anaphylaxis and epinephrine

Anaphylaxis and Anaphylaxis and Epinephrine Epinephrine

The Role of the EMT-BasicN.H. Patient Care Protocols

N.H. Department of Safety Division of Fire Standards & Training

andEmergency Medical Services

• Overview of General Pharmacology• Review the signs & symptoms & types of allergic

reactions• Review of emergency care of a patient experiencing

an anaphylactic reaction• Develop a basic knowledge of epinephrine & it’s

administration • Identify situations when epinephrine may be

indicated• Understand NH Patient Care Protocol - Anaphylaxis

GoalsGoals

General PharmacologyGeneral Pharmacology• For every medication you may

administer, you must thoroughly understand the following:

•Actions•Indications•Contraindications

•Dosage•Route•Side effects

General PharmacologyGeneral Pharmacology

• Generic name– Original chemical name

• Trade name– Brand name given by manufacturer

General PharmacologyGeneral PharmacologyMedication Forms

• Solutions – Liquid mixture of one or more

substances• Other forms

– tablets, suspensions, vaporized, gels, etc.

General PharmacologyGeneral Pharmacology• Right Patient• Right Drug• Right Dose• Right Time• Right Route• Right Documentation

What Is Medical Control?What Is Medical Control?Off-Line / Standing Orders Online Medical Control

• contact with an emergency department physician at the receiving facility

NH Patient Care Protocols• “Minimum” menu - Saf-C 5900• “Maximum” menu - Medical Control

Board• Scope of Education v. Scope of

Practice

Allergic ReactionsAllergic Reactions• Very Common • Range from mild and local to

severe and systemic.

Common Causes of Allergic Common Causes of Allergic ReactionsReactions

Mild Allergic ReactionsMild Allergic Reactions– Mild reactions usually affect only one

area of the body– Slow onset, and minor symptoms

(i.e. localized redness, swelling, itching)

– NO respiratory or cardiac signs or symptoms

Mild Allergic ReactionsMild Allergic Reactions

A mild, local reaction

caused by a bee sting

Severe Allergic ReactionSevere Allergic Reaction• A Clear History of Allergen Exposure

AND Signs and Symptoms including:– Shock (hypoperfusion)– Respiratory distress– Wheezing, stridor, cough,

hoarseness– Chest / throat tightness

• Itching, skin flushing

• Urticaria (hives) (look at the torso!) and /or swelling (Especially the face and the extremities)

Severe Allergic ReactionSevere Allergic Reaction

Severe Allergic ReactionSevere Allergic Reaction• Increased Pulse• Decreased Blood Pressure• Nausea & Vomiting• Altered Mental Status• Sense of impending doomsure with

history of anaphylaxis

AnaphylaxisAnaphylaxis• An exaggerated immune

response to an allergen• Sudden, rapid onset• Systemic involvement • Severe allergic reaction

EpinephrineEpinephrine• Generic Name

– Epinephrine• Trade Name

– EpiPen– EpiPen Jr.– Adrenalin

EpinephrineEpinephrineActionsActions

• Dilates bronchioles• Constricts blood vessels• Increases heart rate• Increases cardiac output

EpinephrineEpinephrineIndicationsIndications

• Signs and symptoms of severe allergic reaction

• Compliance with the NH Patient Care Protocols

EpinephrineEpinephrineContraindicationsContraindications

None when dealing with anaphylaxis!

BUT MUST FOLLOW NH BUT MUST FOLLOW NH PATIENT CARE PATIENT CARE PROTOCOLS!PROTOCOLS!

EpinephrineEpinephrineDosageDosage

• Adult– 1 adult Epi-pen auto-injector (0.3 mg)

• Child– Child: greater than 10 kg and fit on a

pediatric length based resuscitation tape (Broselow tape).

– Epi-pen Jr. auto-injector (0.15 mg)

EpinephrineEpinephrineRouteRoute

– Deep Intramuscular Injection– Lateral thigh, midway between

waist and knee

EpinephrineEpinephrine Side EffectsSide Effects

– Increased pulse rate

– Pallor– Dizziness– Chest Pain– Headache

• Nausea• Vomiting• Excitability /

nervousness• Anxiety • Syncope

Epi auto-injector Epi auto-injector AdministrationAdministration

• Remove safety cap from auto-injector• Hold auto-injector from center

(Do Not place thumb over either end!)• Place against patient’s thigh

– Lateral portion, midway between waist and knee

Epi auto-injectorEpi auto-injector AdministrationAdministration

• Push until auto-injector activates

• Hold until medication injected (10 seconds).

• Record Time• Record Response to

Medication•Dispose of auto-injector in biohazard Dispose of auto-injector in biohazard

“sharps” container.“sharps” container.

Emergency Medical CareEmergency Medical Care

Allergic Reaction/Anaphylaxis

Patient Care ProtocolJanuary 2005

Patient AssessmentPatient Assessment•Routine Patient Care•Scene Size-up•Initial Assessment (watch

the airway!)

Focused HistoryFocused History• Determine SAMPLE Hx and Hx of

Present Illness (HPI) :– Hx of allergies– What was patient exposed to now & then?– How was patient exposed? Now? Past?– Past & Current Signs and Symptoms? – Time of onset?– Progression?– Treatments already performed?

Focused Focused Physical AssessmentPhysical Assessment

• Reassess ABCs• Breath Sounds• Baseline Vital

Signs• O2 Saturation

• Assess respiratory system

• Assess cardiovascular system

Assess for Signs & Symptoms of Anaphylaxis

ANAPHYLAXISANAPHYLAXIS• Summer of 2002, the NH Medical Control

Board (MCB) and Seacoast Food and Allergy Group worked on the development of a protocol to allow EMT-Basic to administer Epipens and Epipen Jr.s supplied on EMS Units.

• Adopted by MCB for 2003 Local Option Protocols

• Standing Orders adopted by MCB 2005

NH Patient Care AnaphylaxisNH Patient Care AnaphylaxisProtocolProtocol

• Call ALS• Administer oxygen• Assess respiratory status• Assess cardiac status• Vital signs

NH Patient Care AnaphylaxisNH Patient Care AnaphylaxisProtocol(cont.)Protocol(cont.)

• Caution needed when administering epinephrine to patients with history of CAD, HTN, etc.

• If patient has signs / symptoms of an allergic reaction (hives, itch, anxiety) but is otherwise hemodynamically stable, contact medical control for further direction.

NH Patient Care AnaphylaxisNH Patient Care AnaphylaxisProtocol(cont.)Protocol(cont.)

• If trained to do so, administer Epi-Pen 0.3 mg or Epi-Pen Jr 0.15 mg IM for patient with signs / symptoms of anaphylaxis.

• Do not delay transport, except for epinephrine administration.

• Consider ALS intercept

Ongoing assessmentOngoing assessment• Monitor A-B-Cs• Reassess vital signs• Oxygen!• Watch for changes in

patient condition

Ongoing AssessmentOngoing AssessmentIf the patient deteriorates...• Oxygenate• Contact Medical Control for order for

second dose• Prepare for resuscitation• Oxygenate• Treat for shock

Did we mention Oxygenate?

Ongoing AssessmentOngoing Assessment

– Contacted Medical Control to administer a second auto-injector.

– Be prepared to perform CPR if patient deteriorates.

CommunicationCommunication• What?

– Assessment Finding– Treatments– Result of Treatment

• Who?– Other EMS providers– Receiving Facility personnel

DocumentationDocumentation• What?

– Assessment Finding– Treatments – Result of Treatment

• Where?– PCR– Performance Improvement / Quality

Improvement

Goals Review!Goals Review!• Overview of General Pharmacology• Review the signs & symptoms & types of

allergic reactions• Review of emergency care of a patient

experiencing an anaphylactic reaction• Develop a basic knowledge of epinephrine &

it’s administration • Identify situations when epinephrine may be

indicated• Understand NH Patient Care Protocol -

Anaphylaxis

Questions?Questions?