 33 30 16 15 6
4.5
1.5

31. Signs and Symptoms

32. Common Presentation of Anaphylaxis
Onset of 30 to 60 seconds following exposure, may be delayed over an hour.
Sense of impending doom;
Flushed skin;
Pruritus (generalized itching);
Increase heart rate;
Often urticaria (hives).

33. The more rapidly a reaction develops, the more potentially
Signs and Symptoms
Remember –
The more rapidly a reaction
develops, the more potentially
severe it can be!!!
Discuss progressive

34. Another way of looking at it…
1. Acute onset of an illness with involvement of skin/mucus membranes AND EITHER
Dyspnea
Hypotension
Notice no mention of allergen!

35. Another way of looking at it…
OR 2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient
Mucus Membrane/skin involvement
Dyspnea
Hypotension
Persistant GI symptoms

36. Another way of looking at it…
OR 3. Hypotension after exposure to known allergen

37. Putting it simply…. Anaphylaxis is either….
Allergy involving 2 or more systems
Hypotension following exposure to a known allergen

38. Signs and Symptoms Hives
Can be a single symptom of an allergic reaction
or the beginning of a cascade.
Use of epinephrine for hives alone is NOT
warranted.
Ice packs can be used to relieve itching.

39. Differential Diagnosis
History of exposure to an antigen that is an identifiable trigger, in the presence of signs and symptoms of anaphylaxis is a reliable indicator of an anaphylactic reaction.
However, signs and symptoms of allergy/anaphylaxis may present without the history!

40. Differential Diagnosis
In the absence history of exposure, the following should be considered in the differential diagnosis:
respiratory difficulty, wheezing, stridor
circulatory collapse, including vasovagal reactions
asthma
foreign body obstruction
pulmonary embolism
epiglottitis
myocardial infarction
hypoglycemia
seizures
overdose of medication
cold urticaria
sulfite or monosodium glutamate ingestion
Niacin ingestion

41. Foreign Body Obstruction
Conditions that Mimic
Asthma
Similar s/s: wheezing
Foreign Body Obstruction
Similar s/s: SOB, altered mental status
Respiratory Distress
- Similar s/s: SOB, altered mental status
All single organ systems!!!

42. Conditions that Mimic Acute M.I. CHF
Similar s/s: chest tightness, SOB, shock
CHF
Similar s/s: SOB, altered mental status, shock

43. Pharmacology Epinephrine Auto-Injector Medication Name
Liquid Medication administered by an automatically injectable needle and syringe system.
Medication Name
Generic: Epinephrine
Trade: Adrenalin ™
EpiPen® or EpiPen Jr. ®

44. Pharmacology
Epi-pen exposed!

45. Pharmacology Twinject A two dose system Anakit 2nd dose SQ inject
Not for EMT use
Anakit
Old kit
No longer made in US
Being d/c’d in Canada
Also beyond scope

46. Pharmacology Indications Contraindications Action Side Effects
Signs and symptoms of severe allergic reaction.
Contraindications
None in a life threatening scenario-caution in pts with CAD
Action
Bronchodilation – Dilation of airways.
Vasoconstriction – constriction of blood vessels.
Side Effects
Increase in heart rate
Pallor
Dizziness
Chest Pain
Headache
Nausea
Vomiting
Anxiety, Excitement

47. Administration Protocol
Perform scene size-up and initial patient assessment. Do not delay transport;
Administer 100% oxygen using a non-rebreather mask at a flow rate of lpm, unless the patient is unable to tolerate the mask, in which case use a nasal cannula at a flow rate of 1-6 lpm;
Request advanced life support services;
Obtain baseline vital signs and obtain the SAMPLE history. "SAMPLE history" means the present and past medical history of a patient, so called because the elements of the history begin with the letters of the word sample: Signs/Symptoms, Allergies, Medications, Pertinent past history, Last oral intake, and Events leading to the injury or illness;
Conduct the focused assessment and physical exam.

48. Apply high-concentration oxygen.

49. Assessing Allergic Reactions
Request ALS

50. Take baseline vital signs.

51. Obtain SAMPLE history.

52. Assessing Allergic Reactions
Any history of allergies?
What was patient exposed to?
How was the patient exposed?
What signs and symptoms does the patient have?

53. Assessing Allergic Reactions
Any progression of the signs and symptoms?
Have any interventions been performed on the patient?

54. Administration Protocol
Initiate treatment with the appropriate epinephrine auto injector if a patient prsents with clinical evidence of allergic reaction/anaphylaxis that may include the following symptoms:
A chief complaint of respiratory distress.
Respiratory arrest;
Signs and symptoms of shock (hypoperfusion) with an increased heart rate. Look for the following indications:
Heart rate of greater than 180 bpm for an infant (0-12 months) and/or blood pressure less than 60 mmHg for an infant (0-12 months);
Heart rate of greater than 140 bpm for a child (1-12 years) and/or blood pressure less than 70 mmHg for a child (1-12 years);
Heart rate of greater than 120 bpm for an adult (older than 12 years) and/or blood pressure less than 80 mmHg for an adult (older than 12 years);

55. Administration Protocol
A tightening feeling in the chest and/or throat;
Wheezing or stridor;
Altered appearance with restlessness and/or agitation, seizure, unconsciousness;
Swelling of the face/tongue/lips or generalized urticaria;

56. Administration Protocol
If the patient possesses his/her own prescribed Epinephrine auto injector, use theirs if readily available.
If the patient does not possess his/her own prescribed Epinephrine auto injector, use the appropriate Epinephrine auto injector from your vehicle's stock.
For patients under 4 years of age, use the pediatric epinephrine auto injector (0.15 mg).
For patients 4 years of age or older, use the adult epinephrine auto injector (0.3 mg).

57. Estimating Patient Age & Weight
Pedi-Wheel
Broselow Tape
A tool for determining the correct dosage of medications and equipment sizes for children, based on their length.

58. Broselow Tape

59. Broselow Tape

60. Broselow Tape

61. Broselow Tape

62. Broselow Tape

63. Administration Protocol
Administer the appropriate Epinephrine auto injector as follows:
Check the color of the medication (if able to view) and the manufacturer's expiration date. If the medication is discolored (yellowed) or beyond the expiration date, do not use;
Carefully remove the safety cap from the auto injector;

64. Remove safety cap.

65. Administration Protocol
Place the auto injector firmly against the lateral portion of the patient's thigh, midway between the waist and the knee. Firm pressure will activate the spring loaded mechanism in the auto injector and force the needle through the patient's clothing and into the thigh muscles;

66. Administration Protocol
Hold the auto injector in place for at least 10 seconds to ensure that the medication is injected;
Dispose of the auto injector in a biohazard sharps container or the product container on a temporary basis;
Record the location of the injection site, time, dose, medication name, vital signs and any changes in the patient's condition after administration of medication on a patient care report.

67. Hold firmly in place for ten seconds, then remove
Hold firmly in place for ten seconds, then remove. Massage the area of injection
AI 17©

68. Administration Protocol
Continuously monitor the patient (level of consciousness, level of distress, respiratory rate and quality, pulse rate and quality, blood pressure, temperature, etc.).
Maintain normal body temperature.
Notify the receiving hospital if ALS is not available.

69. If patient’s condition
Treating Allergic Reactions
If patient’s condition
IMPROVES:
Continue oxygen
Treat for shock (preventative)

70. If patient’s condition
Treating Allergic Reactions
If patient’s condition
WORSENS:
Treat for shock
Be prepared to use CPR/AED.

71. Treating Allergic Reactions
No Second Stick!!!
Per NJ OEMS Policy

72. And there is no change in symptoms … (before giving EMS dose)
Treating Allergic Reactions
Exception –
If patient gives Epi-Pen to themselves prior to squad arrival, or you assist with their epi pen…
And there is no change in symptoms …
Wait 10 MINTUES!
(before giving EMS dose)

73. Administration Protocol
Carefully monitor patient for respiratory and/or circulatory failure. If condition deteriorates, patient may experience cardiac arrest.
Respiratory failure
Provide ventilation at a rate of
Adult 10 to 12 breaths per min.
Child/Infant 12 t0 20 breaths per min.
Cardiac Arrest
If witnessed immediate AED if available
If unwitnessed or asphyxial 2 min. CPR then AED
Compression Ratio
30:2 Adults and 1 rescuer child/infant
15:2 two rescuer child/infant

74. Treating Allergic Reactions
The patient’s condition may be stable initially but deteriorate to the point where he/she needs aggressive airway management.
Call ALS/Do not delay tranport!
Best you can do: oral/nasal airways

75. Administration Protocol
Leave a copy of the patient care report at the receiving hospital.
Deliver a copy of the patient care report to the physician medical director. The medical director shall review all instances of the use of epinephrine auto injectors for quality assurance.
Provide agency specific notifications to ensure appropriate reporting to OEMS.
72 hours verbal, 45 days written
Have ED diagnosis and disposition when possible

76. Recurrent Anaphylaxis
Treating Allergic Reactions
Recurrent Anaphylaxis
Reappearance of allergic symptoms following complete resolution of original reaction, and WITHOUT re-exposure to the offending allergen
May involve mild or severe symptoms, may be = in severity or more severe than initial reaction

77. Recurrent Anaphylaxis cont.
Treating Allergic Reactions
Recurrent Anaphylaxis cont.
Can occur in up to 20% of cases, up to 72 hours after initial event.
Large antigen load
Repeat internal exposure (i.e. insect venom)
Listen to patient history – seen three days ago,……..

78. Accidental Auto-Injection of Epi-Pen
Treating Allergic Reactions
Accidental Auto-Injection of Epi-Pen
Most often occurs to a finger
Potentially can cause local tissue death
Often can be treated with application
of heat, local massage,
topical nitrates.
Requires IMMEDIATE ED visit!

79. Storage Must be kept btwn 59-74 degrees F Thermos Bottle to insulate
Medical grade IV fluid warmers or incubators
Commercial 12-volt heater/cooler containers
Don’t mix food and stored meds!