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Epinephrine auto injectors. Anaphylactic Reaction Protocol Changes Aaron J. Katz, AEMT-P, CIC. Overview. Not just “Any allergic reaction”! Once you see it – you’ll never forget it! Reactions tend to worsen with each “exposure” You have a responsibility to educate patients and families.

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Epinephrine auto injectors

Epinephrine auto injectors

Anaphylactic Reaction

Protocol Changes

Aaron J. Katz, AEMT-P, CIC


  • Not just “Any allergic reaction”!

  • Once you see it – you’ll never forget it!

  • Reactions tend to worsen with each “exposure”

  • You have a responsibility to educate patients and families

Some interesting cases
Some interesting cases

  • Post Dental Visit

  • Bee Sting (2 cases)

  • Cookies with hidden nuts

  • Milk – 6 month old

  • Milk – 2 year old

  • Touched the fish

  • Penicillin shots

  • Allergy injections

  • The cheese danish

  • Neighborhood “X”


  • Anaphylactic shock is a potentially life threatening emergency

  • This condition has a high mortality rate when not recognized and treated early

  • With allergies increasing, mortality has also increased

  • We don’t know why allergies are increasing

Introduction cont
Introduction Cont.

  • Hatzoloh responds to approximately 400 calls per year for anaphylaxis of which 15% are of patients with true anaphylactic shock

  • Patients in anaphylactic shock are those that benefit from epinephrine injections

  • ALS units are not always readily available

  • More of a problem for FDNY/EMS?


  • Many studies have shown that the use of an EPI- PEN can be safely administered by an EMT

  • The EMT must be appropriately trained


  • Early recognition of anaphylaxis

  • Early BLS intervention

  • Early ALS intervention

  • Administration of Epinephrine using the Epi-Pen Auto injector


  • Allergic reaction – immune response to any substance.

  • Reaction can be localized or severe and life threatening (anaphylaxis)

  • Allergen – substance that causes the immune response

Common allergens
Common allergens

  • Insects – bees, wasps

  • Food – nuts, fish, milk, chocolate

  • Plants – poison ivy, oak

  • Medications – antibiotics

  • Other – outdoor allergens, fragrances

  • Latex

Epinephrine auto injectors

  • Swelling to face, neck, hands, feet, tongue and periorbitally

  • Urticaria – hives

  • Itching

  • Erythema – redness

  • Flushed skin

  • Warm tingling feeling to face, mouth, chest, feet and hands

Respiratory system
Respiratory system

  • Tightness to throat and chest

  • Cough

  • Tachypnea

  • Labored breathing

  • Hoarseness

  • Noisy breathing – stridor or wheezing

  • bronchoconstriction

Cardiovascular system
Cardiovascular system

  • Tachycardia

  • Vasodilation

  • Hypotension

  •  Poor cardiac output!

Other systems
Other systems

  • Itchy, watery eyes

  • Headache

  • Sense of impending doom

  • Runny nose, nasal congestion

  • Decreased mental status

  • Abdominal distress

Critical point
Critical Point

  • Findings that reveal hypoperfusion (shock), or respiratory distress (upper airway obstruction, lower airway disease, severe bronchospasm ) may indicate the presence of a severe allergic reaction (anaphylaxis)

Past treatment protocol
Past Treatment Protocol

  • Perform initial assessment

  • Perform focused history and physical exam, including:

    • History of allergies

    • What was patient exposed to

    • How were they exposed

    • Effects

    • Time of onset

    • Progression

    • interventions

Past treatment cont
Past Treatment Cont.

  • Assess baseline vital signs and SAMPLE history

  • Administer high concentration oxygen

  • Monitor breathing for adequacy

  • Request ALS assistance

  • Assist the patient with self-administration of their own prescribed Epinephrine

  • Loosen restrictive clothing or jewelry

  • Assess for shock and treat if appropriate

New treatment protocol patients over age 9 or weighing over 30 kilos
New Treatment Protocolpatients over age 9 or weighing over 30 kilos

  • Determine that patients history includes past history of anaphylaxis, severe allergic reactions, and/or recent exposure to an allergen

  • Administer high concentration oxygen

  • Request ALS assistance

  • Assess the cardiac and respiratory status of the patient


  • If both the cardiac & respiratory status of the patient are normal, initiate transport

  • If either the cardiac or respiratory status of the patient is abnormal, proceed as follows:


  • If the patient has severe respiratory distress or shock and has a prescribed Epi-Pen assist the patient in administration

  • If the auto injector is not available or expired and the EMS agency carries one, administer (0.3 mg.) as authorized by the agency medical directors

  • If the patient does not have a prescribed Epi-Pen, begin transport and contact medical control for authorization to administer 0.3 mg via auto injector

Epinephrine auto injectors

  • If unable to make contact with on-line medical control and the patient is under 35 years old, you may administer 0.3 mg epinephrine via an auto-injector if indicated.

  • The incident should be reported to medical control or your medical director as soon as possible

Protocol cont
Protocol cont.

  • Contact medical control for authorization to administer a second dose if needed

  • Refer to other protocols as needed (resp distress/failure, obstructed airway, shock)

  • If patient arrests treat as per the non-traumatic cardiac arrest protocol

Pediatric differences
Pediatric differences

  • The age for pediatrics in this protocol is patients under 9 years old or weighing less than 30 kg (66 lbs)

  • The dose of epinephrine is 0.15 mg

  • It can not be given without medical control authorization

Pharmacology epinephrine
Pharmacology - Epinephrine

  • Medication name:

    • Generic – Epinephrine

    • Trade – Adrenalin

Pharmacology epinephrine cont
Pharmacology – Epinephrine cont

  • Properties

    • Bronchodilation

    • Vasoconstriction


  • Must meet the following three criteria

    • Patient must exhibit findings of severe allergic reaction (anaphylaxis)

    • Medication is prescribed for this patient by their physician, direction by medical control, or inability to contact medical control and epinephrine is indicated

    • Administration of medication is authorized by REMAC or a physician


  • None when used to treat anaphylaxis

Medication form
Medication form

  • Liquid contained in an auto injector needle and syringe system


  • Adult- one adult auto injector (0.3 mg)

  • Infant and Child- one auto injector (infant/child) 0.15 mg


  • Obtain order from medical control either on line or as per protocol

  • Obtain patients prescribed unit if available

  • Ensure prescription is written for patient

  • Ensure medication is not discolored

  • Remove safety cap from device

Administration cont
Administration cont.

  • Place tip of device against the patients thigh:

  • Use lateral portion of thigh midway between the waist and knee

  • Push firmly until the injector activates

    • Keep in contact for 10-15 seconds

  • Record activity and time

  • Dispose of injector in appropriate container

  • Can be administered through patients clothes


  • Dilates the bronchioles

  • Constricts blood vessels

Side effects
Side effects

  • Increased heart rate

  • Pallor

  • Dizziness

  • Chest pain/ sudden death

  • Headache

  • Nausea/ vomiting

  • Excitability, anxiousness


  • Continually assess ABC’S for signs of worsening patient condition such as:

  • Mental status change

  • Increased respiratory rate

  • Decreasing B/P


  • Be prepared to initiate BCLS measures if indicated including: CPR, AED, ALS intercept

  • Treat for shock

  • As the drug lasts in the system 10-20 minutes, be prepared for a potential return of the anaphylactic reaction


  • As many as 25% of those having an anaphylactic reaction will have a recurrence of life threatening symptoms within hours of the first attack

Transportation decision
Transportation Decision

  • Any patient who received Epinephrine should be transported to an Emergency Room for evaluation

  • On-Line Medical Control must be contacted for any patient refusing treatment or transportation after treatment with Epi.

Special consideration
Special Consideration

  • A BLS crew may encourage an authorized layperson to administer an Epi-Pen to a patient if all of the following conditions are met:

    • The BLS unit is not equipped with an Epi-Pen

    • The Patient is having an anaphylactic reaction where Epi-Pen is indicated

    • ALS assistance is not readily available

    • An authorized layperson is present with an Epi-Pen and in the clinical judgment of the EMTs it is in the best interests of the patient to allow the authorized layperson to administer the Epi-Pen