Epinephrine Auto-Injector - PowerPoint Presentation

Slide1

Epinephrine Auto-Injector

Program Approved by the

Los Angeles County EMS AgencySlide2

Special Thanks for the Development of this Program

UCLA Center for Prehospital Care

Los Angeles County EMS Agency Curriculum CommitteeSlide3

This training program meets the regulatory requirements for training of EMTs in the administration of the epinephrine via auto-injector.

Other

counties

may have

different

policies,

procedures,

and

training

requirements.Slide4

Objectives

Review history and physical assessment of the patient with a complaint of asthma and/or anaphylaxis.

Review the causes and pathophysiology and initial treatment of asthma and anaphylaxis.

Discuss the scope of practice changes for the use of auto-injectors by EMT’s.

Understand the indications, mechanism and actions, adverse effects, dosage, contraindications of epinephrine injection.Slide5

Objectives

Understand the assessment indications for the EMT to administer epinephrine in L. A. County.

Discuss the procedure to check a medication before administration.

Demonstrate the ability to successfully administer epinephrine by auto-injector using the L. A. County Skill sheet.

Know the appropriate documentation needed for medication administration in L. A. County.Slide6

Scope of Practice

An EMT Provider Agency may

stock

an epinephrine auto-injector

on the ambulance or fire apparatus if they have applied and have been approved by the EMS Agency Medical Director to do so.

An EMT may use the epinephrine auto-injector stocked in the unit when they are on duty and working for the EMS provider agency that has been approved by the EMS Agency Medical Director.

Reminder: An EMT may assist the patient with the patient’s own prescribed epinephrine.Slide7
Slide8

Causes

and

Pathophysiology

of

Asthma and

AnaphylaxisSlide9

Asthma Attack

Causes

Insect

stings

Air

pollutants

Infection (URI)

Weather

Strenuous

exercise

Psychological

stress

Irritants

ObesitySlide10

Asthma

Pathophysiology

Inflammation plays a lead role

Cellular response (epithelial cells)

 Airway Inflammation

 Bronchoconstriction

Immune system responseSlide11

Anaphylaxis/Shock

Cause

Allergic reaction to:

Insects

Animals (dander)FoodsPlants

Medications (Aspirin)

Products / ChemicalsSlide12

Anaphylaxis/Shock

Pathophysiology

Foreign protein (antigen) enters body

Causing the release of histamines, which cause:

Blood vessels dilateCausing drop in blood pressure

Capillaries leak

 swelling (edema)

Tissues lining the airways and bronchioles swell



bronchial constriction





air movement to the alveoliSlide13

History / ClinicalSigns AND Symptoms

of

Asthma and AnaphylaxisSlide14

Asthma Attack History

History

(OPQRST)

O

nset – gradual vs. sudden and when it began

P

rovokes - what caused event

Q

uality - adequate ventilations, tidal volume

R

ate/Re-occurrence/Relief - fast, slow, irregular, patterns

S

everity – mild, moderate, severe

T

ime – duration of current episode

H

as patient ever been intubated for asthma?Slide15

SHORTNESS

OF BREATH SEVERITY SCALE

S/S

MILD

MODERATE

SEVERE

Dyspnea

When walking

When talking

At rest

Speech

Full sentences

Phrases or partial sentences

Single words

Heart Rate

Borderline Tachycardia

100-120bpm

>120bpm

Respiratory Rate

Tachypnea

Tachypnea

>30/min

Breath Sounds

Mild wheezes at the end expiration

Throughout expiration

Inspiration and expiration

Accessory

Muscle Use

None

Common

All

Mental Status

Anxious

Agitation

Drowsy to agitated

Body Position

Normal posture

Sits upright

Tripod position

Skin Signs

Normal – warm, normal color, dry

Cool, pale, dry,

Cool, pale, moist (diaphoretic)Slide16

Asthma

Attack

Symptoms

Shortness of

breath

Difficulty

in

speaking

Tightness

in

chest

Scared / Feeling

of

impending

doom

Signs

Sitting

upright

(

Tripod

position)

Use of accessory

muscles

Wheezing

Cyanotic

TachycardiaSlide17

ANAPHYLAXIS History

History

(OPQRST)

O

nset – gradual vs. sudden and when it began?

P

rovokes – What were they exposed to?

Q

uality - adequate ventilations, tidal volume

R

ate/Re-occurrence/Relief - fast, slow, irregular, patterns

S

everity – mild, moderate, severe

T

ime – When did you come into

contact with the allergen?

H

as patient ever been intubated for anaphylaxis?Slide18

Anaphylaxis/Shock

Symptoms

Moderate to severe SOB

Tightness in chest

Feeling of impending doom

Signs

Flushed skin

Generalized hives

Swelling of face, lips, eyes, tongue, mouth

Muffled voice

Wheezing

Stridor

Skin

Pale, cool, moist , cyanotic

Tachypnea

Tachycardia

HypotensionSlide19

ALLERGIC REACTION VS. anaphylaxis

(PrehospitAl Emergency Care, 11

th

edition, Mistovich)

SYSTEM

ALLERGIC

ANAPHYLACTIC

Respiratory Complaints

Sneezing, coughing, mild dyspnea

Moderate to severe dyspnea, tightness,

Respiratory Sounds

Wheezing

Wheezing, muffled voice, stridor

Skin Texture

Local hives

Generalized hives

Skin Color

Possible pallor, mild

SwellingLocal swelling

Swelling

of face, lips, eyes, tongue, injection site

Vital Signs

Normal or nearly normal vital signs

Tachycardia, hypotension, tachypnea,

 SPO2

Mental Status

Mild, moderate, or severe anxiety

Feeling of impending

doomSlide20

Initial Treatment

of

SEVERE Asthma & anaphylaxis

Reassure patient and make them comfortable

Calming approachPositioning

Remove restrictive clothing

Administer oxygen*

Assist in the patient with their own medication administration**

Reassess vital and physical signs

*

G

oal

is

to

administer

the

minimum amount

of

oxygen to meet the needs of the patient and to maintain an oxygen saturation at or above 94%** Do not delay oxygen administration in critical patientsSlide21

Epinephrine Auto-InjectorSlide22

Primary Assessment

General Impression

Life Threating Condition*

Mental Status/Stimulus (AVPU)

Assess and Management of Airway and Breathing*

* IMMEDIATELY consider high flow oxygen, assisted ventilations, and use of a metered dose inhaler (MDI)Slide23

Secondary Assessment

SAMPLE

Focused assessment of the specific body regions

How fast has the shortness of breath occurred

Time of onsetBaseline vitals (continue to monitor)Skin signs

Accessory muscle use

Lung sounds / Stridor

Obtain oxygen saturation SpO2 (if available)

NOTE: Patients with asthma and anaphylaxis can deteriorate rapidly, you must constantly reassess the patient for changing signs and symptomsSlide24

Criteria for Assisting Patients with their own Medications

ALS unit has been requested

Prescribed to the patient

Meets indications

No contraindicationsSlide25

EpinephrineMechanism of Action

Hormone that causes:

Beta 1 and Beta 2 effects

Bronchodilation

Relaxes smooth muscle

Opens constricted bronchioles

Vasoconstriction

Reverses shock

Increases blood pressure

(SNS) Fight or flight effects (sympathetic nervous response):

Increases pulse rate

Reduces shortness of breathSlide26

EpinephrineMechanism of Action

Fight or flight effects (sympathetic nervous response Beta 1 & Beta 2 response):

Increased heart rate (1)

Increased blood pressure (1)

Increased contractility of the heart (1)

Increased AV conduction (1)

Bronchodilation (2)

Blood vessel dilation in skeletal musclesSlide27

Epinephrine

Adverse (side) Effects

Cardiovascular

Tachycardia

Hypertension

Chest Pain/Angina

Arrhythmias

Increase oxygen demand

Central Nervous System

Seizures

Tremors

Cerebral hemorrhage

Dizziness

Anxiety

Nervousness/restlessness

Headache

Gastrointestinal

Nausea/vomiting

RespiratoryTachypneaBronchodilationSlide28

Indications for Epinephrine

IN Anaphylaxis

Signs and symptoms of anaphylaxis

Severe shortness of breath

Wheezinginspiratory and expiratory

Stridor

Hypotension (BP < 90)

Flushed, pale, cool, or moist skin

Pulse thready / Unobtainable

The patient is awake but you cannot feel a pulse, or it is very weakSlide29

Indications for Epinephrine FOR SEVERE Asthma

Signs and symptoms of

severe asthma

:

Sitting forward (tripod position)Nasal Flaring

Using accessory muscles

Chest, back and abdominal

Wheezing (Inspiratory and expiratory)

Speaking in 2-3 word sentences

Cyanosis

Cool, Diaphoretic skin signsSlide30

Contraindications for Epinephrine ADMINISTRATION

There are no absolute contraindications to the use of epinephrine if the patient is experiencing life threatening anaphylaxis and asthmaSlide31

Epinephrine Auto-Injector

ProcedureSlide32

Types of Auto InjectorsSlide33

Most Common Auto InjectorsSlide34

Procedure

Calls for an Advanced Life Support Unit

Check medication* (DICCE)

D

rug - Confirm proper medication I

ntegrity of container/medication

C

oncentration/dose

C

larity

E

xpiration date

* If

problem

do

not use

injectorSlide35

Criteria for administering Epinephrine by an EMT

An ALS unit must be contacted and

enroute

if administering epinephrine.

EMTs may transport the patient if the ETA for the ALS unit exceeds the ETA to the most appropriate emergency department.Slide36

Epi-Pen®

Adult and Pediatric Dose

Adult EpiPen® Dose

0.3mg

Pediatric EpiPen® Dose

0.15mg

15 – 30 kg (33 – 66

lbs

)

May repeat adult/pediatric dose in 10 minutes if ALS is > 10 minutes, or if transporting, the ETA to the closest ED is > 10 minutes

The auto-injector dose of epinephrine is different than the ALS weight-based doseSlide37

EpinephrineOnset and Duration

As

quick as

5-10

minutes

Peak

effects

within 20

minutes

May

last

in the

body

for

4

to

6 hoursSlide38

Injection Site

Remove clothing from thigh area.

It is

NOT

recommended for EMTs to inject through clothingThe only approved site for auto-injector is the upper outer thighMidway between the groin and the kneeSlide39

Intramuscular injection

Auto-injector

Cleanse injection site with alcohol wipe

Cleanse in a circular motion from inner to outerSlide40

Intramuscular injection

Auto-injector

Remove auto injector from protective case

Remove safety cap from injector

Place tip of injector at 90 degrees to the upper outer thighSlide41

Intramuscular injection

Auto-injector

Forcefully push the tip firmly into thigh until you hear a “click”

Hold in place for at least 3 seconds

Remove injector and place in sharps containerSlide42

Intramuscular injection

Auto-injector

Evaluate the patient response

Respiratory - effort, rate, and volume

Cardiovascular - heart rate and skin signsMental status - AVPU

Lung soundsSlide43

Re-assessmentEPIPEN Auto-injector

Reassess the patient

at least

every 5 minutes

Primary assessmentRelevant portion of the secondary assessmentVital signs

Manage patient’s condition as indicated

Administer a repeat dose of epinephrine in 10 minutes if indicatedSlide44

RE-ASSESSMENT Intramuscular injection

Auto-injector

Transfer

of Care/Transport

Provide transfer of care to Advanced Life Support Unit

If epinephrine administration is required, an ALS Unit must be contacted and be enroute. However, if the ETA for the responding ALS unit exceeds the ETA to the most appropriate emergency department, the EMT should consider transporting the patient.

Contact the receiving ED with ETASlide45

Patient Report and Documentation

Documentation must be on the Provider’s form or ePCR.

Document medication administration in the appropriate section.

Make sure all assessment findings are well documented, including any reassessment findings of patients response to epinephrine

Ongoing re-assessment information must be documented on the provider’s form or ePCR.Slide46

Skill Demonstration and Verification

You will be given the opportunity to practice the auto-injector skill

You will required to demonstrate competency in the administration of epinephrine by auto-injector, using the L. A. County EMS Agency skill sheetSlide47

References

California Code of Regulations Title 22, Division 9, Chapter 10

L. A. County EMS Agency Administration of Epinephrine by Auto-injector Supplemental Information

L. A. County Medication Administration, Epinephrine Auto-Injector skill sheet