Epinephrine Administration and Anaphylaxis Management

Objectives of Epinephrine Administration

  • Discuss the general factors that are associated with anaphylactic shock.
  • Describe the patient presentation requiring the possible administration of epinephrine 1:1000.
  • Identify the following aspects of epinephrine 1:1000 administration in adult and pediatric patients:
    • Therapeutic effects
    • Indications
    • Contraindications
    • Side Effects
    • Complications with administration.
  • State the local protocols for the administration of epinephrine 1:1000.
  • Demonstrate the appropriate technique for the administration of intramuscular epinephrine 1:1000.
  • Select the appropriate prepackage of epinephrine.

Allergic Reactions vs. Anaphylaxis

  • Allergic Reaction: Exaggerated response by the immune system to a foreign substance.
  • Anaphylaxis: The most severe type of allergic reaction; characterized by rapid onset and can develop within seconds.

Characteristics of Anaphylaxis

  • Life-threatening emergency.
  • Most Common Causes:
    • Injected Penicillin (PCN)
    • Bee and Wasp Stings
  • Principal Body Systems Affected:
    • Cardiovascular System
    • Respiratory System
    • Gastrointestinal (GI) System
    • Skin

Signs and Symptoms of Anaphylaxis

  • Laryngeal Edema: Swelling of the larynx.
  • Tachypnea: Increased respiratory rate.
  • Wheezing and/or Diminished Breath Sounds: Indicative of airway constriction.
  • Urticaria: Hives or skin rash.
  • Diaphoresis: Sweating, possibly leading to cyanosis (blue discoloration of the skin).
  • Nausea/Vomiting: Gastrointestinal distress.

Epinephrine Overview

  • Sympathomimetic Actions:
    • Heart Rate and Contractile Force: Increases both, enhancing cardiac output.
    • Bronchodilation: Dilates the air passages in the lungs, aiding in respiratory distress.
    • Increased Arterial Blood Pressure: Supports systemic circulation.
    • Increased Systemic Vascular Resistance: Contributes to elevated blood pressure.
    • Increased Myocardial Oxygen Consumption: Ensures adequate oxygen supply to heart tissue during stress.

Indications for EMT-B Administration of Epinephrine

  • Anaphylaxis/Allergic Reaction with respiratory distress.

Contraindications

  • None in the emergency setting.

Side Effects

  • Anxiety: Patient may experience a feeling of unease or apprehension.
  • Tremor: Involuntary shaking, usually due to increased activity of the nervous system.
  • Palpitations: Heart may feel like it's pounding or racing.
  • Headache: Resulting from changes in blood flow.
    • Relatively Contraindicated: In patients with hypertension, hyperthyroidism, angina, or cerebrovascular insufficiency.

Epinephrine Administration Details

  • How Supplied:
    • 1:1000: 1 mg in 1 mL ampule.
    • 1:1000: 30 mg in 30 mL flip-top vial.

Dosage Information

  • Adult:
    • 0.3 mg (0.3 mL) - Repeat as needed every 5 minutes.
  • Pediatric:
    • 0.01 mg/kg (0.01 mL/kg) - Maximum adult dose; repeat PRN every 5 minutes.
  • Special Notes:
    • Pay close attention to the concentration given; very potent if 1:1000 is administered intravenously. Ensure proper route of administration.

Generalized Allergic Reaction Treatment

Medication Considerations:

  • Benadryl: Not repeated.
    • Adult: 50 mg bolus over 2 minutes, administered IV/IM/PO.
    • Pediatric: 2 mg/kg bolus over 2 minutes IV/IM/PO, NOT to exceed 50 mg.
  • Epinephrine 1:1000: Administer as needed every 3-5 minutes.
    • Adult: 0.3 mg (0.3 mL) IM.

Signs of Poor Perfusion

  • Monitor the presence of dyspnea (difficulty breathing).
  • General supportive care mandates examination of vital signs and maintaining airway patency.

Special Considerations in Treatment

  • EMTs may use Epipen auto-injector if available, whenever IM epinephrine is indicated.
  • Consider fluid therapy to treat hypotension.
  • Evaluate for localized lethal edema which may cause airway obstruction; prepare for intubation if necessary.
  • Be cautious administering epinephrine in patients >50 years, those with existing cardiac disease, and/or those with heart rates exceeding 150 bpm.
  • A 12-lead EKG must be completed.
  • In severe cases, consider DuoNeb (Albuterol with Atrovent) administration

Continued Treatments for Severe Cases

  • Epinephrine 1:10,000: PRN every 3-5 minutes.
    • Adult: 0.1 mg (1 mL) IV/IO.
    • Pediatric: 0.01 mg/kg (0.1 mL/kg) IV.
  • Consider Epinephrine Infusion for both Adult and Pediatric:
    • 1 mg (1 mL) of epinephrine in a 1,000 mL normal saline bag. Infuse to achieve a blood pressure >90 systolic and/or return of palpable distal pulses and/or improved mental status.
  • General supportive care and additional medications:
    • Dexamethasone: Not repeated. Adult: 10 mg IV/IM/PO. Pediatric: 0.5 mg/kg, max of 10.
    • Methylprednisolone: Not repeated. Adult: 125 mg IV/IM/PO; Pediatric: 2 mg/kg IV/10/IM, MAX of 125.

Administration Protocols

Review: 6 Rights of Medication Administration

  • Right Patient: Ensure the target patient is accurately identified.
  • Right Medication: Confirm the medication being given is correct.
  • Right Dose: Verify the dosage is appropriate for the patient’s condition.
  • Right Route: Ensure the correct route of administration (e.g., IM).
  • Right Time: Administer at the correct time relative to the patient's needs.
  • Right Documentation: Maintain accurate records of the administration.

Required Equipment for Injections

  • Medical vial or ampule
  • Filter needle
  • 1 mL syringe (23 gauge, 1.25 inches)
  • Alcohol wipes (x2)
  • Adhesive bandage
  • Sharps disposal container

Intramuscular Injection Technique

  • Purpose: Used for faster onset and longer duration of action; employed in various scenarios, including vaccinations and pain management.
  • Common Site: Deltoid area, especially in a pre-hospital setting.
  • Volume: Typically, less than 5 mL.
  • Needle: Use a 25-20 gauge needle, 3/4 to 1 inch in length.
  • Injection Technique:
    • Insert the needle at a 90° angle.
    • Aspirate before injecting to check for blood return (indicating a blood vessel).
    • Remove the needle and cover the injection site with an adhesive bandage.

Patient Monitoring

  • After administration, continually monitor the patient for effectiveness and possible adverse reactions.

Scenario Practice

Case Study: Bee Sting Reaction

  • Call Description: Prompted to attend a park for a male patient stung by a bee.
  • Patient Presentation: 20-year-old male in tripod position, showing distress.
  • Patient History: Known bee allergy; utilized EPI Pen approximately 5 minutes prior to arrival.

Vital Signs Recorded

  • Respiratory Rate (RR): 36 (labored)
  • Pulse (P): 140
  • Blood Pressure (BP): 100/64
  • Lung Sounds: Diminished with wheezing.

Discussion Points: Determine treatment protocols based on patient condition.