1. Introduction to Emergency Medical Care 1
Advance Preparation
Research related multimedia links for illustration purposes.
Prepare epinephrine auto-injectors and auto-injector training devices for demonstration.
Invite assistant instructors and programmed patients to assist with psychomotor sessions.

2. How to identify a patient experiencing an allergic reaction
Differences between a mild allergic reaction and anaphylaxis
How to treat a patient experiencing an allergic reaction
Who should be assisted with an epinephrine auto-injector

3. Topics Allergic Reactions Self-Administered Epinephrine
Planning Your Time: Plan 70 minutes for this chapter.
Allergic Reactions (40 minutes)
Self-Administered Epinephrine (30 minutes)
Note: The total teaching time recommended is only a guideline.

4. Allergic Reactions Teaching Time: 40 minutes
Teaching Tips: Relate the pathophysiology of anaphylaxis to previous lessons on shock and respiratory problems. Discuss how the signs and symptoms may be similar. Multimedia graphics may be helpful in demonstrating patient assessment of an allergic reaction. Use examples of real-life allergic reaction and anaphylaxis to add realism to pathophysiology. Spend time discussing how to differentiate anaphylaxis. Epinephrine is not a benign drug, and EMTs should take care to give it only in the correct circumstances. Teach providers to be constantly alert for anaphylaxis. Rapid changes occur.

5. Allergic Reactions
Immune system naturally responds to foreign substances in body
Allergic reaction: exaggerated response to foreign substance
Allergen: substance causing exaggerated effect
Point to Emphasize: An allergic reaction is an exaggerated immune response to a foreign invader in the body.

6. Body’s Reaction to Allergen
First exposure
Immune system forms antibodies
Antibodies identify and attack particular foreign substance
Antibodies combine only with allergen they were formed in response to
continued

7. Body’s Reaction to Allergen
Second (and subsequent) exposures
Antibodies exist
Antibody combines with allergen, leading to release of histamine and other chemicals into bloodstream
Chemicals cause harmful effects
continued

8. Body’s Reaction to Allergen
Effects of histamine and other chemicals
Inflammation (swelling)
Bronchoconstriction
Vasodilation
Knowledge Application: Have students work in small groups. Assign each group a negative effect of an allergic reaction (for example: bronchoconstriction). Have each group describe how assessment would identify that effect (for example: bronchoconstriction = wheezes).

9. Anaphylaxis Severe, life-threatening allergic reaction Can cause:
Dilation of blood vessels (hypotension)
Airway swelling (airway obstruction)
Bronchoconstriction (respiratory failure)
Point to Emphasize: Anaphylaxis is a severe and systemic form of an allergic reaction and should be considered a life-threatening emergency.
Discussion Topic: Define allergy. How is an allergic reaction different from an anaphylactic reaction?

10. Common Allergens Insects Foods Plants Medications Others
Dust, makeup, soap, etc.
Point to Emphasize: Food, insect bites and stings, plants, and certain medications can cause allergic reactions.
Discussion Topic: Discuss the potential causes of an allergic reaction. Describe at least three common allergies.
Knowledge Application: Assign common causes of allergy. Ask students to research and report on prevalence, severity, and morbidity and mortality.
Critical Thinking: How might an ingested allergen cause a different reaction from that of an injected allergen? Why might these reactions present differently?

11. Latex Allergy Common concern in EMS
Many patients have latex sensitivity
Providers can develop latex allergy from prolonged exposure

12. Course of Reaction
No way to predict exact course of an allergic reaction
Severe reaction often takes place immediately, but can be delayed 30 minutes or more
Mild allergic reaction can rapidly progress to anaphylaxis
Talking Points: When you have a patient with an exposure to a known allergen but who is displaying only minor signs and symptoms, you must closely monitor the patient for signs that the condition is becoming more serious.

13. Signs and Symptoms: Skin
Swelling
Flushing (red skin)
Warm, tingling feeling in face, mouth, chest, feet, or hands
Talking Points: Swelling (edema) is most common in the face (especially the eyes and lips), neck, hands, feet, or tongue.

14. Signs and Symptoms: Hives
Talking Points: Hives, also known as urticaria, can be localized, especially around the area of a bite or sting, or generalized, presenting over wide areas of the body. Swelling (edema) is most common in the face (especially the eyes and lips), neck, hands, feet, or tongue.

15. Signs and Symptoms: Respiratory
Tightness in throat or chest
Cough
Rapid, labored, and/or noisy breathing
Hoarseness, muffled voice, loss of voice
Stridor
Wheezing

16. Signs and Symptoms: Cardiac
Increased heart rate
Decreased blood pressure

17. Signs and Symptoms: Generalized
Itchy, watery eyes and/or runny nose
Headache
Feeling of impending doom

18. Signs and Symptoms: Anaphylactic Shock
Altered mental status
Flushed, dry skin or pale, cool, clammy skin
Nausea or vomiting
Changes in vital signs
Increased pulse, respirations
Decreased blood pressure
Point to Emphasize: Anaphylaxis can be identified by the signs of an allergic reaction plus airway, breathing, or circulatory challenges.
Discussion Topic: Describe the common signs and symptoms of an allergic reaction and of anaphylaxis. What signs are specific to anaphylaxis?

19. Distinguishing Anaphylaxis from Mild Allergic Reaction
Any of previous signs and symptoms can be associated with an allergic reaction
Anaphylaxis: patient has either respiratory distress or signs and symptoms of shock
Point to Emphasize: Patient assessment will determine if the patient is having an anaphylactic reaction or just an allergic reaction. Beware, however, for allergy can rapidly progress to anaphylaxis.
Talking Points: Patients can and do present in many different ways. One patient in anaphylaxis may have severe difficulty breathing with no hives or decreased blood pressure, while another patient may have a rapid heartbeat and decreased blood pressure with no difficulty breathing.

20. Assessment Primary assessment
Identify and treat life-threatening problems
Airway
Breathing
Circulation
continued

21. Assessment History and physical exam History of allergies Exposure
What was the patient exposed to?
How (what method/route) was the patient exposed?
Signs and symptoms
Progression
Interventions
Talking Points: Suspect an allergic reaction whenever the patient has come in contact with a substance that has caused an allergic reaction in the past, and whenever the patient complains of itching, hives, or difficulty breathing or shows signs or symptoms of shock.
Class Activity: Describe scenarios involving various patients having allergic reactions and anaphylactic reactions. Have a class discussion about whether the signs and symptoms described in each case would be classified as an allergic reaction or an anaphylactic reaction.
Knowledge Application: Use a programmed patient and/or multimedia graphics. Demonstrate various types of allergic reactions and ask groups of students to use patient assessment to identify anaphylaxis.

22. Treatment Manage patient’s airway and breathing
Apply high-concentration oxygen
Provide artificial ventilations if patient is not breathing adequately
Consider assisting patient with epinephrine auto-injector
Talking Points: Remember that the airway of an anaphylactic patient can change rapidly. Mental status changes and increasing upper airway edema can rapidly threaten a previously patent airway.
continued

23. Treatment
If patient is not wheezing or showing signs of respiratory distress or shock
Continue with assessment
Consult medical direction regarding use of auto-injector
Talking Points: Some patients have histories of very rapid onset of severe symptoms, so the physician may ask you to give the medication even though the patient does not appear to need it.

24. Use of Auto-Injector When use of auto-injector may be appropriate
If patient has come in contact with substance that caused allergic reaction in the past
If patient also has respiratory distress or exhibits signs and symptoms of shock
Talking Points: Always follow local protocols. In some situations you may administer an auto-injector you carry on the ambulance while in other situations you may assist the patient with his or her prescribed auto-injector. Local protocols may require online medical control.
Discussion Topic: Discuss the indications for epinephrine.

25. After Administering Auto-Injector
Record administration of auto-injector
Transport patient
Reassess
Knowledge Application: Describe various patients with allergic reactions. Ask students whether they would administer epinephrine. Critique the decision and discuss.

26. Additional Doses of Epinephrine
Reassessment may show patient condition deteriorating
Additional doses of epinephrine may be necessary
Requires on-line medical control
Requires bringing patient’s additional auto-injectors in ambulance
Talking Points: Some patients are prescribed multiple auto-injectors. Reassessment may reveal the need for additional doses. (Most auto-injectors are designed for single use. Additional doses will generally require the use of additional auto-injectors.) Remember that additional epinephrine may require on-line medical control. Always follow local protocol.
continued

27. Additional Doses of Epinephrine
If no auto-injector available
Request ALS intercept
Treat for shock
Class Activity: Take a voluntary class poll. Find out what types of allergies are present in the class. How severe have prior reactions been? Ask willing students to discuss.

28. Think About It
Should you administer an auto-injector for a simple allergic reaction?
What assessment findings would indicate the need for epinephrine?
Talking Points: You should probably not administer epinephrine for a simple allergic reaction. Epinephrine is a potent drug with potential complications and should not be given without serious consideration. In this case medical control may be able to offer better insight. The findings that would indicate administration in a patient with an allergic reaction include respiratory distress and shock.

29. Epi Pen Auto injectors
Commonly prescribed to patients with a history of allergy
Auto-injectors are common for people to carry or have at home
Hormone produced by body
Constricts blood vessels
Dilates bronchioles
Point to Emphasize: Epinephrine is a natural hormone produced by the body. It is given in cases of anaphylaxis to constrict blood vessels and dilate the bronchioles.
Talking Points: Some systems allow EMTs to carry auto-injectors on the ambulance. Refer to your local protocols for more information. Constriction of blood vessels helps to raise the blood pressure and improve perfusion. Dilation of bronchioles helps to open the airway and improve respiration.
Discussion Topic: Describe the indications for the use of epinephrine.

30. Side Effects of Epinephrine
Increased heart rate
Increased cardiac workload
Point to Emphasize: Epinephrine is indicated in anaphylactic reactions but not in localized allergic reactions.
Talking Points: If the dose of epinephrine in the auto-injector is more than the patient needs, the patient’s heart will be working harder than it needs to. This can be dangerous in a patient with a heart condition or who is hypertensive. EMTs must carefully evaluate the need versus the potential side effects before administration. Always follow local protocol.
Discussion Topic: Describe the side effects of the use of epinephrine.
Class Activity: Present a variety of allergic reaction and anaphylaxis scenarios to the class. Ask students whether they would administer epinephrine. Discuss the decision-making process.
Critical Thinking: Patients who take beta-blocking medications can have a different response to epinephrine. Explain how this response might be different.

31. Auto-Injector
Spring-loaded needle and syringe with a single dose of epinephrine
Upon administration, medication automatically releases and injects
Point to Emphasize: An auto-injector is a spring-loaded needle and syringe with a single dose of epinephrine that will automatically release and inject the medication. People with severe allergies commonly carry these devices to deploy in the event of an anaphylactic reaction.
Knowledge Application: Review various types of epinephrine auto-injectors. Review the steps in administering each type.

32. Administering Auto-Injector
Injection site typically anterior-medial thigh (midway between waist and knee)
Remove clothing from site if possible
Use standard precautions
Remove cap
Point to Emphasize: Always consider the “five rights” of medication administration before administering an epinephrine auto-injector.
Talking Points: It is not absolutely necessary to remove clothing from the injection site, as an auto-injector can be administered through clothing in most cases. If it is possible and can be done quickly, consider baring the site prior to administration. Pressing the auto-injector against the patient’s thigh will engage the needle to inject into the soft tissue. It is common to feel the spring loaded needle deploy.
Knowledge Application: Use programmed patients and practice assisting with an epinephrine auto-injector. Pay particular attention to explaining the steps to the patient.
continued

33. Administering Auto-Injector
Press tip of auto-injector firmly against patient’s thigh
Once needle is deployed, allow full injection of medication before removing from injection site
Carefully discard auto-injector into sharps container
Point to Emphasize: In a severe anaphylactic patient, additional doses of epinephrine may be necessary.
Talking Points: Resist the temptation to remove the needle immediately. Allow 3–5 seconds for the medication to fully inject prior to removal. Once the needle has deployed, handle the auto-injector carefully, as it now has a sharp end. Dispose of it in a sharps container.
Discussion Topics: Describe the steps involved in correctly administering an epinephrine auto-injector. Describe the circumstances that might indicate the need for additional epinephrine administration.
Knowledge Application: Use programmed patients to present reassessment scenarios. Have students work through the decision-making process of secondary epinephrine administration.

34. Pediatric Note Two sizes of auto-injectors Adult dose: 0.3 mg
Children’s dose (for child less than 66 pounds): 0.15 mg
Skill Demonstration: Using a manikin and an auto-injector training device, demonstrate the proper procedure for administering medication via an auto-injector device.

35. Activity
Create an education brochure for a person newly diagnosed with an allergic reaction.
Decorate your brochure and make it colorful and visually appealing.
Include a section over signs and symptoms of a sever allergic reaction
Include a sections that educates of common substances people may be allergic to
Include information about the proper steps to self administer an Epi Pen shot.
Include side effects of a Epi Pen shot and information about the type of medicine that it contains.

36. Chapter Review

37. Chapter Review
Allergic reactions are common. Anaphylaxis, a true life-threatening allergic reaction, is rare.
The most common symptom in these cases is itching. Patients with anaphylaxis will also display life-threatening difficulty breathing and/or signs and symptoms of shock.
continued

38. Chapter Review
Patients with anaphylaxis will be extremely anxious. Their bodies are in trouble and are letting them know it.
The signs and symptoms of anaphylaxis result from physiological changes: vasodilation, bronchoconstriction, leaky capillaries, and thick mucus.
continued

39. Chapter Review
By quickly recognizing the condition, consulting medical direction, and administering the appropriate treatment, you can literally make the difference between life and death for these patients.

40. Remember
In an allergic reaction, the body’s immune system overreacts to an allergen and causes potentially harmful side effects.
Anaphylaxis is a severe, systemic form of allergic reaction; it is a life-threatening emergency.
continued

41. Remember
EMTs must use assessment to differentiate a localized allergic reaction from a systemic anaphylactic reaction.
Epinephrine is useful in anaphylaxis because it constricts dilated blood vessels and opens bronchial passages.
continued

42. Remember
Epinephrine has potentially dangerous side effects and should be used only in the event of anaphylaxis.

43. Questions to Consider
What are the indications for administration of an epinephrine auto-injector?
List some of the more common causes of allergic reactions.
Talking Points: Indications include signs of an allergic reaction plus respiratory distress and/or shock. Allergic reactions are caused by an exaggerated immune response. Common allergens include medications, insects, and foods.
continued

44. Questions to Consider
List signs or symptoms of an anaphylactic reaction associated with each of the following:
Skin
Respiratory system
Cardiovascular system
Talking Points: Skin signs include flushing, tingling sensation, and hives. Respiratory signs include difficulty breathing, wheezing, and difficulty speaking. Cardiovascular signs include increased heart rate, hypotension, and pale skin.

45. Critical Thinking
A 24-year-old male ate a meal that he believes contained shellfish. He is allergic to shrimp. He is sweating and nervous. He appears to be breathing adequately. You do not note any wheezing or stridor.
continued

46. Critical Thinking
His face is slightly red. His pulse is 88 strong and regular, respirations 24, blood pressure 108/74, and skin warm and moist. Should you administer epinephrine?
Talking Points: Probably not yet and definitely not until you contact medical control. Although this patient is at high risk due to his known allergy, he does not yet have the signs of anaphylaxis. He is breathing normally and no signs of shock are present. You should reassess frequently and consult medical control.

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