1. Anaphylaxis and Epinephrine The Role of the EMT-Basic N.H. Patient Care Protocols N.H. Department of Safety Division of Fire Standards & Training and Emergency Medical Services

2. 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 Goals

3. General Pharmacology For every medication you may administer, you must thoroughly understand the following: Actions Indications Contraindications Dosage Route Side effects

4. General Pharmacology Generic name –Original chemical name Trade name –Brand name given by manufacturer

5. General Pharmacology Medication Forms Solutions –Liquid mixture of one or more substances Other forms –tablets, suspensions, vaporized, gels, etc.

6. General Pharmacology Right Patient Right Drug Right Dose Right Time Right Route Right Documentation

7. 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

8. Allergic Reactions Very Common Range from mild and local to severe and systemic.

9. Common Causes of Allergic Reactions

10. Mild 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

11. Mild Allergic Reactions A mild, local reaction caused by a bee sting

12. Severe Allergic Reaction A Clear History of Allergen Exposure AND Signs and Symptoms including: –Shock (hypoperfusion) –Respiratory distress –Wheezing, stridor, cough, hoarseness –Chest / throat tightness

13. Itching, skin flushing Urticaria (hives) (look at the torso!) and /or swelling (Especially the face and the extremities) Severe Allergic Reaction

14. Increased Pulse Decreased Blood Pressure Nausea & Vomiting Altered Mental Status Sense of impending doomsure with history of anaphylaxis

15. Anaphylaxis An exaggerated immune response to an allergen Sudden, rapid onset Systemic involvement Severe allergic reaction

16. Epinephrine Generic Name – Epinephrine Trade Name – EpiPen – EpiPen Jr. – Adrenalin

17. Epinephrine Actions Dilat es bronchioles Constricts blood vessels Increases heart rate Increases cardiac output

18. Epinephrine Indications Signs and symptoms of severe allergic reaction Compliance with the NH Patient Care Protocols

19. Epinephrine Contraindications None when dealing with anaphylaxis! BUT MUST FOLLOW NH PATIENT CARE PROTOCOLS!

20. Epinephrine Dosage 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)

21. Epinephrine Route –Deep Intramuscular Injection –Lateral thigh, midway between waist and knee

22. Epinephrine Side Effects –Increased pulse rate –Pallor –Dizziness –Chest Pain –Headache Nausea Vomiting Excitability / nervousness Anxiety Syncope

23. Epi auto-injector Administration 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

24. Epi auto-injector Administration Push until auto-injector activates Hold until medication injected (10 seconds). Record Time Record Response to Medication Dispose of auto-injector in biohazard “sharps” container.Dispose of auto-injector in biohazard “sharps” container.

25. Emergency Medical Care Allergic Reaction/Anaphylaxis Patient Care Protocol January 2005

26. Patient Assessment Routine Patient Care Scene Size-up Initial Assessment (watch the airway!)

27. Focused 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?

28. Focused Physical Assessment Reassess ABCs Breath Sounds Baseline Vital Signs O 2 Saturation Assess respiratory system Assess cardiovascular system  Assess for Signs & Symptoms of Anaphylaxis

29. ANAPHYLAXIS 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

30. NH Patient Care Anaphylaxis Protocol Call ALS Administer oxygen Assess respiratory status Assess cardiac status Vital signs

31. NH Patient Care Anaphylaxis 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.

32. NH Patient Care Anaphylaxis 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

33. Ongoing assessment Monitor A-B-Cs Reassess vital signs Oxygen! Watch for changes in patient condition

34. Ongoing Assessment If the patient deteriorates... Oxygenate Contact Medical Control for order for second dose Prepare for resuscitation Oxygenate Treat for shock Did we mention Oxygenate?

35. Ongoing Assessment –Contacted Medical Control to administer a second auto- injector. –Be prepared to perform CPR if patient deteriorates.

36. Communication What? –Assessment Finding –Treatments –Result of Treatment Who? –Other EMS providers –Receiving Facility personnel

37. Documentation What? –Assessment Finding –Treatments –Result of Treatment Where? –PCR –Performance Improvement / Quality Improvement

38. 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

39. Questions?