Epinephrine auto injectors Anaphylactic Reaction Protocol Changes Aaron

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

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

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

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

Patient Assessment

Skin n n n 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

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

Cardiovascular system n n Tachycardia Vasodilation Hypotension Poor cardiac output!

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

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

Past Treatment Cont. n n n n 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 Protocol patients over age 9 or weighing over 30 kilos n n 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 n n 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 n n n 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 n n If unable to make contact with online 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. n n n 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 nontraumatic cardiac arrest protocol

Pediatric differences n n n 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 w. Medication name: ØGeneric ØTrade – Epinephrine – Adrenalin

Pharmacology – Epinephrine cont Properties n n n Bronchodilation Vasoconstriction

Indications n Must meet the following three criteria Ø Ø Ø 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 n None when used to treat anaphylaxis

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

Dosage n n Adult- one adult auto injector (0. 3 mg) Infant and Child- one auto injector (infant/child) 0. 15 mg

Administration n n 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. n n n 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 n Keep in contact for 10 -15 seconds Record activity and time Dispose of injector in appropriate container Can be administered through patients clothes

Actions n n Dilates the bronchioles Constricts blood vessels

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

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

Reassessment n n n 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 n 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 n A BLS crew may encourage an authorized layperson to administer an Epi-Pen to a patient if all of the following conditions are met: n n 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