anaphylaxis and epinephrine the role of the emt-basic n.h. patient care protocols n.h. department of...
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Anaphylaxis and Anaphylaxis and Epinephrine Epinephrine
The Role of the EMT-Basic
N.H. Patient Care Protocols
N.H. Department of Safety Division of Fire Standards & Training
andEmergency Medical Services
• 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
GoalsGoals
General PharmacologyGeneral Pharmacology• For every medication you may
administer, you must thoroughly understand the following:
•Actions
•Indications
•Contraindications
•Dosage
•Route
•Side effects
General PharmacologyGeneral Pharmacology
• Generic name– Original chemical name
• Trade name– Brand name given by manufacturer
General PharmacologyGeneral PharmacologyMedication Forms
• Solutions – Liquid mixture of one or more
substances
• Other forms– tablets, suspensions, vaporized, gels,
etc.
General PharmacologyGeneral Pharmacology• Right Patient• Right Drug• Right Dose• Right Time• Right Route• Right Documentation
What Is Medical Control?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
Allergic ReactionsAllergic Reactions
• Very Common
• Range from mild and local to severe and systemic.
Common Causes of Allergic Common Causes of Allergic ReactionsReactions
Mild Allergic ReactionsMild 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
Mild Allergic ReactionsMild Allergic Reactions
A mild, local reaction
caused by a bee sting
Severe Allergic ReactionSevere Allergic Reaction
• A Clear History of Allergen Exposure AND Signs and Symptoms including:– Shock (hypoperfusion)– Respiratory distress– Wheezing, stridor, cough,
hoarseness– Chest / throat tightness
• Itching, skin flushing
• Urticaria (hives) (look at the torso!) and /or swelling (Especially the face and the extremities)
Severe Allergic ReactionSevere Allergic Reaction
Severe Allergic ReactionSevere Allergic Reaction
• Increased Pulse• Decreased Blood Pressure• Nausea & Vomiting• Altered Mental Status• Sense of impending doomsure with
history of anaphylaxis
AnaphylaxisAnaphylaxis• An exaggerated immune
response to an allergen• Sudden, rapid onset• Systemic involvement • Severe allergic reaction
EpinephrineEpinephrine• Generic Name
– Epinephrine
• Trade Name– EpiPen– EpiPen Jr.– Adrenalin
EpinephrineEpinephrineActionsActions
• Dilates bronchioles
• Constricts blood vessels
• Increases heart rate
• Increases cardiac output
EpinephrineEpinephrineIndicationsIndications
• Signs and symptoms of severe allergic reaction
• Compliance with the NH Patient Care Protocols
EpinephrineEpinephrineContraindicationsContraindications
None when dealing with anaphylaxis!
BUT MUST FOLLOW NH BUT MUST FOLLOW NH PATIENT CARE PATIENT CARE PROTOCOLS!PROTOCOLS!
EpinephrineEpinephrineDosageDosage
• 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)
EpinephrineEpinephrineRouteRoute
– Deep Intramuscular Injection
– Lateral thigh, midway between waist and knee
EpinephrineEpinephrine Side EffectsSide Effects
– Increased pulse rate
– Pallor– Dizziness– Chest Pain– Headache
• Nausea• Vomiting• Excitability /
nervousness• Anxiety • Syncope
Epi auto-injector Epi auto-injector AdministrationAdministration
• 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
Epi auto-injectorEpi auto-injector AdministrationAdministration
• Push until auto-injector activates
• Hold until medication injected (10 seconds).
• Record Time• Record Response to
Medication
•Dispose of auto-injector in biohazard Dispose of auto-injector in biohazard “sharps” container.“sharps” container.
Emergency Medical CareEmergency Medical Care
Allergic Reaction/Anaphylaxis
Patient Care ProtocolJanuary 2005
Patient AssessmentPatient Assessment•Routine Patient Care•Scene Size-up•Initial Assessment (watch
the airway!)
Focused HistoryFocused 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?
Focused Focused Physical AssessmentPhysical Assessment
• Reassess ABCs
• Breath Sounds
• Baseline Vital Signs
• O2 Saturation
• Assess respiratory system
• Assess cardiovascular system
Assess for Signs & Symptoms of Anaphylaxis
ANAPHYLAXISANAPHYLAXIS
• 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
NH Patient Care AnaphylaxisNH Patient Care AnaphylaxisProtocolProtocol
• Call ALS• Administer oxygen• Assess respiratory status• Assess cardiac status• Vital signs
NH Patient Care AnaphylaxisNH Patient Care AnaphylaxisProtocol(cont.)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.
NH Patient Care AnaphylaxisNH Patient Care AnaphylaxisProtocol(cont.)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
Ongoing assessmentOngoing assessment
• Monitor A-B-Cs• Reassess vital signs• Oxygen!• Watch for changes in
patient condition
Ongoing AssessmentOngoing 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?
Ongoing AssessmentOngoing Assessment
– Contacted Medical Control to administer a second auto-injector.
– Be prepared to perform CPR if patient deteriorates.
CommunicationCommunication
• What?– Assessment Finding– Treatments– Result of Treatment
• Who?– Other EMS providers– Receiving Facility personnel
DocumentationDocumentation• What?
– Assessment Finding– Treatments – Result of Treatment
• Where?– PCR– Performance Improvement / Quality
Improvement
Goals Review!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
Questions?Questions?