1. Epinephrine auto injectors
Anaphylactic Reaction
Protocol Changes
Aaron J. Katz, AEMT-P, CIC

2. 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

3. 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”

4. 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

5. 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?

6. 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

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

8. 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

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

10. Patient Assessment

11. 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

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

13. Cardiovascular system
Tachycardia
Vasodilation
Hypotension
 Poor cardiac output!

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

15. 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)

16. 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

17. 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

18. New Treatment Protocol patients 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

19. 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:

20. 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

21. 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

22. 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

23. 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

24. Pharmacology - Epinephrine
Medication name:
Generic – Epinephrine
Trade – Adrenalin

25. Pharmacology – Epinephrine cont
Properties
Bronchodilation
Vasoconstriction

26. 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

27. Contraindications
None when used to treat anaphylaxis

28. Medication form
Liquid contained in an auto injector needle and syringe system

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

30. 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

31. 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 seconds
Record activity and time
Dispose of injector in appropriate container
Can be administered through patients clothes

32. Actions
Dilates the bronchioles
Constricts blood vessels

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

34. Reassessment
Continually assess ABC’S for signs of worsening patient condition such as:
Mental status change
Increased respiratory rate
Decreasing B/P

35. Reassessment
Be prepared to initiate BCLS measures if indicated including: CPR, AED, ALS intercept
Treat for shock
As the drug lasts in the system minutes, be prepared for a potential return of the anaphylactic reaction

36. 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

37. 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.

38. 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