Epinephrine Auto-Injector
Training Program
Authored and Editied by…
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Ian Malik, NREMT-B, Captain,
Hopewell Valley Emergency Services
Jennifer Morris, EMT-B, Mount Laurel
EMS
Robin Plumer, DO; Medical Director,
Mount Laurel EMS
Stephen Vetrano, DO, EMT-B; Chair,
BLS Subcommittee, MICU Advisory
Council
Disclaimer
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This presentation was created to assist in the education of
EMTs in epinephrine auto injector administration. This
presentation is available for public use and
copying/distribution is encouraged.
It is the intent that this program may serve as the lecture
based portion of a BLS medical director’s epinephrine auto
injector program. A practical program is also encouraged.
The creators and staff of OEMS recognize that an individual
medical director may modify any or all of this presentation
to serve his/her organization’s needs.
The OEMS policy may not be changed under any
circumstances
Objectives
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Identify the common causes of an allergic reaction.
Review the pathophysiology of an allergic reaction.
Identify signs and symptoms of severe allergic reactions
(anaphylaxis).
Review differential diagnosis of anaphylaxis.
Review pharmacology of epinephrine.
Identify protocols for administration of epinephrine autoinjector.
Identify proper storage, handling, and disposal techniques
for the epinephrine auto-injector.
Review documentation and regulatory requirements.
What this program is…
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A review of pathophysiology you
already know
A review of a skill you already know
New State Policy
New State Policy
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December 13, 2006
Epinephrine auto injectors can be stocked
on approved emergency service vehicles
(not required)
MUST be an EMT-B to administer
Squad Must Register with OEMS
• Must have a physician medical director
MEDICAL PRACTICE ACT
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State legislation that defines scope
and role of EMS personnel
Local modifications authorized by
medical oversight physician or board
Usually based on Department of
Transportation (DOT) National
Standard Curricula for each EMT
level
New State Policy
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No change in indications –
allergic reaction & anaphylaxis
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ONLY!
MEDICAL DIRECTION
LIABILITY
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Respondent superior- an individual
supervising a borrowed servant is
ultimately liable for the acts and
omissions of the borrowed servant
while that individual remains under
his supervision
MEDICAL DIRECTION
LIABILITY
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Borrowed servant- a servant directed
or permitted by his master to
perform services for another may
become the servant of such other in
performing the service (i.e.
delegated practice)
MEDICAL DIRECTION
LIABILITY
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Borrowed servant- a servant directed
or permitted by his master to
perform services for another may
become the servant of such other in
performing the service (i.e.
delegated practice)
NJ Regulation
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Epinephrine Auto Injector Interim Policy
Found at
www.state.nj.us/health/ems/documents/epi_
policy.pdf
May be made more stringent by the Medical
Director
Applicable to EMT’s
• Medics and MICN’s/RN’s have the knowledge
base
• Should be familiar with the policy
Allergic Reaction
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Allergic reaction – hypersensitivity to a given
antigen. A reaction more pronounced than would
occur in the general population.
• Acquired hypersensitivity, an individual must first
be exposed or sensitized to the antigen; the body
forms antibodies to fight the allergen. Subsequent
exposure to the antigen results in an allergic
reaction.
• Allergen – an antigen that results in the release of
IgE, resulting in a hypersensitive reaction.
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Anaphylaxis – an acute, generalized, and violent
antigen-antibody reaction that can be rapidly
fatal.
Causes of Allergic Reactions
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Insects (bees, wasps)
Foods (nuts, eggs, shrimp)
Plants (poison ivy, oak, summac)
Medications (antibiotics, NSAIDS)
Other allergens (dust, chemicals, foreign
proteins, hormones, preservatives, X-ray
contrast)
Pathophysiology
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Sensitization – initial exposure to an antigen
(allergen). Usually asymptomatic or very mild
reaction, immune system forms antibodies to
recognize this antigen.
Delayed Hypersensitivity – cellular immunity that
does not involve antibodies. Different from
anaphylaxis. Usually occurs in hours and days
post exposure and commonly manifests as a skin
rash. The rash associated with poison ivy
exposure is an example of delayed
hypersensitivity.
Immediate Hypersensitivity – is commonly
referred to by the public as an allergy.
Pathophysiology (cont)
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When an individual who has been
previously sensitized to an allergen comes
in contact with that allergen the immune
system responds by releasing the antibody
immunoglobulin E (IgE). IgE attaches to
basophiles and mast cells, when the
allergen binds to IgE attached to
basophiles and mast cells histamine and
heparin are released (degranulation).
Sensitization Stage
 Antigen (allergen)
exposure
Antigen
 Plasma cells
produce IgE antibodies
against the allergen
Plasma cell
IgE
 IgE antibodies
attach to mast
cells
and basophils
Mast cell with
fixed IgE
antibodies
Granules
containing
histamine
Anaphylactic Reaction
 More of
same allergen
invades body
 Allergen combines
with IgE attached to
.
mast cells and
basophils,
which triggers
degranulation and
release
of histamine and other
chemical mediators
Antigen
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Mast cell granules
release contents
after antigen binds
with IgE
antibodies
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Histamine and
other mediators
Pathophysiology (cont)
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Histamine is the principal chemical mediator of an allergic
reaction. Histamine acts on H1 and H2 receptors resulting
in;
• Bronchiochonstriction;
• Increased intestinal mobility;
• Vasodilatation;
• Increased vascular permeability;
• Increased secretion of gastric acids.
The action of histamine is the bodies attempt to
minimize exposure to the antigen.
Anaphylaxis
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Massive amounts of histamine and other
substances are released resulting in peripheral
vasodilatation as well as increased vascular
permeability. Massive amounts of plasma may
leak out of capillaries resulting in hypotension.
Release of slow-reacting substance of
anaphylaxis (SRA) causes spasm of the smooth
muscle surrounding the bronchioles resulting in
an asthma like attack.
Clinical Presentation of
Allergies and Anaphylaxis
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Skin
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Flushed
Itching (pruritus)
Hives (urticaria)
Swelling
Cyanosis
Respiratory System
• Respiratory difficulty
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Asthmatics, particularly poorly controlled, have
increased risk of fatality
Sneezing, coughing
Wheezing, stridor
Laryngeal edema
Laryneospasm
Bronchospasm
Clinical Presentation of
Allergies and Anaphylaxis
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Cardiovascular System
• Vasodilatation
• Increased heart rate
• Decreased blood pressure
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Gastrointestinal System
• Nausea and vomiting
• Abdominal cramping
• Diarrhea
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Nervous System
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Dizziness
Headache
Convulsions
Tearing
Clinical Spectrum of Allergic Reaction
Mild
Severe
Nasal Congestion
Hives
Itching
Watery & Itchy Eyes
Cardiovascular Collapse
Respiratory Failure
Some define anaphylaxis as involvement
Of at least TWO organ systems!!!
Common Allergens
Insect Bite Reactions
• Large local reactions, without SYSTEMIC hives
or other involvement of another body system
other than skin, do not raise the risk of
anaphylaxis on next exposure
• Does NOT require
treatment with
Epi-Pen
Common Allergens
Large Allergen Exposure
• People who may not have pre-existing allergy,
but get an overwhelming amount of exposure
• May develop anaphylaxis
Common Allergens
Kissing & Peanut Allergies
• A 15 year old girl with a severe peanut allergy died
after she kissed her boyfriend, who had eaten
peanut butter
•
Recommended to wait up to 5 hours after eating
peanuts to be peanut-free
Common Allergens
Deaths from anaphylaxis in the US
Radiographic
Meds Meds Food Items Insect Stings Latex -
900/yr
400-800/yr
100-200/yr
40-100/yr
3/yr
Clinical Manifestations of Anaphylaxis
Signs/symptoms
Incidence (%)
Urticaria and angioedema
Upper airway edema*
Dyspnea and wheezing
Flush*
Dizziness, syncope, and hypotension
Gastrointestinal symptoms
Rhinitis*
Headache*
Substernal pain*
Itch without rash*
Seizure*
*Symptom or sign not reported in all four series
88
56
47
46
33
30
16
15
6
4.5
1.5
Signs and Symptoms
Common Presentation of Anaphylaxis
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Onset of 30 to 60 seconds following exposure,
may be delayed over an hour.
Sense of impending doom;
Flushed skin;
Pruritus (generalized itching);
Increase heart rate;
Often urticaria (hives).
Signs and Symptoms
Remember –
The more rapidly a reaction develops,
the more potentially severe it can be!!!
Another way of looking at it…
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1. Acute onset of an illness with
involvement of skin/mucus
membranes AND EITHER
• Dyspnea
• Hypotension
Notice no mention of allergen!
Another way of looking at it…
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OR 2. Two or more of the following
that occur rapidly after exposure to a
likely allergen for that patient
• Mucus Membrane/skin involvement
• Dyspnea
• Hypotension
• Persistant GI symptoms
Another way of looking at it…
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OR 3. Hypotension after exposure to
known allergen
Putting it simply….

Anaphylaxis is either….
• Allergy involving 2 or more systems
• Hypotension following exposure to a
known allergen
Signs and Symptoms
Hives
•
Can be a single symptom of an allergic reaction
or the beginning of a cascade.
• Use of epinephrine for hives alone is NOT
warranted.
• Ice packs can be used to relieve itching.
Differential Diagnosis
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History of exposure to an antigen that is an identifiable
trigger, in the presence of signs and symptoms of
anaphylaxis is a reliable indicator of an anaphylactic
reaction.
However, signs and symptoms of allergy/anaphylaxis may
present without the history!
Differential Diagnosis
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In the absence history of exposure, the following should be
considered in the differential diagnosis:
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respiratory difficulty, wheezing, stridor
circulatory collapse, including vasovagal reactions
asthma
foreign body obstruction
pulmonary embolism
epiglottitis
myocardial infarction
hypoglycemia
seizures
overdose of medication
cold urticaria
sulfite or monosodium glutamate ingestion
Niacin ingestion
Conditions that Mimic
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Asthma
• Similar s/s: wheezing
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Foreign Body Obstruction
- Similar s/s: SOB, altered
mental status
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Respiratory Distress
- Similar s/s: SOB, altered
mental status
Conditions that Mimic
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Acute M.I.
• Similar s/s: chest tightness,
SOB, shock
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CHF
• Similar s/s: SOB, altered
mental status, shock
Pharmacology
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Epinephrine Auto-Injector
• Liquid Medication administered by an automatically
injectable needle and syringe system.
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Medication Name
• Generic: Epinephrine
• Trade: Adrenalin ™
• EpiPen® or EpiPen Jr. ®
Pharmacology
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Epi-pen exposed!
Pharmacology
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Twinject
• A two dose system
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2nd dose SQ inject
Not for EMT use
• Anakit
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Old kit
No longer made in US
Being d/c’d in Canada
Also beyond scope
Pharmacology
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Indications
• Signs and symptoms of severe allergic reaction.
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Contraindications
• None in a life threatening scenario-caution in pts
with CAD
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Action
• Bronchodilation – Dilation of airways.
• Vasoconstriction – constriction of blood vessels.
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Side Effects
•Increase in heart rate
•Pallor
•Dizziness
•Chest Pain
•Headache
•Nausea
•Vomiting
•Anxiety, Excitement
Administration Protocol
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Perform scene size-up and initial patient assessment. Do
not delay transport;
Administer 100% oxygen using a non-rebreather mask at a
flow rate of 12-15 lpm, unless the patient is unable to
tolerate the mask, in which case use a nasal cannula at a
flow rate of 1-6 lpm;
Request advanced life support services;
Obtain baseline vital signs and obtain the SAMPLE history.
"SAMPLE history" means the present and past medical
history of a patient, so called because the elements of the
history begin with the letters of the word sample:
Signs/Symptoms, Allergies, Medications, Pertinent past
history, Last oral intake, and Events leading to the injury or
illness;
Conduct the focused assessment and physical exam.
Apply high-concentration oxygen.
Assessing Allergic Reactions
Request ALS
Take baseline vital signs.
Obtain SAMPLE history.
Assessing Allergic Reactions
Any history of allergies?
What was patient exposed to?
How was the patient exposed?
What signs and symptoms does the
patient have?
Assessing Allergic Reactions
Any progression of the signs and
symptoms?
Have any interventions been
performed on the patient?
Administration Protocol
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Initiate treatment with the appropriate
epinephrine auto injector if a patient prsents with
clinical evidence of allergic reaction/anaphylaxis
that may include the following symptoms:
• A chief complaint of respiratory distress.
• Respiratory arrest;
• Signs and symptoms of shock (hypoperfusion) with
an increased heart rate. Look for the following
indications:
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Heart rate of greater than 180 bpm for an infant (0-12
months) and/or blood pressure less than 60 mmHg for an
infant (0-12 months);
Heart rate of greater than 140 bpm for a child (1-12 years)
and/or blood pressure less than 70 mmHg for a child (1-12
years);
Heart rate of greater than 120 bpm for an adult (older than 12
years) and/or blood pressure less than 80 mmHg for an adult
(older than 12 years);
Administration Protocol
• A tightening feeling in the chest and/or throat;
• Wheezing or stridor;
• Altered appearance with restlessness and/or
agitation, seizure, unconsciousness;
• Swelling of the face/tongue/lips or generalized
urticaria;
Administration Protocol
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If the patient possesses his/her own prescribed
Epinephrine auto injector, use theirs if readily
available.
If the patient does not possess his/her own
prescribed Epinephrine auto injector, use the
appropriate Epinephrine auto injector from your
vehicle's stock.
• For patients under 4 years of age, use the pediatric
epinephrine auto injector (0.15 mg).
• For patients 4 years of age or older, use the adult
epinephrine auto injector (0.3 mg).
Estimating Patient Age & Weight
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Pedi-Wheel
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Broselow Tape
• A tool for determining the correct dosage of medications and
equipment sizes for children, based on their length.
Broselow Tape
Broselow Tape
Broselow Tape
Broselow Tape
Broselow Tape
Administration Protocol
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Administer the appropriate Epinephrine
auto injector as follows:
• Check the color of the medication (if able
to view) and the manufacturer's expiration
date. If the medication is discolored
(yellowed) or beyond the expiration date,
do not use;
• Carefully remove the safety cap from the
auto injector;
Remove safety cap.
Administration Protocol
• Place the auto injector firmly against the lateral portion
of the patient's thigh, midway between the waist and
the knee. Firm pressure will activate the spring loaded
mechanism in the auto injector and force the needle
through the patient's clothing and into the thigh
muscles;
Administration Protocol
• Hold the auto injector in place for at least 10
seconds to ensure that the medication is injected;
• Dispose of the auto injector in a biohazard sharps
container or the product container on a temporary
basis;
• Record the location of the injection site, time, dose,
medication name, vital signs and any changes in
the patient's condition after administration of
medication on a patient care report.
Hold firmly in place for ten seconds, then
remove. Massage the area of injection
AI 17©
Administration Protocol
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Continuously monitor the patient (level of
consciousness, level of distress, respiratory rate
and quality, pulse rate and quality, blood
pressure, temperature, etc.).
Maintain normal body temperature.
Notify the receiving hospital if ALS is not
available.
Treating Allergic Reactions
If patient’s condition
IMPROVES:
Continue oxygen
Treat for shock
(preventative)
Treating Allergic Reactions
If patient’s condition
WORSENS:
Treat for shock
Be prepared to use CPR/AED.
Treating Allergic Reactions
No Second Stick!!!
Per NJ OEMS Policy
Treating Allergic Reactions
Exception –
If patient gives Epi-Pen to themselves
prior to squad arrival, or you assist with
their epi pen…
And there is no change in symptoms …
Wait 10 MINTUES!
(before giving EMS dose)
Administration Protocol

Carefully monitor patient for respiratory and/or circulatory
failure. If condition deteriorates, patient may experience
cardiac arrest.
• Respiratory failure

Provide ventilation at a rate of
• Adult 10 to 12 breaths per min.
• Child/Infant 12 t0 20 breaths per min.
• Cardiac Arrest
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If witnessed immediate AED if available
If unwitnessed or asphyxial 2 min. CPR then AED
Compression Ratio
• 30:2 Adults and 1 rescuer child/infant
• 15:2 two rescuer child/infant
Treating Allergic Reactions
The patient’s condition may be
stable initially but deteriorate to the
point where he/she needs
aggressive airway management.
Call ALS/Do not delay tranport!
Best you can do: oral/nasal
airways
Administration Protocol
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Leave a copy of the patient care report at the
receiving hospital.
Deliver a copy of the patient care report to the
physician medical director. The medical director
shall review all instances of the use of
epinephrine auto injectors for quality assurance.
Provide agency specific notifications to ensure
appropriate reporting to OEMS.
• 72 hours verbal, 45 days written
• Have ED diagnosis and disposition when possible
Treating Allergic Reactions
Recurrent Anaphylaxis
• Reappearance of allergic symptoms following complete
resolution of original reaction, and WITHOUT re-exposure to the
offending allergen
• May involve mild or severe symptoms, may be =
or more severe than initial
reaction
in severity
Treating Allergic Reactions
Recurrent Anaphylaxis cont.
• Can occur in up to 20% of cases, up to 72
initial event.
• Large antigen load
• Repeat internal exposure (i.e. insect venom)
hours
after
Treating Allergic Reactions
Accidental Auto-Injection of Epi-Pen
• Most often occurs to a finger
• Potentially can cause local tissue death
• Often can be treated with application
of heat, local massage,
topical nitrates.
• Requires IMMEDIATE ED visit!
Storage
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Must be kept btwn 59-74 degrees F
Thermos Bottle to insulate
Medical grade IV fluid warmers or
incubators
Commercial 12-volt heater/cooler
containers
Don’t mix food and stored meds!