1. Epinephrine Administration by the EMT Training Module 2013
WVOEMS Approved Education
MPCC addition of skill set and treatment options for EMT Protocol changes

2. Learning Objectives
With successful completion of this training module, the EMT will be able to describe and/or correctly demonstrate …
Epinephrine identification as a medication
Identify steps in aseptic technique
Preparation Epinephrine for administration
Administer Epinephrine via the IM route
Evaluate the mechanism of action and effects of Epinephrine

3. EMT Utilization of Epinephrine
6501-Allergic Reaction (Anaphylaxis)
6302-Respiratory Distress (Bronchospasm)
In both protocols Epi can be given by an EMT with Medical Command contact
Auto-injectors may be utilized in both protocols as well as IM Injection

4. Key Terms
Anaphylaxis - a life-threatening, hypersensitivity reaction of the immune system Aseptic technique - a procedure performed under sterile conditions Asphyxia - suffocation as a result of blockage of the airway Dyspnea - labored or difficult breathing Epinephrine - a hormone released from the adrenal glands that activates several tissues in the “fight-or-flight” response Histamine - one of several chemical messages released from immune cells that promote inflammation as a defense mechanism Intramuscular - a medication route by injection into the belly of a muscle which encourages rapid transport by the bloodstream Shock - a severe reduction in blood pressure (by any cause) that results in inadequate blood flow (oxygen & glucose) to tissues

5. What is Epinephrine…
A synthetic reproduction of the naturally occurring hormone Epinephrine
Released during “fight or flight” responses
reflex stimulation of the adrenal gland
sympathetic division of the autonomic nervous system

6. What is Epinephrine A catacholamine, sympathomimetic
Acts on cardiovascular system
Increases the strength of heart muscle contraction
Increases heart rate
Increases systolic blood pressure
Acts on respiratory system
Bronchodilation

7. Actions of Epinephrine
Relaxes smooth muscle in the airways
Counteracts histamine and other cytokines
Raises blood sugar level
Raises heart rate, blood pressure, and myocardial oxygen demand
For Intramuscular injection of Epinephrine…
Onset of effect: 3-5 min
Duration of effect: 1-4 hours

8. Epinephrine Precautions
DO NOT give epinephrine to these patients:
ONLY hives, flushing or itching
Ongoing chest pain
Use caution (contact Medical Command) when giving epinephrine to patients with a history of heart attack, angina, or stroke

9. Epinephrine Considerations
Give epinephrine with a clear history of insect bite or sting, or history of other allergy
MUST have at least one of the below signs and symptoms of severe allergic reaction
Respiratory Tract
Wheezing, Stridor, Shortness of Breath
Skin
Facial swelling involving lips, tongue, mouth (airway involvement)
Cardiovascular
Dizziness, HR>120, BP <90, AMS

10. Epinephrine Onset IM/SC, 5-15 minutes Danger:
IV onset immediate, however at the 1:1000 concentration can cause arrhythmia and death
This is the reason for drawing back on syringe prior to injection to ensure you are not in a vessel

11. Side Effects of Epinephrine
Palpitations
Tachycardia & arrhythmias
Hypertension
Headache
Tremor, weakness
Pallor, sweating
Nausea & vomiting
Nervousness & anxiety
Pain, redness at the injection site

12. Medication Packaging Name of medication
Concentration (1:1,000 or 1mg/1ml)
Expiration date

13. Indications for Use EMTs may administer Epinephrine for:
Allergic Reaction/Anaphylaxis
Respiratory Distress/Bronchospasm

14. Dosage Epi Pen Auto Injector IM Injection Drawn Up Dosage:
Adults mg of 1:1,000
Pediatrics mg of 1:2,000
Dosage:
Adults mg of 1:1,000
Pediatrics mg of 1:1,000
Is 0.3 mg of Epi ever too much?
Can you really overdose a child?

15. Special Considerations
SPECIAL CONSIDERATIONS Assessment 1. Known or suspected exposure to allergen. Sting? If unclear contact base. 2. History of allergic reactions 3. Medication use prior to arrival. AnaGuard/Epi-pen, Benadryl? 4. PMH: heart disease, stroke, hypertension? 5. Medications: Beta-blockers (atenolol, propranolol)? May block effects of epinephrine 6. Vital signs including mental status 7. Respiratory status: Airway swelling? Wheezes? Stridor? Medication Issues Use epinephrine with caution in the following patients (contact base when possible but do not withhold if patient in severe distress and base contact cannot be made easily): Over 70 years of age History of heart disease, stroke or hypertension. Taking a beta-blocker (example: atenolol, propranolol) Transport Priorities: Any patient with signs or symptoms of a severe reaction requires immediate evacuation. Consider helicopter and/or rendezvous with higher level of care unless symptoms responding well to therapy.

16. Anaphylaxis is an over-reaction of the Immune System
Sudden, severe allergic reaction involving the whole body (systemic)
multisystem involvement, including the skin, airway, vascular system, and GI
Most common allergens: insect sting, food, medication, latex
Widespread immune system response causes itching, hives & swelling
May also cause circulatory shock; tracheal and bronchial swelling resulting in asphyxia

18. Allergic Reactions Range from mild to life threatening
Early symptoms may be vague
Classic skin signs are urticaria, (hives)
Red, itchy raised welts anywhere on the body
Swelling of face, lips, eyes
Symptoms can occur seconds after exposure or up to 30 minutes

19. Mild Reactions Itching Hives Redness
Treatment is close observation and watching for progression of symptoms

20. Severe Reactions
Respiratory Tract
Skin
Cardiovascular

21. Respiratory Tract Signs and Symptoms
Wheezing
Upper airway noisy breathing (stridor)
Chest and throat tightness
Shortness of Breath
Nasal congestion*
*alone does not indicate a severe reaction

22. Skin – Signs and Symptoms
Facial Swelling
Involving lips, tongue, mouth (airway involvement)
Redness*
Hives*
Itching*
*alone does not indicate a severe reaction

23. Cardiovascular Signs and Symptoms
Decreased Blood Pressure (<90)
Increased Heart Rate (>120)
Severe Dizziness
Fainting
Decreased Mental Status
confusion, lethargy, coma

24. EMT Treatment Ensure an open airway Administer oxygen
History and Physical
Vital signs
Epinephrine

25. Intramuscular Drug Administration

26. Intramuscular Drug Administration
THE SIX “RIGHTS”
Right person
Right drug
Right dose
Right time
Right route
Right documentation

27. Intramuscular Drug Administration
Intramuscular sites allow a drug to be injected into the belly of a muscle so that the blood vessels supplying that muscle distribute the medication to its site of action via the bloodstream.
First steps:
Prep the site with approved antiseptic by scrubbing vigorously and allowing to dry. DO NOT TOUCH, BLOW ON OR FAN THE INJECTION SITE!
Align the syringe and needle above the injection site at a 90 degree angle, with the bevel of the needle facing up.
NOTE: IM Injections CANNOT be administered through clothing as the auto-injectors could.

28. Intramuscular Drug Administration
90º

29. Administration Sites

30. Deltoid Dorsogluteal Ventrogluteal Vastus lateralis

31. Needle Handling Minimize the tasks performed in a moving ambulance.
Immediately dispose of used sharps in a sharps container.
NEVER recap needles.

32. Ampules and Vials
Store epinephrine AWAY from light; leave it in its carton until ready to use. Also keep away from extreme heat and danger of freezing.
Vials
Ampules

33. Document all information concerning the patient and medication, including:
Indication for drug administration
include appearance, work of breathing, vitals, lung sounds, skin signs, and ability to speak
Drug, dosage, and delivery site
Patient response to the medication
include appearance, work of breathing, vitals, lung sounds, skin signs, and changes in ability to speak
both positive and negative responses

34. Obtaining Medication from a Glass Ampule

35. Common Packaging of Epinephrine
Medication name
Dosage (1:1,000 or 1mg/1ml)
Expiration date
Not cloudy; no color or precipitate

36. Hold the ampule upright and tap its top to dislodge any trapped solution.

37. Place Gauze around the neck

38. Snap off the Top

39. Draw up the Medication
Using a 1cc syringe, insert the needle into the ampule and draw the plunger back on the syringe until you reach the correct dosage (0.30cc).

40. Consideration
WVOEMS does not require the use of a filtered needle when drawing from an ampule.
Individual squads may have policies in place that require the use of a filtered needle. Please refer to your squad training officer.

41. Obtaining Medication from a Vial

42. Epinephrine in a Vial Medication name Dosage (1:1,000 or 1mg/1ml)
Expiration date
Not cloudy; no color or precipitate

43. Prepare the syringe and hypodermic needle

44. Clean the vial’s rubber top

45. Insert the hypodermic needle into the rubber top and inject the air from the syringe into the vial.

46. Withdraw the appropriate volume of medication
Using a 1cc (ml) syringe, insert the needle into the vial or ampule, draw the plunger back on the syringe until you reach 0.3cc (ml) mark on the syringe.

47. Administration Prepare the site – Insert needle at a 90 degree angle
Vigorously rub an alcohol prep in a circular motion
Allow to air dry
Use your fingers to stretch skin and make it taut
Insert needle at a 90 degree angle
Draw back slightly to insure you have not cannulated a vessel.
Push slow and steady until medication is administered
Remove needle and cover puncture site
Dispose of needle properly

48. Assessment of Medication Response
Document patient’s response to treatment:
LOC, behavior, breathing effort, lung sounds, skin signs, vital signs, and changes in ability to speak
Document adverse effects, if any

49. The body’s stress response causes the normal release of epinephrine to maintain homeostasis during vigorous activity: “fight or flight”. These same actions of epinephrine counteract e.g. the bronchoconstriction and low blood pressure of anaphylaxis when administered by medical personnel.
Airway dilation
Blood flow to skeletal muscles increases
Pupils dilate
Blood sugar level increases
Heart rate increases
Blood pressure increases
Breathing rate increases
EPINEPHRINE

50. Document Vital Signs before and after treatment with Epinephrine
Because epinephrine is expected to cause widespread changes in function, it is important to frequently monitor and document vital signs:
HR, RR, BP
include general appearance, work of breathing, lung sounds, skin signs, and ability to speak

51. Always Wear PPE
Wear gloves and goggles when assessing the patient, preparing the medication, cleaning the site of injection, and administering the drug.

52. Vastus lateralis (lateral thigh) is the approved site for administration

53. Vastus lateralis (lateral thigh) is the approved site for administration
Good site for all ages
Far from major blood vessels & nerves
Medical Command may authorize other sites

54. If no significant improvement within 10 minutes, consider second dose
If patient is wheezing consider, Albuterol nebulizer 2.5 mg with oxygen 8-10 LPM per order of MCP
Second dose of Epinephrine requires consultation and order of MCP. It is indicated if patient remains in moderate distress

55. Equipment Size Syringe Needle Size - Adult Needle Size - Pediatric
The EMT should chose a 1 cc (ml) syringe
DO NOT select a 1cc (ml) insulin syringe with a subcutaneous injection needle attached
Needle Size - Adult
Hypodermic needle 21 to 23 gauge
1 to 1.5 inches long
Obese patients may require a 2 inch long needle
Needle Size - Pediatric
Hypodermic needle 25 to 27 gauge
1 inch long

56. EMT Epinephrine Administration
Scope: EMT Indications: Anaphylaxis (allergic reaction with respiratory distress); Bronchospasm Equipment: Epinephrine kit containing:1, 1 ml ampule of epinephrine 1:1000, 1 tuberculin syringe with needle, alcohol prep Procedure: 1. Refer to Allergic Reactions and Respiratory Distress Protocols for detailed assessment. 2. Ask patient if they have any drug allergies. 3. Confirm medication, concentration, dose and clarity of liquid in vial 4. Tap ampule to get medicine down from top, break top off ampule with gauze 2x2, place top in sharps container. 5. Draw up 0.3cc (ml) of epinephrine 1mg/ml 1:1000, syringe approximately 1/3 full. 6. Pointing syringe up, expel all air. 7. Inform patient they are going to receive an injection, side effects may include feeling shaky or heart racing. 8. Select and cleanse area for Intramuscular injection, primary is the thigh unless directed otherwise by medical command. 9. Keeping the skin taut, insert needle at 90 degrees into administration site and draw back checking for blood return. If there is blood return, select a different site, and insert needle, again check for blood return. 10. If no blood, administer 0.3 cc (ml) of epinephrine (1/3 of syringe) for any patient. 11. Discard needle properly in sharps container. 12. Observe patient for improvement or deterioration of condition. Repeat exam and vitals after each dose. 13. Document procedure, vitals and response to treatment. 14. If an additional dose is required consult Allergic Reactions and Respiratory Distress Protocols. 15. If indicated by protocol, begin again from step 5.

57. Potential Pitfalls Dose Error Drug Error
Drawing up epinephrine can potentially result in over or under dosing
Concentration error – (1:10,000) vs (1:1000) since both drugs are available
Administration error – epinephrine given IV instead of IM/SQ
Drug Error
Giving the correct dose of the wrong drug
Who stocks the EMT drugs?
Potential to stock the wrong drug

58. Questions ?