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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.

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Epinephrine administration by the emt training module 2013

EpinephrineAdministration 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
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
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
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
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 epinephrine1
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
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
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
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
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
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
Medication Packaging

  • Name of medication

  • Concentration (1:1,000 or 1mg/1ml)

  • Expiration date


Indications for use
Indications for Use

EMTs may administer Epinephrine for:

  • Allergic Reaction/Anaphylaxis

  • Respiratory Distress/Bronchospasm


Dosage
Dosage

  • Epi Pen Auto Injector

  • IM Injection Drawn Up

Dosage:

Adults- 0.30 mg of 1:1,000

Pediatrics- 0.15 mg of 1:2,000

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

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
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
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
Mild Reactions

  • Itching

  • Hives

  • Redness

  • Treatment is close observation and watching for progression of symptoms


Severe reactions
Severe Reactions

  • Respiratory Tract

  • Skin

  • Cardiovascular


Respiratory tract signs and symptoms
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
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
Cardiovascular Signs and Symptoms

  • Decreased Blood Pressure (<90)

  • Increased Heart Rate (>120)

  • Severe Dizziness

  • Fainting

  • Decreased Mental Status

    • confusion, lethargy, coma


Emt treatment
EMT Treatment

  • Ensure an open airway

  • Administer oxygen

  • History and Physical

  • Vital signs

  • Epinephrine



Intramuscular drug administration1
Intramuscular Drug Administration

THE SIX “RIGHTS”

  • Right person

  • Right drug

  • Right dose

  • Right time

  • Right route

  • Right documentation


Intramuscular drug administration2
Intramuscular Drug Administration

Intramuscularsites 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:

  • Prep the site with approved antiseptic by scrubbing vigorously and allowing to dry. DO NOT TOUCH, BLOW ON OR FAN THE INJECTION SITE!

  • 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 administration3

90º

Intramuscular Drug Administration



Epinephrine administration by the emt training module 2013

Deltoid

Dorsogluteal

Ventrogluteal

Vastus lateralis


Needle handling
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
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.

Vials

Ampules


Epinephrine administration by the emt training module 2013

Document all information concerning the patient and medication, including:

  • 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



Common packaging of epinephrine
Common Packaging of Epinephrine

  • Medication name

  • Dosage (1:1,000 or 1mg/1ml)

  • Expiration date

  • Not cloudy; no color or precipitate



Place gauze around the neck
Place Gauze around the neck trapped solution.


Snap off the top
Snap off the Top trapped solution.


Draw up the medication
Draw up the Medication trapped solution.

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
Consideration trapped solution.

  • 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
Obtaining Medication trapped solution.from a Vial


Epinephrine in a vial
Epinephrine in a Vial trapped solution.

  • Medication name

  • Dosage (1:1,000 or 1mg/1ml)

  • Expiration date

  • Not cloudy; no color or precipitate


Prepare the syringe and hypodermic needle
Prepare the syringe and trapped solution.hypodermic needle



Insert the hypodermic needle into the rubber top and inject the air from the syringe into the vial
Insert the hypodermic needle into the rubber top and inject the air from the syringe into the vial.


Withdraw the appropriate volume of medication
Withdraw the appropriate volume of medication the air from the syringe into the vial.

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
Administration the air from the syringe into the vial.

  • 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
Assessment of Medication Response the air from the syringe into the vial.

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


Epinephrine administration by the emt training module 2013

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.

EPINEPHRINE


Document vital signs before and after treatment with epinephrine
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
Always Wear PPE Epinephrine

  • Wear gloves and goggles when assessing the patient, preparing the medication, cleaning the site of injection, and administering the drug.


Epinephrine administration by the emt training module 2013

Vastus Epinephrinelateralis (lateral thigh)is the approved site for administration


Vastus lateralis lateral thigh is the approved site for administration
Vastus Epinephrinelateralis (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


Epinephrine administration by the emt training module 2013

If no significant improvement within 10 Epinephrine

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
Equipment Size Epinephrine

  • 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
EMT Epinephrine Administration Epinephrine

Scope: EMT

Indications: Anaphylaxis (allergic reaction with respiratory distress); Bronchospasm

Equipment: 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
Potential Pitfalls Epinephrine

  • 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
Questions ? Epinephrine