Download Monmouth Ocean Hospital Consortium (MONOC)

New Jersey’s Hospital Service Corporation
Epinephrine Auto Injector
A Lifesaving Tool
Now In the Hands of the EMT-B
EMS EDUCATION
© MONOC 2007
Epinephrine Auto Injector
A Lifesaving Tool Now In the
Hands of the EMT-B
Immediate Treatment
= Saved Lives
OBJECTIVES
At the conclusion of this program the EMT-B will
have the cognitive, psychomotor, and affective
skills that are needed to properly administer an
Epinephrine Auto Injector to a prehospital
patient who is having an Anaphylactic reaction
in accordance with the NJ OEMS Policy
OBJECTIVES
• Describe the scope of the problem
• Define Anaphylaxis
• Explain the Epinephrine Auto Injector Policy
• Define role and responsibility of the Medical
Director, the First Aid Squad, the individual
EMT-B, OEMS and MONOC in this program
• Explain the importance of FAST care
OBJECTIVES
• Describe progressive pathophysiology
of Anaphylactic Reactions
• Describe the Signs and Symptoms that
an Anaphylaxis patient presents with
• List the common “triggers” that lead to
an Anaphylactic Reaction
• List conditions that mimic Anaphylaxis
OBJECTIVES
• Describe the actions, side effects, route, and
injection site for Epinephrine Auto Injector
• State when to use the pediatric dose of Epi
and how to estimate patient weight and age
• Describe the procedure to follow to check for
device expiration and drug clarity
• State how to safely and properly dispose of
an Epinephrine Auto Injector
OBJECTIVES
• Describe proper patient assessment by an
EMT-B for a Anaphylaxis patient
• Explain the Procedure for an EMT-B to follow
to administer an Epinephrine Auto Injector
• Describe common errors in Auto Injector use
• Describe proper Documentation after use
OBJECTIVES
• Describe the proper method to deliver
Ventilations to patients of all ages
• Explain the proper procedure for use of
Basic Airway Adjuncts by EMT-B
• Describe how to deliver Quality CPR
• Explain how the EMT-B can assist ALS
• State where to find more information
DEFINITION
WHAT IS
•
Anaphylaxis ?
Systemic allergic reaction
 Affects body as a whole
 Multiple organ systems may be involved
•
Onset generally acute
•
Manifestations vary from mild to fatal
Now let us take a look at
New Jersey’s Epinephrine
Auto Injector Policy
Definitions & OEMS Policy
The Medical Director
Responsibilities of the Squad
Responsibilities of each EMT-B
DEFINITIONS
• National EMT-B Curriculum allows EMTs to ASSIST a patient with EpiPen
• The OEMS Policy allows EMTs to ADMINISTER an EpiPen to the patient
ASSIST
• The medication must be
prescribed to the patient
• The patient carries the
medication with him
ADMINISTER
• The medication will be
prescribed to the squad
• The medication is carried
on the ambulance
In either case the extent to which the patient or EMT-B participate with
the use of the EpiPen can vary significantly. The EMT-B may just watch
patient use the EpiPen or the EMT-B may actually perform the “stick”.
NJ Epinephrine
Auto Injector Policy
The National Standard Curriculum for
EMT-B provides that EMT-Basic’s are
trained to recognize clinical signs and
symptoms of anaphylactic shock and
establishes that it is within the scope of
practice of the EMT-Basic to assist a
patient in the self-administration of a
patient's Epinephrine Auto Injector
NJ Epinephrine
Auto Injector Policy
• PL 2003, c,1., N.J.S.A. 26:2K-47.1, presently
authorizes OEMS to certify the NJ EMT-B to
administer the epinephrine auto injector to
patients suffering from anaphylactic shock
• NJ OEMS recognizes that the expeditious
implementation of this law would have an
immediate benefit to the general public
• Accordingly, OEMS shall now authorize the NJ
certified EMT-B to administer the epinephrine
auto injector to patients in accordance with the
following policies and protocols
NJ Epinephrine
Auto Injector Policy
• The EMT-B is allowed to administer an
•
•
•
Epinephrine Auto Injector to prehospital
patients only before an ALS Unit arrives
Once the ALS Unit arrives the Paramedics
will administer Epinephrine from their stock
NJ Paramedics can administer Epinephrine
immediately under Standing Orders
The Paramedics Medical Control Physician
will provide on line medical control after the
Paramedics complete the Standing Orders
NJ Epinephrine
Auto Injector Policy
• Only EMT-Basics meeting the following
•
•
requirements are authorized by OEMS to
carry on their ambulance and administer
epinephrine auto injectors to patients
Only EMT-Basics acting with the general
authority of a physician medical director,
will be allowed to administer epinephrine
auto injectors to prehospital patients
BLS agencies must complete an approved
training program prior to obtaining or using
epinephrine auto injectors
NJ Epinephrine
Auto Injector Policy
• Only EMT -Basics who are members of
BLS agencies that are registered with
NJ OEMS may possess or administer
the Epinephrine Auto Injector to patients
• OEMS will monitor the EMT-B use of
epinephrine auto injectors according to
these policies and will take corrective
action as is deemed necessary for the
safe implementation of this policy
Medical Director
DR. MICHAEL MARCHETTI
• Provides Off-line Medical Control
• Will provide the prescriptions for the
Epinephrine Auto Injectors
• Responsible for all clinical aspects of
the MONOC EpiPen Program
• Training and Quality Assurance
The First Aid Squad
•
•
•
•
Register with OEMS
Contract with MONOC
Initial training at FAS location
Fill Medical Director’s prescription
for the Epinephrine Auto Injector
• Stock the squad’s ambulances with
the Epinephrine Auto Injector and a
sharps disposal container
The First Aid Squad
• Send new EMT-B certified members to the
regional Initial MONOC training programs
• Epinephrine Auto Injector administered by
EMT-Bs certified as per OEMS Policy only
• Proper disposal and replacement of used or
expired Epinephrine Auto Injectors
• Send required reports to MONOC and OEMS
upon using an Epinephrine Auto Injector
NJ OEMS
BLS Agency
Application
The EMT-B
• Attend Initial and Renewal classes
• Sign the MONOC contract to administer
the Epinephrine Auto Injector
• Maintain Current EMT-B and CPR certs
• Adhere to all MONOC & OEMS Policies
• Submit required reports to MONOC and
OEMS on use Epinephrine Auto Injector
NJ Epinephrine
Auto Injector Law
Immunity From Civil Liability
An EMT-B certified to administer epinephrine
auto injector pursuant to this law… or officers
and members of any first aid, ambulance or
rescue squad shall not be liable for any civil
damages as the result of any act or the any
omission of an act committed while in training
to administer, or in the administration of, the
epinephrine auto injector in good faith and in
accordance with the provisions of this law
Now let us take a look at
Pathogenesis of Anaphylaxis
Progression of Allergic Reaction
Myths & Reality
Anaphylaxis Fatalities
Common Causes of Anaphylaxis
Myth:
Anaphylaxis Is Rare
The
Reality!
• Anaphylaxis is underreported
• Incidence seems to be increasing
• Anaphylaxis leads to 200 deaths a year
• Up to 41 million Americans at risk
• 63,000 new cases per year
• 5% of adults have history of anaphylaxis
DEFINITION
WHAT IS
•
Anaphylaxis ?
Systemic allergic reaction
 Affects body as a whole
 Multiple organ systems may be involved
•
Onset generally acute
•
Manifestations vary from mild to fatal
Myth: Anaphylaxis is Easy
to Avoid If You Know What
You are Allergic To
REALITY:
Most cases of
Anaphylaxis are
Accidental Exposures
Immediate Treatment
= Saved Lives
Pathogenesis of Anaphylaxis
• Hypersensitivity
• Sensitization Stage
• End result is an anaphylactic
response – The clock is ticking
Immediate Treatment
= Saved Lives
Pathogenesis of Anaphylaxis
 Antigen (allergen) exposure
•
Antigen
Antigen: A substance that is capable of causing the
production of an antibody
•
Antigens may or may not lead to an allergic reaction
•
Allergens: Antigens that cause an allergic reaction
and the production of a substance called IgE
Pathogenesis of Anaphylaxis
 Antigen (allergen) exposure
Antigen
Allergic Reactions Don’t Occur at First Exposure to Allergen
•
First Exposure

•
Immune system sees substance as allergic trigger or ALLERGEN
and attempts to protect the body from that specific allergen by
creating specific chemicals called ANTIBODIES
Later Exposure with that same Allergen

On subsequent exposures to same allergen, the antibodies attack
& engage the invading allergens to produce the allergic response
Pathogenesis of Anaphylaxis
 Plasma cells produce IgE
antibodies against the allergen
Plasma Cell
•
Immunoglobulin: A protein produced by plasma cells
•
IgE: A class of immunoglobulins (Ig) that includes the
antibodies elicited by an allergic substance (allergen)
•
A person who has an allergy usually has elevated
blood levels of IgE antibodies that will attack and
engage the invading army of allergens
Pathogenesis of Anaphylaxis
 IgE antibodies attach to
mast cells and basophils
Mast cell with fixed
IgE antibodies
Granules that
contain histamine
•
Mast cell: A connective tissue cell whose normal function is
unknown but which is frequently injured in allergic reactions,
releasing chemicals including histamine that are very irritating
and cause itching, swelling, and fluid leakage from cells
•
Basophil: A type of white blood cell with coarse bluish-black
granules of uniform size within the cytoplasm. Basophils are
so named because their cytoplasmic granules stain with basic
dyes. Basophils contain and can release histamine
Pathogenesis of Anaphylaxis
 IgE antibodies attach to
mast cells and basophils
Mast cell with fixed
IgE antibodies
Granules that
contain histamine
•
Basophils contain and can release histamine
•
Histamine: A substance that plays a major
role in many allergic reactions. Histamine
dilates blood vessels and makes the vessel
walls abnormally permeable. This will result
in systemic swelling.
HISTAMINES
• Symptoms progress FAST!
• These actions cause fluid loss
– Swelling
– Hypotension
VASODILATION
↑
PERMEABILITY
Anaphylactic Reaction
•
A Systemic allergic reaction
- Affects body as a whole
IMMEDIATE TREATMENT
= SAVED LIVES
Antigen
 More of
same allergen
invades body
 Allergen combines with
IgE attached to mast cells
and basophils, which will
trigger degranulation and
release of histamine and
other chemical mediators
.
•
•
•
• ••
•
•
• •
•
•
• • •• •
•
• •
• •
• •
•
•
• •
•
•
• • •• •
•
•
• •
•
•• • • •
••••
•
• • • • •• •
•
•
•
• •• •
• •
• ••
•
•
•
•• •
••
• •
•• •
•• • • •
•
•
• •• • • • •
•
•• • • •• • • •
•
• •
• • •• •
• •• • • •• •
•
•
••
•• •
•
•
• • • ••
•• ••
•
• •
•
•
• • •• ••
• • • • • ••
•
•
•
•
•
•
•
•
•
•
•
•• •
•
• •• • •
•
•
• • ••• • • • • • •• • • • •
•
•
•
• • ••
•• • •
•• • •
•
•
•
• • ••
•
• • • •• •
•
•
•
•
••
• •
•
•
• •
•
•
•
•
•
• •
•
•
••
•
••
••
•
•
• • ••
••
••
••
•
•
•
•
•
•
•
•
•
•
•• • •
•
•
•
•
•
•
Mast cell granules
releases contents
after the antigen
binds with IgE
antibodies
Histamine and
other mediators
Anaphylaxis Fatalities
• Estimated 200 deaths annually
• Symptoms progress FAST!
• Risk factors:
– Rapid IV allergen
– Failure to administer epinephrine immediately
Immediate Treatment
= Saved Lives
Common Causes of
Anaphylaxis
Common Causes of
Anaphylaxis
• Foods
• Insect venoms
• Latex
• Medications
• Immunotherapy
– Insect venom
– Inhalant allergens
Now let us take a look at
Clinical Presentation Anaphylaxis
Signs & Symptoms of Anaphylaxis
Myths & Reality
Food - Venom – Latex
Other Conditions Mimic Anaphylaxis
Clinical Presentation of
Anaphylaxis
Immediate Treatment
= Saved Lives
Severe
Allergic Reaction
HIVES are
also known
medically as
URTICARIA
Immediate Treatment
= Saved Lives
Myth: Anaphylaxis Always
Presents with Hives
REALITY:
• Approximately 10%-20%
of all anaphylaxis cases
will not present with any
hives or other cutaneous
manifestations
• 80% of food-induced, fatal anaphylaxis cases
were not associated with any cutaneous signs
or symptoms
Myth: The Cause of
Anaphylaxis is Always Obvious
REALITY:
Idiopathic anaphylaxis is common
• Triggers may be hidden
– Foods
– Latex
• Patient may not recall details of exposure
Clinical Presentation of
Anaphylaxis
• Cardiovascular System:
– Tachycardia or Bradycardia
– Hypotension
– Arrhythmias
– Chest Pain (Only 6% of the time)
Immediate Treatment
= Saved Lives
Clinical Presentation of
Anaphylaxis
• Respiratory System:
– Shortness of Breath
– Throat Tightness
– Tongue Swelling
– Wheezing or Stridor
Immediate Treatment
= Saved Lives
Clinical Presentation
of Anaphylaxis
Signs & Symptoms
Incidence (%)
Urticaria and swelling
Upper airway edema
Dyspnea and wheezing
Flushed skin
Dizziness, syncope, and hypotension
Gastrointestinal symptoms
Rhinitis
Headache
Substernal chest pain
Itch without rash
Seizure
88
56
47
46
33
30
16
15
6
4.5
1.5
Clinical Presentation of
Anaphylaxis
Hives
88% of the time
Swelling of the Tongue
56% of the time
These Sx RARELY present with any other conditions
Conditions That Can
Mimic Anaphylaxis
•
•
•
•
•
•
Foreign Body Airway Obstruction
Wheezing or Stridor from Other Etiology
Other Respiratory Impairments
Acute MI
CHF
Asthma
Conditions That Can
Mimic Anaphylaxis
Foreign Body Airway Obstruction
ANAPHYLAXIS
FBAO
Hives
>88 % of the time
NO HIVES
Tongue Swollen
>50 % of the time
NOT PRESENT
Prior Episodes
May Have Had Hx
Usually NONE
Progression
Symptoms progress
increased SOB
Reflexes relax & often
lead to reduced Sx
WITHOUT ANY INTERVENTION
Breath Sounds
47% Bilateral Wheeze 65% Unilateral ↓ BS
History - Events Leading Up to Episode?
Conditions That Can
Mimic Anaphylaxis
Wheezing or Stridor Other Etiology
ANAPHYLAXIS
Wheeze - Stridor
Hives
>88 % of the time
NO HIVES
Tongue Swollen
>50 % of the time
NOT PRESENT
Prior Episodes
May Have Had Hx
What is prior Hx?
Progression
Symptoms progress
increased SOB
Inhaler or Humidity
often will reduce Sx
Breath Sounds
>47 % will wheeze
History - Events Leading Up to Episode?
Conditions That Can
Mimic Anaphylaxis
Other Respiratory Impairments
ANAPHYLAXIS
Other Resp Prob
Hives
>88 % of the time
NO HIVES
Tongue Swollen
>50 % of the time
NOT PRESENT
Prior Episodes
May Have Had Hx
What is prior Hx?
Progression
Symptoms progress
increased SOB
OXYGEN
often will reduce Sx
Breath Sounds
>47 % will wheeze Rales or Rhonchi?
Look at the patient’s Meds & Prior History
Conditions That Can
Mimic Anaphylaxis
Acute MI
ANAPHYLAXIS
Other Resp Prob
Hives
>88 % of the time
NO HIVES
Tongue Swollen
>50 % of the time
NOT PRESENT
Substernal Chest Pain Only 6% of the time >70 % of the time
Pain Radiates
NO
OFTEN
Arrythmias
RARE
OFTEN
Look at the patient’s Meds & Prior History
Conditions That Can
Mimic Anaphylaxis
Acute MI
Chest Pain in >70% of MIs – Only 6% of Anaphylaxis
Conditions That Can
Mimic Anaphylaxis
CHF
ANAPHYLAXIS
Other Resp Prob
Hives
>88 % of the time
NO HIVES
Tongue Swollen
>50 % of the time
NOT PRESENT
Breath Sounds
>47 % will wheeze Rales (Wheeze early)
Blood Pressure
33 % with ↓ BP
Very High (Drops late)
Pedal edema - + JVD –
Frothy Pink Sputum
NO
OFTEN
History – Orthopnia – Sleeping Position (# of Pillows?)
Conditions That Can
Mimic Anaphylaxis
CHF
CHF Occurs Primarily in the Geriatric Population
Conditions That Can
Mimic Anaphylaxis
ASTHMA
ANAPHYLAXIS
ASTHMA
Hives
>88 % of the time
NO HIVES
Tongue Swollen
>50 % of the time
NOT PRESENT
Breath Sounds
50% will not wheeze Wheeze (Absent Late)
Progression
Only Epi Reduces Sx !
Inhaler or Humidity
often will reduce Sx
Area Effected
Upper Airway
Lower Airway
Many Patients will also have History
of Both Anaphylaxis and Asthma
ASTHMA
This drawing shows a By contrast, this drawing shows
tightened airway and inflamed
normal, relaxed airway
air sacs in the lungs
and air sacs in the lungs
Myth: Prior Episodes
Predict Future Reactions
REALITY:
• No predictable pattern
• Severity depends on:
–Sensitivity of the individual
–Dose of the allergen
Anaphylaxis:
Food Induced
• Food allergies are usually due to the protein
component of the offending food
• For some reason some of the food protein is
absorbed from the intestine intact, instead of
being digested as most proteins are
• Once the intact protein is in the blood stream,
it is recognized as a foreign protein to the
body, or in other words as an ANTIGEN
Anaphylaxis:
Food Induced
• 35%–55% of anaphylaxis is caused by food allergy
• 6%–8% of children have food allergy
• 1%–2% of adults have food allergy
• Incidence is increasing
• Accidental exposures are common and unpredictable
Immediate Treatment
= Saved Lives
Food Induced
Anaphylaxis:
Common Triggers
Food-induced Anaphylaxis:
Common Symptoms
• Oropharynx: Swelling of lips and tongue,
throat tightening, slurred speech
• GI: Cramps, diarrhea, nausea, vomiting
• Cutaneous: Urticaria, angioedema
• Respiratory: Shortness of breath, cough,
wheezing or stridor
Anaphylaxis: Venom-induced
Common Culprits (Triggers)
13 million Americans are sensitive to insect venoms
 Culprit
– Bees
– Wasps
– Hornets
– Yellow jackets
 Geographical
 Culprit
– Fire ants
– Marine life
– Spiders
– Honeybees and yellow jackets most common in East,
Midwest, and West regions of US
– Wasps, fire ants common in Southwest & Gulf Coast
Venom-induced Reactions:
Common Symptoms
• Normal: Local pain, Redness, Mild swelling
• Large local: Extended swelling, Redness
• Anaphylaxis: Usual onset within 15–20 minutes
– Cutaneous: Urticaria, Flushing, Edema
– Respiratory: Dyspnea, Wheeze or Stridor
– Cardiovascular: Dizziness, Loss of Consciousness,
Tachycardia or Bradycardia (late), Hypotension,
30%–60% of patients have a systemic reaction
with multiple stings
Anaphylaxis:
Latex
Latex Gloves
• 1%–6% of Americans (> 16 million) affected
• 8%–17% incidence with health care workers
• Repeated exposure leads to a higher risk
• Incidence has increased since mid 1980s
• Proteins in natural rubber latex
• Component of ~40,000 commonly used items
Anaphylaxis:
Latex
Latex Gloves
•
The sudden, large-scale increase in latex glove
use by healthcare workers since the 1980s lies at
the heart of the growing problem of latex allergy
•
As health care workers protect themselves from
AIDS and other bloodborne diseases, latex glove
use became virtually universal in hospitals
•
Healthcare workers, were exposed to more latex
than ever - many have become sensitized to it
Anaphylaxis:
Latex
Latex Gloves
• Irritant contact dermatitis
– Dry, itchy, irritated hands
• Allergic contact dermatitis
– Delayed hypersensitivity
• Latex allergy
– Immediate hypersensitivity
– Sx: hives, itching, sneezing, rhinitis, cough,
wheezing or stridor, shortness of breath
– Greatest risk with mucosal contact
Latex Anaphylaxis:
Prevention
AVOIDANCE
• Use latex-free products
• Alert employer/health care providers, schools about
•
•
need for latex-free products and equipment
Wear MedicAlert bracelet
Awareness of cross-sensitivity with foods:
– Banana
– Avocado
– Chestnuts
– Kiwi
– Stone fruit
– Others
Other Causes of
Anaphylactic Reactions
• Antibiotics
• Chemotherapeutic agents
• Aspirin
• Biologicals (vaccines)
• Radiocontrast media (IV Dye)
Now let us take a look at
The Treatment of Anaphylaxis
Epinephrine
Epinephrine Auto Injector
Maintaining the Auto Injector
EPI Auto Injector Administration
Treatment of
Anaphylaxis
Immediate Treatment with
Epinephrine Imperative
– No contraindications in Anaphylaxis
– Failure or delay = Fatalities
– Must be available at all times
Immediate Treatment
= Saved Lives
Epinephrine Auto Injector
A Lifesaving Tool Now In the
Hands of the EMT-B
Immediate Treatment
= Saved Lives
What Is Epinephrine ?
EPINEPHRINE = ADRENALINE
• Adrenaline is a natural hormone released in
response to stress
• It is a natural "antidote" to the chemicals
released with severe allergic reactions
triggered by a drug, food, or insect allergy
• It is destroyed by enzymes in the stomach,
so must be injected
• When injected, it rapidly reverses the effects
of a severe allergic reaction
CLINICAL PHARMACOLOGY
EPINEPHRINE = ADRENALINE
• Strong vasoconstrictor action
– Acts quickly to counteract both vasodilation and
increased vascular permeability which can lead
to loss of volume and hypotension Anaphylaxis
• Epinephrine causes smooth muscle relaxation of
the bronchial walls in the airway
– ↑ air flow alleviates wheezing & dyspnea
• Epinephrine is a sympathomimetic drug
– Heart beats stronger and faster = more effective
Side Effects ?
EPINEPHRINE = ADRENALINE
• Side effects of epinephrine may include
palpitations, tachycardia, apprehension,
sweating, nausea and vomiting, pallor,
respiratory difficulty, tremor, headache,
dizziness, weakness, and nervousness
• Cardiac arrhythmias may occur after the
administration of epinephrine
Myth:
Epinephrine is Dangerous
The
Reality!
• Risks of anaphylaxis far outweigh
risks of epinephrine administration
• Minimal cardiovascular effects in
children (Simons et al, 1998)
• Use caution when administering
epinephrine in elderly patients or
those with known cardiac disease
THE AUTO INJECTOR
Preloaded Unit Dose
Spring Loaded Trigger
AUTO INJECTORS ONLY
THE EMT-B IS NOT
PERMITTED TO USE A
SYRINGE
X
TWINJECT
CANNOT BE USED BY THE EMT-B
X
AUTO INJECTORS ONLY
CANNOT BE USED BYTHE EMT-B IS NOT
THE EMT-B
PERMITTED TO USE A
SYRINGE
The First Dose is an
AUTO INJECTOR
Second Dose is a
SYRINGE
The
EpiPen®
Dismantled EpiPen®
The Spring
The Needle
The Syringe
How Does It Work ?
Expiration Dates
MONITOR THE EXPIRATION DATES

Check the expiration date when you get the
prescription - You should be able to obtain an
expiration date 12 - 14 months out

Return expired Auto Injectors to Pharmacy
Expiration Date and Lot Number
Expiration Dates
Join the Free EpiPen®Center for
Anaphylactic Support™!
www.epipen.com/epipen_reminder
Expiration Dates
EpiPen®Center for Anaphylactic Support™
• There is a free expiration reminder program
• Register every time you purchase EpiPen®
• You get reminders before the expiration date
Expiration Date and Lot Number
Storage of
EpiPen®
X
•
Clear Window
CHECK FOR CLARITY
X
Improper storage of the Auto Injector can
cause the Epinephrine to oxidize & go bad
• Check the Epinephrine periodically through
the viewing window - be sure the solution is
clear and colorless
• Replace Auto Injector immediately if solution is
found to be clouded
Storage of
EpiPen®
X
•
Clear Window
CHECK FOR CLARITY
X
Epi stable at room temp until expiration date
• Epinephrine should not be refrigerated refrigeration may cause unit to malfunction
• Epi should not be exposed to high heat
• Do not expose the EpiPen® to direct sunlight
for prolonged periods of time
How is Epinepherine Given?
Intramuscular (IM) Injection
• A shot where the needle goes into the muscle
•
to deliver a certain amount of medicine
The drug is absorbed in the muscle and the
bloodstream then carries it through the body
• IM injections are made into the
striated muscle fibers under the
subcutaneous layer of the skin
Where Do I Give
Epinepherine?
VASTUS LATERALIS MUSCLE
• Forms part of quadriceps muscle group
• Located on anteriolateral aspect of thigh
• Used as the site for IM injections as it is
generally thick and well formed in patients
of all ages and is not located close to any
major arteries or nerves
• This site is readily accessed
• Middle third of muscle is the injection site
QUADRICEPS
Where is Epinepherine Given?
ANTERIOLATERAL MID THIGH AREA
• Same site is used for both Adult and Pediatric
• The EpiPen should simply be pushed against
the fleshy outer (lateral) portion of the thigh
• There is no need for more precise placement
• Do not attempt an injection
into a vein or the buttocks
.3 mg
.15 mg
OEMS Policy
Use the EpiPen® Jr
For Patients
Under 4 Years Old
EpiPen®
.3 mg
.15 mg
EpiPen®
• Epinephrine dosing is based on body weight
• The EpiPen® Auto Injector (0.3 mg) is for individuals
weighing 66 lbs. or more
• The EpiPen® Jr Auto Injector (0.15 mg) is for those
individuals weighing between 33 and 66 lbs
• The OEMS Epinephrine Auto Injector Policy states to
use a EpiPen® Jr Auto Injector (0.15 mg) for patients
Under 4 years of age
Determining Weight & Age
Don’t Forget the Obvious
ASK THE PARENT !
PEDI - WHEEL
BROSELOW SYSTEM
Now let us take a look at
Using the Epinephrine Auto Injector
The Patient Assessment
Using the Auto Injector
Common Errors
Post Use
Epinephrine Auto Injector
How Do I Use It ?
AUTO INJECTORS ONLY
X
THE EMT-B IS NOT
PERMITTED TO USE A
SYRINGE
Epinephrine Auto Injector
EMT CHECKLIST






My BLS Agency is registered with and has
been approved by OEMS
I have completed the mandated training
program for Epinephrine Auto Injectors
I am a current NJ EMT-B
I have a current CPR card
The patient does not have his own
ALS has not yet arrived on location
Remember Safety First
Look Around!
Be Alert!
The
Scene Size-Up
STOP
LOOK
• Remember crew safety and BSI!
• You already have Off Line Medical Control
• Check environment for source of the
reaction—insects, foods, medications
• Call ALS immediately
• How many patients?
• Do you need additional resources?
Initial Assessment
• As you approach develop
a General Impression
• Assess mental status
• Assess Airway
• Assess the adequacy of
Breathing
• Assess Circulation
• Identify patient priority
Initial Assessment
Identify the patient priority
• If unresponsive, then
immediately evaluate
and treat life threats
• ABCs
• Provide 100% oxygen
Provide 100% OXYGEN
Provide 100% oxygen via NRB, but be ready to
assist ventilations if necessary with a BVM
High Con O2
BVM for Ventilations
• Nonrebreather mask • For inadequate tidal
@ 10-15 liters per min
10-15 lpm
volume or resp rate
Set @ 15 lpm
General Impression
& Chief Complaint
Consider the need for an Epinephrine Auto
Injector if any of the following are present:
–
–
–
–
–
–
Generalized urticaria (Present >80% of the time)
Swelling of the face, tongue, or lips
Chief Complaint of respiratory distress or arrest
A tightness in the chest and or throat
Wheezing or Stridor
Altered mental status
• Restlessness, Anxiety, Confusion
• Seizure, Unresponsiveness
Initial Assessment
• Look for indications of any
circulatory distress
• Indications of Hypoperfusion
– Rapid heart rate
– Cool, moist skin
– Delayed capillary refill times
• If unable to palpate a pulse,
then begin CPR and AED
resuscitation immediately
Focused History
and Physical Exam
• Obtain Baseline Vital Signs
• Look for Medical Alert Tags
• Check environment for source of the
ALLERGY
reaction—insects, foods, medications
• Where is the ALS Unit ??
• Responsive patients - SAMPLE HISTORY
• Unresponsive patients need to receive a
Rapid Physical Exam
Immediate Treatment
= Saved Lives
SHOCK ??
Consider an Epinephrine Auto Injector if any
signs or symptoms of shock are present:
CHILD
1 TO 12 years old
Heart Rate > 140
AND/OR
BP < 70 Systolic
ADULT
OLDER THAN 12
Heart Rate > 120
AND/OR
BP < 80 Systolic
INFANT
UNDER 12 months
Heart Rate > 180
AND/OR
BP < 60 Systolic
Fast pulses and hypotension are ominous signs
SAMPLE
•S
— Signs and Symptoms
What signs & symptoms occurred at onset?
• A — Allergies
Is patient allergic to meds, foods, or other?
• M — Medications
What medications is the patient taking?
• P — Pertinent Past History
Does the patient have any medical history?
• L — Last Oral Intake
When & What did patient last eat or drink?
• E — Events Leading Up To
What events led to this incident?
ASK
LISTEN
STAY
GO
Transport
Decision
TRANSPORT
Transport Promptly
• Take patient medications and the
Epinephrine Auto Injector with you
• Treat respiratory distress and shock,
then transport immediately
Auscultate
Breath Sounds
WHEEZING
STRIDOR
RALES (CRACKLES)
RHONCHI
LISTEN
Focused History and
Detailed Physical Exam
• Consider if:
– Complaint or history is confusing
– There is extended transport time
– You need to clarify findings
• In severe Anaphylaxis reactions
the Focused & Detailed Physical
exams may be omitted
Immediate Treatment
= Saved Lives
HIS
MINE
Do I Use the
Patient’s or Mine ?
WHAT IF THE PATIENT HAS
HIS OWN EpiPen® ?
If the patient has a prescribed
Epinephrine Auto Injector then
ASSIST the patient with theirs
EpiPen/EpiPen Jr:
Directions for Use
Remove the Auto Injector from the Storage Tube
Check the Expiration Date & Color of the Epi
Storage Tube
EpiPen/EpiPen Jr:
Directions for Use
Remove the Safety Cap
The device is
now LOADED
X
AFTER THE SAFETY CAP IS REMOVED
KEEP YOUR FINGERS AWAY FROM THE END
EpiPen/EpiPen Jr:
Directions for Use
Insert in the Lateral Mid Thigh
• Place auto injector
firmly against lateral
portion of the thigh,
midway between the
waist and the knee
• Firm pressure activates
spring mechanism in
the auto injector and
forces the needle into
the thigh muscles
EpiPen/EpiPen Jr:
Directions for Use
Hold For 10 Seconds and Remove
•
•
•
Hold in place for 10-15
seconds while the epi is
injected in muscle
Remove auto injector
from the thigh - careful
the needle will now be
projecting
Massage the injection
site – this will enhance
absorption of the epi
COMMON ERRORS
MISTAKE NUMBER 1
• The black tip contains
•
the needle and needs to
be placed against the
mid-thigh.
Holding the wrong end
and injecting the thumb
(blue line) is painful and
not very effective ...
COMMON ERRORS
MISTAKE NUMBER 2
• Unless the safety
cap is removed
(blue line), the
EpiPen will NOT
work, no matter how
hard you push ...
COMMON ERRORS
MISTAKE NUMBER 3
• This photograph is
more subtle. The
patient is pressing
the white end very
hard (blue line),
assuming there is a
"button" at the white
end. There is not!
EpiPen/EpiPen Jr:
Directions for Use
Needle is Exposed – BE CAREFUL !
•
•
Clear Window
Place the used Auto
Injector in a sharps
container for Safety
Note: Most of the liquid
(about 90%) stays in the
auto-injector and cannot
be reused - The correct
epinephrine dose was
given if the RED FLAG
appears in clear window
TRANSPORT
The Ongoing
Assessment
• You should have already initiated your patient
TRANSPORT to the hospital – DO NOT DELAY
• Take the Epinephrine Auto Injector with you
• Where is ALS ? Consider meeting the ALS unit
Line of Sight en route to the hospital
• Notify Receiving Hospital (If NO ALS)
Immediate Treatment
= Saved Lives
TRANSPORT
The Ongoing
Assessment
• Monitor with Vigilance Level of Distress, Level
of Consciousness, Blood Pressure, Respirations,
Pulse, Breath Sounds
• Repeat a second Epinephrine dose if the signs
and symptoms still persist after 10-15 minutes
• Maintain Normal Body Temp
• Where is the ALS unit?
Immediate Treatment
= Saved Lives
TRANSPORT
Biphasic
Reactions
• Biphasic reactions - Sx occur again after the initial
•
•
•
anaphylaxis Sx have completely resolved
Biphasic reactions can occur several hours after
the initial Anaphylactic episode
Biphasic reactions happen in up to 20% of cases
Biphasic reactions are treacherous – more difficult
to treat than initial episode
– Patients often require intubation
Immediate Treatment
= Saved Lives
DOCUMENTATION
REQUIRED ON PCR
• Location of the Injection Site
• Medication Name and Dose
• Time Epi was Administered
• Vital Signs Pre and Post Epi
• Any changes in the patient’s condition
Immediate Treatment
= Saved Lives
DOCUMENTATION
REQUIRED
FINISH THE
PAPERWORK!
• Leave a copy of the Patient Care
Report (PCR) at the hospital
• Complete the MONOC QA Form
• Send a copy of the PCR to
– MONOC within 7 days after the call
– OEMS within 45 days after the call
Immediate Treatment
= Saved Lives
Medical Director
DR. MICHAEL MARCHETTI
• You administered the Auto Injector
under his Off-line Medical Control
• Responsible for all clinical aspects of
the MONOC EpiPen Program
• Will review documentation provided
for Quality Assurance purposes
Now let us take a look at
AHA 2010 Guidelines for
CPR and Emergency Cardiac Care
Assessing Ventilations
C-A-B Sequence
Quality CPR
Interfacing With ALS
Check Responsiveness
• Tap the patient’s shoulder – ask “are
you all right?”
• Check for movement / chest rise and
fall .
• Check for breathing / adequate
breathing.
AGONAL Breathing
Assess For Effective Breathing
 Occasional gasps = agonal breathing
 Will soon lead to cardiac arrest
 Called “Guppie Breathing”
 This is NOT effective breathing
Pulse Check
• Check the carotid artery for at least 5
seconds and no longer than 10 seconds to
determine presence of a pulse.
• If no pulse, perform 5 cycles of
compressions and breaths (ratio 30:2)
beginning with chest compressions.
Chest Compressions
Compress HARD & FAST
• Compress at a rate of at least 100/min.
• Ratio of compressions to breaths same for
1 rescuer or 2 rescuers – 30:2
• Each set of 30 compressions should take
18 seconds or less.
Ventilations
This is much
too FAST
Avoid the Urge To
Ventilate TOO FAST or TOO HARD!
• Ventilations delivered TOO FAST or with TOO MUCH
VOLUME are NOT beneficial and may even be HARMFUL
• Deliver just enough volume to make the chest rise
• Each breath should be delivered over one second
Each time you ventilate intrathoracic
pressure increases and the flow of
blood through the heart and the
blood vessels in chest decreases
Rate of
Ventilations
This is
much too
FAST
Adult patient in respiratory arrest with a pulse:
– Deliver about 10 - 12 breaths per minute
– Give just enough volume to allow the chest to rise
– Resist the urge to ventilate faster or harder!
Child or Infant in respiratory arrest with a pulse:
– Deliver 12 - 20 effective breaths per minute
– Resist the urge to ventilate faster or harder!
Each rescue breath should be delivered over one second
A Word About
Advanced Airways
211
MICU
When ALS arrives on scene the paramedics will
secure the airway with an Endotracheal Tube
Once the ET is in place
ventilate at:
8 times per minute
Once every 7 seconds
• DO NOT PAUSE your cardiac
compressions to give breaths
• This will optimize blood flow
Delivery of
Ventilations
AGE GROUP
Breaths Per Min
ADULT
10 per min
CHILD
15 per min
INFANT
20 per min
ADULT with ET
8 per min
Each rescue breath should be delivered over one second
AIRWAY EQUIPMENT
Provide 100% oxygen via NRB, but be ready to
assist ventilations if necessary with a BVM
High Con O2
BVM for Ventilations
• Nonrebreather mask • For inadequate tidal
@ 10-15 liters per min
10-15 lpm
volume or resp rate
Set @ 15 lpm
Best Use of the BVM
2 Rescuer Bag Valve Mask
Technique is Preferred
• Minimizes the chance of the 2
•
Note the
PADDING
Note the
E – C Clamp
•
most common BVM errors
- Poor Seal – Loss of Volume
- Squeezing bag inadequately
One rescuer seals the mask
and opens the airway with an
E – C clamp
The second rescuer squeezes
the BVM with both hands - for
good tidal volume (chest rise)
Best Use of the BVM
2 Rescuer Bag Valve Mask
Technique is Preferred
• Sellick Maneuver is done by a
•
Note the
PADDING
Note the
E – C Clamp
•
third rescuer with ventilations
of an unprotected airway
BLS can provide the Sellick
Maneuver early & continually
until a ET tube is inserted by
the Paramedics
Note the padding under the
head for this adult patient –
What if this were a child or infant?
The Sellick
Maneuver
The routine use of the
Sellick Maneuver is no
longer recommended
for use American Heart
Association
The Sellick
Maneuver
BLS Providers can help
with the Sellick Maneuver
• Used to help line up the airway
structures in ET intubation – will
help to visualize the vocal cords
• Also will help to prevent gastric
distension and vomiting as you
ventilate an unprotected airway
The Sellick
Maneuver
BLS Providers can help
with the Sellick Maneuver
• Performed by applying gentle
pressure to the anterior neck at
the Cricoid Cartilage
• BLS can provide this maneuver
early and continually until an ET
tube is inserted
PEDI AIRWAY EQUIPMENT
All BLS Ambulances must have airway adjuncts
of all types available for all age groups of patients
Variety of Sizes
•OPA
•BVM
BROSELOW SYSTEM
SUCTION EQUIPMENT
• BLS Ambulances must have SUCTION available for all
patients – Suction should be set up READY FOR USE
Suction Equip
• READY TO USE
• Rigid tip catheter
• 15 seconds
On Board Equip
• Oxygen
• Suction
Coronary Perfusion
Pressure (CPP)
2010 Guidelines Focus on Maintaining CPP
• Maximizing delivery of quality compressions
• Minimizing the delivery of ventilations and
other “hands off time”
HIGH QUALITY CPR
SAVES LIVES
The Need for
Quality CPR
PUSH HARD
PUSH FAST
• Maintain compression
rate at - least
• This
Per Minute
rate is same in all
AHA age groups - for both
one and multiple rescuers
MAKE EVERY COMPRESSION COUNT!
Every compression done improperly decreases CPP
A Major Change All rescuers acting alone should deliver
Compressions to
Ventilations
for all victims except newborns
• Adequate blood flow is needed to provide
delivery of oxygen to the vital organs
• Scientific studies measured blood flow to
the heart muscle in the coronary arteries
– Coronary Perfusion Pressure (CPP)
Coronary Perfusion Pressure
and the CPR Cycle
Scientific data shows that CPP builds up to the
maximum with the first 5 - 10 compressions
of the CPR cycle
CPP will be maintained by well delivered
uninterrupted cardiac compressions
When cardiac compressions are interrupted
CPP falls to almost zero immediately
It
will
then
take
the
next
several
compressions to build the CPP back up to
the optimal level again
MINIMIZE INTERRUPTIONS
Coronary Perfusion Pressure
Over a
CPR Cycle
Coronary Perfusion Pressure (CPP)
Over CPR Cycle
30 Compressions to 2 Breaths
Coronary Perfusion Pressure (CPP)
Over CPR Cycle
30 Compressions to 2 Breaths
A Cycle of 30 Cardiac Compessions
Delivered at a rate of 100 per minute
PUSH HARD - PUSH FAST
1
10
20
A Cycle of 30 Cardiac Compessions
Delivered at a rate of 100 per minute
PUSH HARD - PUSH FAST
30
PUSH HARD
2 Breaths CPP = 0
2 Breaths CPP = 0
Maximum CPP Maintained
2 Breaths CPP = 0
2 Breaths CPP = 0
Maximum CPP Maintained
1
Per Minute
10
20
30
PUSH FAST
Compressions
to
Ventilations
One Lone
Rescuer
Multiple
Rescuers
ADULT
30 : 2
30 : 2
CHILD
30 : 2
15 : 2
INFANT
30 : 2
15 : 2
MINIMIZE INTERRUPTIONS
Hand
Position
AGE GROUP
Place Your Hands
ADULT
Center of chest between nipples
2 hands - Heel of hand on chest –
other on top
CHILD
Center of chest between nipples
1 hand - Heel of one hand on chest
INFANT
One Rescuer
INFANT
Multiple Rescuers
Just below nipple line
1 Rescuer – 2 Fingers
Just below nipple line
2 Rescuers – 2 Thumbs
NO LANDMARKING
“Eyeball” the correct spot and place your hands
Minimize Hands Off Time
Two Thumb Compression Technique
For Multiple Rescuer Infant CPR
• Encircle the infant’s
chest with both hands
• Spread your 4 fingers
across the thorax and
place your 2 thumbs
together on the lower
half of the sternum
Note the
PADDING
Two Thumb Compression Technique
For Multiple Rescuer Infant CPR
• Squeeze the thorax with
your 4 fingers as you
compress over sternum
with your 2 thumbs
• Second rescuer provides
ventilations (15:2 Ratio)
• This technique has been
proven to achieve higher
CPP in studies
Note the
PADDING
SUMMARY
 NJ Epinephrine Auto Injector Policy
– Allows NJ EMT-B to carry the Epinephrine
Auto Injector in the ambulance & administer
under off-line medical control
 Anaphylaxis
– Anaphylaxis is a condition that progresses
through several phases very rapidly
– Anaphylaxis can be triggered by several
things – Food, Stings, Latex most common
– Other conditions can mimic Anaphylaxis
SUMMARY
 The EpiPen
– The EpiPen is a safe easy device that can
rapidly reverse the effects of Anaphylaxis
– EMT-B should understand the actions, the
side effects, dose, and site to use for EpiPen
 Using the Epi-Pen
– The EMT-B needs to perform an accurate
rapid patient assessment
– Proper documentation required per policy
– Transport should not be delayed
SUMMARY
 Airway and CPR Skills
– It is essential the EMT-B delivers proper
ventilations and compressions to all ages
– The EMT-B must be proficient in AHA 2010
– Quality CPR is an essential skill
 Conclusion
– The Epinephrine Auto Injector is a new
lifesaving tool now in the hands of the EMT
– IMMEDIATE TREATMENT = SAVED LIVES
Additional Information For
Anaphylaxis
-- WEB SITES FOR INFORMATION --
EpiPen Auto Injector
A Lifesaving Tool Now In the
Hands of the EMT-B
Immediate Treatment
= Saved Lives
Thank You For
Your Participation
For More CEUs
www.MONOC.ORG