epinephrine auto injectors anaphylactic reaction protocol changes aaron j. katz, aemt-p, cic
TRANSCRIPT
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Epinephrine auto injectors
Anaphylactic Reaction Protocol Changes
Aaron J. Katz, AEMT-P, CIC
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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
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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”
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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
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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?
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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
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Goals
Early recognition of anaphylaxis Early BLS intervention Early ALS intervention Administration of Epinephrine
using the Epi-Pen Auto injector
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Allergic reaction – immune response to any substance.
Reaction can be localized or severe and life threatening (anaphylaxis)
Allergen – substance that causes the immune response
Anaphylaxis
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Common allergens
Insects – bees, wasps Food – nuts, fish, milk, chocolate Plants – poison ivy, oak Medications – antibiotics Other – outdoor allergens,
fragrances Latex
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Patient Assessment
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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
Skin
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Respiratory system Tightness to throat and chest Cough Tachypnea Labored breathing Hoarseness Noisy breathing – stridor or
wheezing bronchoconstriction
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Cardiovascular system
Tachycardia Vasodilation Hypotension Poor cardiac output!
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Other systems
Itchy, watery eyes Headache Sense of impending doom Runny nose, nasal congestion Decreased mental status Abdominal distress
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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)
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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
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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
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New Treatment Protocolpatients 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
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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:
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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
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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
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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
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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
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Pharmacology - Epinephrine
Medication name:
Generic – Epinephrine
Trade – Adrenalin
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Pharmacology – Epinephrine cont
Properties Bronchodilation Vasoconstriction
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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
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Contraindications
None when used to treat anaphylaxis
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Medication form
Liquid contained in an auto injector needle and syringe system
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Dosage
Adult- one adult auto injector (0.3 mg)
Infant and Child- one auto injector (infant/child) 0.15 mg
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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
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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 10-15 seconds Record activity and time Dispose of injector in appropriate container Can be administered through patients clothes
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Actions
Dilates the bronchioles Constricts blood vessels
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Side effects Increased heart rate Pallor Dizziness Chest pain/ sudden death Headache Nausea/ vomiting Excitability, anxiousness
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Reassessment
Continually assess ABC’S for signs of worsening patient condition such as:
Mental status change Increased respiratory rate Decreasing B/P
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Reassessment
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
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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
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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.
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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