Epinephrine
Administration by the EMT
Training Module 2013
WVOEMS Approved Education
MPCC addition of skill set and treatment options
for EMT Protocol changes 02-01-2013
Learning Objectives
With successful completion of this training module, the EMT will be
able to describe and/or correctly demonstrate …
•
Epinephrine identification as a medication
•
Identify steps in aseptic technique
•
Preparation Epinephrine for administration
•
Administer Epinephrine via the IM route
•
Evaluate the mechanism of action and effects of Epinephrine
EMT Utilization of Epinephrine
• 6501-Allergic Reaction (Anaphylaxis)
• 6302-Respiratory Distress (Bronchospasm)
• In both protocols Epi can be given by an EMT
with Medical Command contact
• Auto-injectors may be utilized in both
protocols as well as IM Injection
Key Terms
Anaphylaxis - a life-threatening, hypersensitivity reaction of the
immune system
Aseptic technique - a procedure performed under sterile
conditions
Asphyxia - suffocation as a result of blockage of the airway
Dyspnea - labored or difficult breathing
Epinephrine - a hormone released from the adrenal glands that
activates several tissues in the “fight-or-flight” response
Histamine - one of several chemical messages released from
immune cells that promote inflammation as a defense
mechanism
Intramuscular - a medication route by injection into the belly of a
muscle which encourages rapid transport by the bloodstream
Shock - a severe reduction in blood pressure (by any cause) that
results in inadequate blood flow (oxygen & glucose) to tissues
What is Epinephrine…
• A synthetic reproduction of the naturally
occurring hormone Epinephrine
• Released during “fight or flight” responses
– reflex stimulation of the adrenal gland
– sympathetic division of the autonomic nervous
system
What is Epinephrine
• A catacholamine, sympathomimetic
• Acts on cardiovascular system
– Increases the strength of heart muscle
contraction
– Increases heart rate
– Increases systolic blood pressure
• Acts on respiratory system
– Bronchodilation
Actions of Epinephrine
•
•
•
•
Relaxes smooth muscle in the airways
Counteracts histamine and other cytokines
Raises blood sugar level
Raises heart rate, blood pressure, and
myocardial oxygen demand
For Intramuscular injection of Epinephrine…
Onset of effect:
3-5 min
Duration of effect: 1-4 hours
Epinephrine Precautions
• DO NOT give epinephrine to these patients:
– ONLY hives, flushing or itching
– Ongoing chest pain
• Use caution (contact Medical Command)
when giving epinephrine to patients with a
history of heart attack, angina, or stroke
Epinephrine Considerations
• Give epinephrine with a clear history of insect
bite or sting, or history of other allergy
• MUST have at least one of the below signs
and symptoms of severe allergic reaction
– Respiratory Tract
• Wheezing, Stridor, Shortness of Breath
– Skin
• Facial swelling involving lips, tongue, mouth (airway
involvement)
– Cardiovascular
• Dizziness, HR>120, BP <90, AMS
Epinephrine Onset
• IM/SC, 5-15 minutes
• Danger:
– IV onset immediate, however at the 1:1000
concentration can cause arrhythmia and death
– This is the reason for drawing back on syringe
prior to injection to ensure you are not in a
vessel
Side Effects of Epinephrine
•
•
•
•
•
•
•
•
•
Palpitations
Tachycardia & arrhythmias
Hypertension
Headache
Tremor, weakness
Pallor, sweating
Nausea & vomiting
Nervousness & anxiety
Pain, redness at the injection site
Medication Packaging
• Name of medication
• Concentration (1:1,000 or 1mg/1ml)
• Expiration date
Indications for Use
EMTs may administer Epinephrine for:
• Allergic Reaction/Anaphylaxis
• Respiratory Distress/Bronchospasm
Dosage
• Epi Pen Auto Injector
Dosage:
Adults - 0.30 mg of 1:1,000
Pediatrics - 0.15 mg of 1:2,000
• IM Injection Drawn Up
Dosage:
Adults - 0.30 mg of 1:1,000
Pediatrics - 0.30 mg of 1:1,000
• Is 0.3 mg of Epi ever too much?
• Can you really overdose a child?
Special Considerations
SPECIAL CONSIDERATIONS
Assessment
1. Known or suspected exposure to allergen. Sting? If unclear contact base.
2. History of allergic reactions
3. Medication use prior to arrival. AnaGuard/Epi-pen, Benadryl?
4. PMH: heart disease, stroke, hypertension?
5. Medications: Beta-blockers (atenolol, propranolol)? May block effects of epinephrine
6. Vital signs including mental status
7. Respiratory status: Airway swelling? Wheezes? Stridor?
Medication Issues
Use epinephrine with caution in the following patients (contact base when possible but do not withhold if
patient in severe distress and base contact cannot be made easily):
Over 70 years of age
History of heart disease, stroke or hypertension.
Taking a beta-blocker (example: atenolol, propranolol)
Transport Priorities: Any patient with signs or symptoms of a severe reaction requires immediate
evacuation. Consider helicopter and/or rendezvous with higher level of care unless symptoms responding
well to therapy.
Anaphylaxis is an over-reaction of the
Immune System
• Sudden, severe allergic reaction involving the
whole body (systemic)
• multisystem involvement, including the skin,
airway, vascular system, and GI
• Most common allergens: insect sting, food,
medication, latex
• Widespread immune system response
causes itching, hives & swelling
• May also cause circulatory shock; tracheal
and bronchial swelling resulting in asphyxia
Allergic Reactions
• Range from mild to life threatening
• Early symptoms may be vague
• Classic skin signs are urticaria, (hives)
– Red, itchy raised welts anywhere on the body
• Swelling of face, lips, eyes
• Symptoms can occur seconds after exposure
or up to 30 minutes
Mild Reactions
• Itching
• Hives
• Redness
• Treatment is close observation and watching
for progression of symptoms
Severe Reactions
• Respiratory Tract
• Skin
• Cardiovascular
Respiratory Tract Signs and Symptoms
•
•
•
•
•
Wheezing
Upper airway noisy breathing (stridor)
Chest and throat tightness
Shortness of Breath
Nasal congestion*
– *alone does not indicate a severe reaction
Skin – Signs and Symptoms
• Facial Swelling
– Involving lips, tongue, mouth (airway
involvement)
• Redness*
• Hives*
• Itching*
– *alone does not indicate a severe reaction
Cardiovascular Signs and Symptoms
• Decreased Blood Pressure (<90)
• Increased Heart Rate (>120)
• Severe Dizziness
• Fainting
• Decreased Mental Status
– confusion, lethargy, coma
EMT Treatment
• Ensure an open airway
• Administer oxygen
• History and Physical
• Vital signs
• Epinephrine
Intramuscular Drug
Administration
Intramuscular Drug Administration
THE SIX “RIGHTS”
1.
2.
3.
4.
5.
6.
Right person
Right drug
Right dose
Right time
Right route
Right documentation
Intramuscular Drug Administration
Intramuscular sites allow a drug to be injected into the
belly of a muscle so that the blood vessels supplying
that muscle distribute the medication to its site of
action via the bloodstream.
First steps:
1. Prep the site with approved antiseptic by scrubbing
vigorously and allowing to dry. DO NOT TOUCH,
BLOW ON OR FAN THE INJECTION SITE!
2. Align the syringe and needle above the injection site
at a 90 degree angle, with the bevel of the needle
facing up.
NOTE: IM Injections CANNOT be administered through
clothing as the auto-injectors could.
Intramuscular Drug Administration
90º
Administration Sites
Deltoid
Dorsogluteal
Ventrogluteal
Vastus lateralis
Needle Handling
• Minimize the tasks performed in a moving
ambulance.
• Immediately dispose of used sharps in a
sharps container.
• NEVER recap needles.
Ampules and Vials
Store epinephrine AWAY from light; leave it in its carton
until ready to use. Also keep away from extreme heat
and danger of freezing.
Ampules
Vials
Document all information concerning the
patient and medication, including:
1.
2.
3.
Indication for drug administration
• include appearance, work of breathing, vitals, lung
sounds, skin signs, and ability to speak
Drug, dosage, and delivery site
Patient response to the medication
• include appearance, work of breathing, vitals, lung
sounds, skin signs, and changes in ability to speak
• both positive and negative responses
Obtaining Medication from a
Glass Ampule
Common Packaging of Epinephrine
•
•
•
•
Medication name
Dosage (1:1,000 or 1mg/1ml)
Expiration date
Not cloudy; no color or precipitate
Hold the ampule upright and tap its top
to dislodge any trapped solution.
Place Gauze around the neck
Snap off the Top
Draw up the Medication
Using a 1cc syringe, insert the needle into the ampule
and draw the plunger back on the syringe until you
reach the correct dosage (0.30cc).
Consideration


WVOEMS does not require the use of a
filtered needle when drawing from an
ampule.
Individual squads may have policies in
place that require the use of a filtered
needle. Please refer to your squad
training officer.
Obtaining Medication
from a Vial
Epinephrine in a Vial


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Medication name
Dosage (1:1,000 or 1mg/1ml)
Expiration date
Not cloudy; no color or precipitate
Prepare the syringe and
hypodermic needle
Clean the vial’s rubber top
Insert the hypodermic needle
into the rubber top and inject
the air from the syringe into
the vial.
Withdraw the appropriate
volume of medication
Using a 1cc (ml) syringe, insert the needle
into the vial or ampule, draw the plunger
back on the syringe until you reach 0.3cc
(ml) mark on the syringe.
Administration
• Prepare the site –
– Vigorously rub an alcohol prep in a circular motion
– Allow to air dry
– Use your fingers to stretch skin and make it taut
• Insert needle at a 90 degree angle
• Draw back slightly to insure you have not
cannulated a vessel.
• Push slow and steady until medication is
administered
• Remove needle and cover puncture site
• Dispose of needle properly
Assessment of Medication Response
Document patient’s response to treatment:
• LOC, behavior, breathing effort, lung sounds,
skin signs, vital signs, and changes in ability
to speak
• Document adverse effects, if any
The body’s stress response causes the normal release of
epinephrine to maintain homeostasis during vigorous activity:
“fight or flight”. These same actions of epinephrine counteract
e.g. the bronchoconstriction and low blood pressure of
anaphylaxis when administered by medical personnel.
Airway
dilation
Breathing
rate
increases
Blood flow to
skeletal muscles
increases
EPINEPHRINE
Blood pressure
increases
Heart rate
increases
Pupils
dilate
Blood sugar
level increases
Document Vital Signs before and after
treatment with Epinephrine
Because epinephrine is expected to cause
widespread changes in function, it is
important to frequently monitor and document
vital signs:
• HR, RR, BP
• include general appearance, work of
breathing, lung sounds, skin signs, and ability
to speak
Always Wear PPE
• Wear gloves and goggles when assessing
the patient, preparing the medication,
cleaning the site of injection, and
administering the drug.
Vastus lateralis (lateral thigh)
is the approved site for administration
Vastus lateralis (lateral thigh)
is the approved site for administration
• Good site for all
ages
• Far from major
blood vessels &
nerves
• Medical
Command may
authorize other
sites
If no significant improvement within 10
minutes, consider second dose
• If patient is wheezing consider, Albuterol
nebulizer 2.5 mg with oxygen 8-10 LPM per
order of MCP
• Second dose of Epinephrine requires
consultation and order of MCP. It is indicated
if patient remains in moderate distress
Equipment Size
• Syringe
– The EMT should chose a 1 cc (ml) syringe
– DO NOT select a 1cc (ml) insulin syringe with a
subcutaneous injection needle attached
• Needle Size - Adult
– Hypodermic needle 21 to 23 gauge
– 1 to 1.5 inches long
• Obese patients may require a 2 inch long needle
• Needle Size - Pediatric
– Hypodermic needle 25 to 27 gauge
– 1 inch long
EMT Epinephrine Administration
Scope:
Indications:
Equipment:
EMT
Anaphylaxis (allergic reaction with respiratory distress); Bronchospasm
Epinephrine kit containing:1, 1 ml ampule of epinephrine 1:1000, 1 tuberculin syringe
with needle, alcohol prep
Procedure:
1. Refer to Allergic Reactions and Respiratory Distress Protocols for detailed assessment.
2. Ask patient if they have any drug allergies.
3. Confirm medication, concentration, dose and clarity of liquid in vial
4. Tap ampule to get medicine down from top, break top off ampule with gauze 2x2, place top in sharps
container.
5. Draw up 0.3cc (ml) of epinephrine 1mg/ml 1:1000, syringe approximately 1/3 full.
6. Pointing syringe up, expel all air.
7. Inform patient they are going to receive an injection, side effects may include feeling shaky or heart
racing.
8. Select and cleanse area for Intramuscular injection, primary is the thigh unless directed otherwise by
medical command.
9. Keeping the skin taut, insert needle at 90 degrees into administration site and draw back checking for
blood return. If there is blood return, select a different site, and insert needle, again check for blood
return.
10. If no blood, administer 0.3 cc (ml) of epinephrine (1/3 of syringe) for any patient.
11. Discard needle properly in sharps container.
12. Observe patient for improvement or deterioration of condition. Repeat exam and vitals after each
dose.
13. Document procedure, vitals and response to treatment.
14. If an additional dose is required consult Allergic Reactions and Respiratory Distress Protocols.
15. If indicated by protocol, begin again from step 5.
Potential Pitfalls
• Dose Error
– Drawing up epinephrine can potentially result
in over or under dosing
– Concentration error – (1:10,000) vs (1:1000)
since both drugs are available
– Administration error – epinephrine given IV
instead of IM/SQ
• Drug Error
– Giving the correct dose of the wrong drug
– Who stocks the EMT drugs?
• Potential to stock the wrong drug
Questions ?