Epinephrine Auto-Injector

Epinephrine administration is included in this California-based EMT program as it is required for skills verification for California Registration.^[1]

Severe Allergic Reaction

In the pre-hospital setting, epinephrine is administered by the EMT via autoinjector to reverse the physiologic effects of severe allergic reactions and anaphylaxis. Allergic reactions can present as a result of exposure to a wide variety of foods, medications, insects, or other environmental insults. If the first responder doesn't recognize that the patient is experiencing an anaphylactic reaction, and then rapidly provide the appropriate treatment, the patient is at risk of dying from respiratory and cardiovascular system collapse.

Signs and Symptoms of a severe allergic reaction may include:

• Trouble breathing, wheezing, hoarseness.
• Hives (a raised reddened rash often found under clothes and on the trunk) and generalized itchiness.
• Redness and swelling of the face, lips, mouth, or tongue.
• Fast heartbeat, weak pulse.
• Feelings of anxiety and confusion.
• Stomach pain/cramps, losing control of urine or bowel movements (incontinence), or diarrhea.
• Dizziness or fainting.

Administration[edit | edit source]

It is critical that the proper steps are taken for administration, and that epinephrine is not used for mild symptoms. Epinephrine is a powerful medication which can exacerbate underlying cardiac or respiratory disease. If time permits, a full health history is important to obtain. However, if patient is having significant signs and symptoms such as breathing difficulties, severe allergic reactions can rapidly degenerate into full blown shock, and you should not delay administration.

Many of these steps have preferred techniques and faster alternatives in emergent situations.

To administer Epinephrine:

1. Check the "Five Rights" of delivering medications
   1. Right Patient: There are no absolute contraindications to epinephrine administration in any patient experiencing anaphylaxis or a severe allergic reaction. In some counties the EMT may only assist a patient in administering their own prescribed epinephrine, in which case you must cross check the name on the injector. In others, epinephrine may be given under medical direction. Always follow your own county protocols.
   2. Right Drug: Epinephrine Auto injector trade names include: Adrenalin EpiPen, EpiPen Jr., AnaPen, Ana-Guard, Sus-Phrine Injection, Twinject, Ana-Kit, etc.
   3. Right Dosage: An adult EpiPen contains 0.3 mg/0.3 mL; The pediatric EpiPen delivers 0.15 mg/0.3 mL. If a pediatric patient is > 3 years of age or weighs > 15 kg, the adult dose is administered.
   4. Right Route: Intramuscular injection in the thigh is the approved route.
   5. Right Date: Ensure the medication is not expired.
   6. Right Documentation: Although not always included when discussing the "5 Rights," accurate documentation is still important to remember.
2. Locate site in the upper-outer thigh. Although the deltoid muscle is sometimes recommended as an alternate site, it is NOT recommended in many counties.^[2]
3. Remove clothing from thigh area. Injection through clothing is not recommended for healthcare providers if time permits removal.^[3]
4. Cleanse injection site with alcohol wipe and allow the area to air dry if time permits.
5. Remove the safety cap from auto-injector. DO NOT cover this end of the safety cap with fingers since the pressure may activate the injector device and inadvertently inject you rather than the patient.
6. Place the tip of the auto-injector at a 90° angle to the thigh.
7. Push tip of auto-injector forcefully against injection site.
8. Continue to hold the injector in place for 3-10 seconds until the medication is injected.
9. Remove the injector and place in biohazard sharps container. (Additional care must be taken with auto-injectors where the needle does not retract.)
10. Massage the injection area for 10 seconds and apply adhesive bandage to the injection site if bleeding.
11. Note medication and time of administration on the patient's care report.

Patient Monitoring[edit | edit source]

The onset of action of epinephrine for anaphylaxis and severe asthma is 5-10 minutes with peak effects occurring within 20 minutes. The duration of action is 4-6 hours. Following administration, continue to provide supportive care and treat for shock or initiate additional BLS procedures if indicated. Request an ALS unit if one is not already en route.

Evaluate your patient's response to epinephrine administration including:

• Respiratory status - rate, tidal volume, lung sounds.
• Cardiovascular status - pulse, blood pressure.
• Changes in skin vitals.
• Mental state.

Common Side Effects after receiving an epinephrine injection include:

• Faster, irregular, or "pounding" heartbeat.
• Sweating.
• Shakiness, paleness, feelings of over excitement, nervousness, or anxiety.
• Headache, weakness, dizziness.
• Nausea or vomiting.
• Breathing problems (continued or new onset).

Tranport[edit | edit source]

If the estimated arrival time for a responding ALS unit exceeds the time for transport to the most appropriate emergency department, the EMT should consider transporting the patient directly.

EMT's may administer a second dose of epinephrine (depending on county EMS protocols) to an adult or pediatric patient in 10 minutes if ALS is delayed greater than 10 minutes or if the transport time to the most accessible emergency department that best meets the need of the patient exceeds 10 minutes.

Documentation[edit | edit source]

Documentation of the epinephrine administration should be included in the Patient Care Report (PCR) in the form:

• "0.3 mg epinephrine administered via autoinjector in the right lateral thigh at 1845. Patient responds positively with reduced work of breathing. Repeat patient LS are equal with faint wheezes bilaterally. Due to extended ALS response time, patient transported code 3 to ED. A second dose of 0.3 mg epinephrine via autoinjector is administered in the right lateral thigh at 1855 for recurrent dyspnea, wheezing, and tachypnea. Full relief of symptoms by time of ED arrival."

Self Assessment[edit | edit source]

Tips and Tricks[edit | edit source]

• Ask if the patient self-administered epinephrine before EMS arrival. If the patient received epinephrine prior to EMS contact, document it on the PCR and be sure to include the information in your hand off report.
• Pay attention to the allergen that sparked the anaphylactic reaction. Allergens such as bee stings may require removal of the stinger but only contain a set amount of allergen that, once removed, may stop the reaction after epinephrine administration. Ingested allergens continue to exert their effects until physically removed from the stomach and are more likely to require repeat doses of epinephrine.
• Despite what movies often show, do not "slam" the autoinjector into the patient's thigh. This has a high probability of missing the intended injection point and may cause the patient significantly more pain. Firm pressure is enough to activate the mechanism.
• Be aware that this procedure is scary and painful. This is especially important to keep in mind with pediatric patients who may not have the necessary understanding or control to prevent reflexively pulling away from painful stimuli. Have a partner firmly secure the child's leg before injection to prevent unintentional autoinjector injury and reduced medication delivery.

Additional Resources[edit | edit source]

TBD - extra videos to watch, links to other pages for more reading

References[edit | edit source]