Epinephrine Auto Injector A Lifesaving Tool Now In the Hands of the EMT-B New Jersey’s Hospital...

Epinephrine Auto Injector A Lifesaving Tool Now In the Hands of the EMT-B New Jerseys Hospital Service Corporation MONOC 2007 EMS EDUCATION

Epinephrine Auto Injector A Lifesaving Tool Now In the Hands of the EMT-B Immediate Treatment = Saved Lives = Saved Lives

OBJECTIVES At the conclusion of this program the EMT-B will have the cognitive, psychomotor, and affective skills that are needed to properly administer an Epinephrine Auto Injector to a prehospital patient who is having an Anaphylactic reaction in accordance with the NJ OEMS Policy

Describe the scope of the problem Describe the scope of the problem Define Anaphylaxis Define Anaphylaxis Explain the Epinephrine Auto Injector Policy Explain the Epinephrine Auto Injector Policy Define role and responsibility of the Medical Director, the First Aid Squad, the individual EMT-B, OEMS and MONOC in this program Define role and responsibility of the Medical Director, the First Aid Squad, the individual EMT-B, OEMS and MONOC in this program Explain the importance of FAST care Explain the importance of FAST care OBJECTIVES

Describe progressive pathophysiology of Anaphylactic Reactions Describe progressive pathophysiology of Anaphylactic Reactions Describe the Signs and Symptoms that an Anaphylaxis patient presents with Describe the Signs and Symptoms that an Anaphylaxis patient presents with List the common triggers that lead to an Anaphylactic Reaction List the common triggers that lead to an Anaphylactic Reaction List conditions that mimic Anaphylaxis List conditions that mimic Anaphylaxis OBJECTIVES

OBJECTIVES Describe the actions, side effects, route, and injection site for Epinephrine Auto Injector Describe the actions, side effects, route, and injection site for Epinephrine Auto Injector State when to use the pediatric dose of Epi and how to estimate patient weight and age State when to use the pediatric dose of Epi and how to estimate patient weight and age Describe the procedure to follow to check for device expiration and drug clarity Describe the procedure to follow to check for device expiration and drug clarity State how to safely and properly dispose of an Epinephrine Auto Injector State how to safely and properly dispose of an Epinephrine Auto Injector

Describe proper patient assessment by an EMT-B for a Anaphylaxis patient Describe proper patient assessment by an EMT-B for a Anaphylaxis patient Explain the Procedure for an EMT-B to follow to administer an Epinephrine Auto Injector Explain the Procedure for an EMT-B to follow to administer an Epinephrine Auto Injector Describe common errors in Auto Injector use Describe common errors in Auto Injector use Describe proper Documentation after use Describe proper Documentation after use OBJECTIVES

Describe the proper method to deliver Ventilations to patients of all ages Describe the proper method to deliver Ventilations to patients of all ages Explain the proper procedure for use of Basic Airway Adjuncts by EMT-B Explain the proper procedure for use of Basic Airway Adjuncts by EMT-B Describe how to deliver Quality CPR Describe how to deliver Quality CPR Explain how the EMT-B can assist ALS Explain how the EMT-B can assist ALS State where to find more information State where to find more information OBJECTIVES

Systemic allergic reaction Systemic allergic reaction Affects body as a whole Multiple organ systems may be involved Onset generally acute Onset generally acute Manifestations vary from mild to fatal Manifestations vary from mild to fatal WHAT IS Anaphylaxis ? DEFINITION

Definitions & OEMS Policy The Medical Director Responsibilities of the Squad Responsibilities of each EMT-B Now let us take a look at New Jerseys Epinephrine Auto Injector Policy

ASSIST The medication must be prescribed to the patient The medication must be prescribed to the patient The patient carries the medication with him The patient carries the medication with him National EMT-B Curriculum allows EMTs to ASSIST a patient with EpiPen National EMT-B Curriculum allows EMTs to ASSIST a patient with EpiPen The OEMS Policy allows EMTs to ADMINISTER an EpiPen to the patient The OEMS Policy allows EMTs to ADMINISTER an EpiPen to the patient DEFINITIONS ADMINISTER The medication will be prescribed to the squad The medication will be prescribed to the squad The medication is carried on the ambulance The medication is carried on the ambulance In either case the extent to which the patient or EMT-B participate with the use of the EpiPen can vary significantly. The EMT-B may just watch patient use the EpiPen or the EMT-B may actually perform the stick.

NJ Epinephrine Auto Injector Policy The National Standard Curriculum for EMT-B provides that EMT-Basics are trained to recognize clinical signs and symptoms of anaphylactic shock and establishes that it is within the scope of practice of the EMT-Basic to assist a patient in the self-administration of a patient's Epinephrine Auto Injector

NJ Epinephrine Auto Injector Policy PL 2003, c,1., N.J.S.A. 26:2K-47.1, presently authorizes OEMS to certify the NJ EMT-B to administer the epinephrine auto injector to patients suffering from anaphylactic shock PL 2003, c,1., N.J.S.A. 26:2K-47.1, presently authorizes OEMS to certify the NJ EMT-B to administer the epinephrine auto injector to patients suffering from anaphylactic shock NJ OEMS recognizes that the expeditious implementation of this law would have an immediate benefit to the general public NJ OEMS recognizes that the expeditious implementation of this law would have an immediate benefit to the general public Accordingly, OEMS shall now authorize the NJ certified EMT-B to administer the epinephrine auto injector to patients in accordance with the following policies and protocols Accordingly, OEMS shall now authorize the NJ certified EMT-B to administer the epinephrine auto injector to patients in accordance with the following policies and protocols

NJ Epinephrine Auto Injector Policy The EMT-B is allowed to administer an Epinephrine Auto Injector to prehospital patients only before an ALS Unit arrives The EMT-B is allowed to administer an Epinephrine Auto Injector to prehospital patients only before an ALS Unit arrives Once the ALS Unit arrives the Paramedics will administer Epinephrine from their stock Once the ALS Unit arrives the Paramedics will administer Epinephrine from their stock NJ Paramedics can administer Epinephrine immediately under Standing Orders NJ Paramedics can administer Epinephrine immediately under Standing Orders The Paramedics Medical Control Physician will provide on line medical control after the Paramedics complete the Standing Orders The Paramedics Medical Control Physician will provide on line medical control after the Paramedics complete the Standing Orders

NJ Epinephrine Auto Injector Policy Only EMT-Basics meeting the following requirements are authorized by OEMS to carry on their ambulance and administer epinephrine auto injectors to patients Only EMT-Basics meeting the following requirements are authorized by OEMS to carry on their ambulance and administer epinephrine auto injectors to patients Only EMT-Basics acting with the general authority of a physician medical director, will be allowed to administer epinephrine auto injectors to prehospital patients Only EMT-Basics acting with the general authority of a physician medical director, will be allowed to administer epinephrine auto injectors to prehospital patients BLS agencies must complete an approved training program prior to obtaining or using epinephrine auto injectors BLS agencies must complete an approved training program prior to obtaining or using epinephrine auto injectors

NJ Epinephrine Auto Injector Policy Only EMT -Basics who are members of BLS agencies that are registered with NJ OEMS may possess or administer the Epinephrine Auto Injector to patients Only EMT -Basics who are members of BLS agencies that are registered with NJ OEMS may possess or administer the Epinephrine Auto Injector to patients OEMS will monitor the EMT-B use of epinephrine auto injectors according to these policies and will take corrective action as is deemed necessary for the safe implementation of this policy OEMS will monitor the EMT-B use of epinephrine auto injectors according to these policies and will take corrective action as is deemed necessary for the safe implementation of this policy

Medical Director DR. MICHAEL MARCHETTI Provides Off-line Medical Control Provides Off-line Medical Control Will provide the prescriptions for the Epinephrine Auto Injectors Will provide the prescriptions for the Epinephrine Auto Injectors Responsible for all clinical aspects of the MONOC EpiPen Program Responsible for all clinical aspects of the MONOC EpiPen Program Training and Quality Assurance Training and Quality Assurance

The First Aid Squad Register with OEMS Register with OEMS Contract with MONOC Contract with MONOC Initial training at FAS location Initial training at FAS location Fill Medical Directors prescription for the Epinephrine Auto Injector Fill Medical Directors prescription for the Epinephrine Auto Injector Stock the squads ambulances with the Epinephrine Auto Injector and a sharps disposal container Stock the squads ambulances with the Epinephrine Auto Injector and a sharps disposal container

The First Aid Squad Send new EMT-B certified members to the regional Initial MONOC training programs Send new EMT-B certified members to the regional Initial MONOC training programs Epinephrine Auto Injector administered by EMT-Bs certified as per OEMS Policy only Epinephrine Auto Injector administered by EMT-Bs certified as per OEMS Policy only Proper disposal and replacement of used or expired Epinephrine Auto Injectors Proper disposal and replacement of used or expired Epinephrine Auto Injectors Send required reports to MONOC and OEMS upon using an Epinephrine Auto Injector Send required reports to MONOC and OEMS upon using an Epinephrine Auto Injector

NJ OEMS BLS Agency Application NJ OEMS BLS Agency Application

The EMT-B Attend Initial and Renewal classes Attend Initial and Renewal classes Sign the MONOC contract to administer the Epinephrine Auto Injector Sign the MONOC contract to administer the Epinephrine Auto Injector Maintain Current EMT-B and CPR certs Maintain Current EMT-B and CPR certs Adhere to all MONOC & OEMS Policies Adhere to all MONOC & OEMS Policies Submit required reports to MONOC and OEMS on use Epinephrine Auto Injector Submit required reports to MONOC and OEMS on use Epinephrine Auto Injector

NJ Epinephrine Auto Injector Law Immunity From Civil Liability An EMT-B certified to administer epinephrine auto injector pursuant to this law or officers and members of any first aid, ambulance or rescue squad shall not be liable for any civil damages as the result of any act or the any omission of an act committed while in training to administer, or in the administration of, the epinephrine auto injector in good faith and in accordance with the provisions of this law

Progression of Allergic Reaction Myths & Reality Anaphylaxis Fatalities Common Causes of Anaphylaxis Now let us take a look at Pathogenesis of Anaphylaxis

Anaphylaxis is underreported Anaphylaxis is underreported Incidence seems to be increasing Incidence seems to be increasing Anaphylaxis leads to 200 deaths a year Anaphylaxis leads to 200 deaths a year Up to 41 million Americans at risk Up to 41 million Americans at risk 63,000 new cases per year 63,000 new cases per year 5% of adults have history of anaphylaxis 5% of adults have history of anaphylaxis The Reality! Myth: Anaphylaxis Is Rare

Systemic allergic reaction Systemic allergic reaction Affects body as a whole Multiple organ systems may be involved Onset generally acute Onset generally acute Manifestations vary from mild to fatal Manifestations vary from mild to fatal WHAT IS Anaphylaxis ? DEFINITION

Myth: Anaphylaxis is Easy to Avoid If You Know What You are Allergic To REALITY: Most cases of Anaphylaxis are Accidental Exposures Accidental Exposures Immediate Treatment = Saved Lives = Saved Lives

Pathogenesis of Anaphylaxis Hypersensitivity Hypersensitivity Sensitization Stage Sensitization Stage End result is an anaphylactic response The clock is ticking End result is an anaphylactic response The clock is ticking Immediate Treatment = Saved Lives

Pathogenesis of Anaphylaxis Antigen (allergen) exposure Antigen Antigen: A substance that is capable of causing the production of an antibody Antigen: A substance that is capable of causing the production of an antibody Antigens may or may not lead to an allergic reaction Antigens may or may not lead to an allergic reaction Allergens: Antigens that cause an allergic reaction and the production of a substance called IgE Allergens: Antigens that cause an allergic reaction and the production of a substance called IgE

Pathogenesis of Anaphylaxis Antigen (allergen) exposure Antigen Allergic Reactions Dont Occur at First Exposure to Allergen First Exposure First Exposure Immune system sees substance as allergic trigger or ALLERGEN and attempts to protect the body from that specific allergen by creating specific chemicals called ANTIBODIES Later Exposure with that same Allergen Later Exposure with that same Allergen On subsequent exposures to same allergen, the antibodies attack & engage the invading allergens to produce the allergic response

Pathogenesis of Anaphylaxis Plasma cells produce IgE antibodies against the allergen Plasma Cell Immunoglobulin: A protein produced by plasma cells Immunoglobulin: A protein produced by plasma cells IgE: A class of immunoglobulins (Ig) that includes the antibodies elicited by an allergic substance (allergen) IgE: A class of immunoglobulins (Ig) that includes the antibodies elicited by an allergic substance (allergen) A person who has an allergy usually has elevated blood levels of IgE antibodies that will attack and engage the invading army of allergens A person who has an allergy usually has elevated blood levels of IgE antibodies that will attack and engage the invading army of allergens

Pathogenesis of Anaphylaxis IgE antibodies attach to mast cells and basophils Mast cell: A connective tissue cell whose normal function is unknown but which is frequently injured in allergic reactions, releasing chemicals including histamine that are very irritating and cause itching, swelling, and fluid leakage from cells Mast cell: A connective tissue cell whose normal function is unknown but which is frequently injured in allergic reactions, releasing chemicals including histamine that are very irritating and cause itching, swelling, and fluid leakage from cells Basophil: A type of white blood cell with coarse bluish-black granules of uniform size within the cytoplasm. Basophils are so named because their cytoplasmic granules stain with basic dyes. Basophils contain and can release histamine Basophil: A type of white blood cell with coarse bluish-black granules of uniform size within the cytoplasm. Basophils are so named because their cytoplasmic granules stain with basic dyes. Basophils contain and can release histamine Mast cell with fixed IgE antibodies Granules that contain histamine

Pathogenesis of Anaphylaxis IgE antibodies attach to mast cells and basophils Basophils contain and can release histamine Basophils contain and can release histamine Histamine: A substance that plays a major role in many allergic reactions. Histamine dilates blood vessels and makes the vessel walls abnormally permeable. This will result in systemic swelling. Histamine: A substance that plays a major role in many allergic reactions. Histamine dilates blood vessels and makes the vessel walls abnormally permeable. This will result in systemic swelling. Mast cell with fixed IgE antibodies Granules that contain histamine

HISTAMINES Symptoms progress FAST! Symptoms progress FAST! These actions cause fluid loss These actions cause fluid loss Swelling Hypotension VASODILATION PERMEABILITY

Anaphylactic Reaction More of same allergen invades body Antigen Mast cell granules releases contents after the antigen binds with IgE antibodies Histamine and other mediators. Allergen combines with IgE attached to mast cells and basophils, which will trigger degranulation and release of histamine and other chemical mediators IMMEDIATE TREATMENT = SAVED LIVES A Systemic allergic reaction - Affects body as a wholeA Systemic allergic reaction - Affects body as a whole

Anaphylaxis Fatalities Estimated 200 deaths annually Estimated 200 deaths annually Symptoms progress FAST! Symptoms progress FAST! Risk factors: Risk factors: Rapid IV allergen Failure to administer epinephrine immediately Immediate Treatment = Saved Lives = Saved Lives

Common Causes of Anaphylaxis

Foods Foods Insect venoms Insect venoms Latex Latex Medications Medications Immunotherapy Immunotherapy Insect venom Inhalant allergens

Signs & Symptoms of Anaphylaxis Myths & Reality Food - Venom Latex Other Conditions Mimic Anaphylaxis Now let us take a look at Clinical Presentation Anaphylaxis

Clinical Presentation of Anaphylaxis Immediate Treatment = Saved Lives

Severe Allergic Reaction Immediate Treatment = Saved Lives HIVES are also known medically as URTICARIA URTICARIA

Myth: Anaphylaxis Always Presents with Hives REALITY: Approximately 10%-20% of all anaphylaxis cases will not present with any hives or other cutaneous manifestations Approximately 10%-20% of all anaphylaxis cases will not present with any hives or other cutaneous manifestations 80% of food-induced, fatal anaphylaxis cases were not associated with any cutaneous signs or symptoms 80% of food-induced, fatal anaphylaxis cases were not associated with any cutaneous signs or symptoms

Myth: The Cause of Anaphylaxis is Always Obvious REALITY: Idiopathic anaphylaxis is common Triggers may be hiddenTriggers may be hidden Foods Latex Patient may not recall details of exposurePatient may not recall details of exposure

Clinical Presentation of Anaphylaxis Cardiovascular System: Cardiovascular System: Tachycardia or Bradycardia Hypotension Arrhythmias Chest Pain (Only 6% of the time) Immediate Treatment = Saved Lives

Clinical Presentation of Anaphylaxis Respiratory System: Respiratory System: Shortness of Breath Throat Tightness Tongue Swelling Wheezing or Stridor Immediate Treatment = Saved Lives

Clinical Presentation of Anaphylaxis Signs & SymptomsIncidence (%) Urticaria and swelling Upper airway edema Dyspnea and wheezing Flushed skin Dizziness, syncope, and hypotension Gastrointestinal symptoms Rhinitis Headache Substernal chest pain Itch without rash Seizure 88 56 47 46 33 30 16 15 6 4.5 1.5

Clinical Presentation of Anaphylaxis Hives 88% of the time Swelling of the Tongue 56% of the time These Sx RARELY present with any other conditions

Conditions That Can Mimic Anaphylaxis Foreign Body Airway Obstruction Foreign Body Airway Obstruction Wheezing or Stridor from Other Etiology Wheezing or Stridor from Other Etiology Other Respiratory Impairments Other Respiratory Impairments Acute MI Acute MI CHF CHF Asthma Asthma

Conditions That Can Mimic Anaphylaxis ANAPHYLAXISFBAOHives >88 % of the time NO HIVES Tongue Swollen >50 % of the time NOT PRESENT Prior Episodes May Have Had Hx Usually NONE Progression WITHOUT ANY INTERVENTION Symptoms progress increased SOB Reflexes relax & often lead to reduced Sx Breath Sounds 47% Bilateral Wheeze 65% Unilateral BS History - Events Leading Up to Episode? Foreign Body Airway Obstruction

Conditions That Can Mimic Anaphylaxis ANAPHYLAXIS Wheeze - Stridor Hives >88 % of the time NO HIVES Tongue Swollen >50 % of the time NOT PRESENT Prior Episodes May Have Had Hx What is prior Hx? Progression Symptoms progress increased SOB Inhaler or Humidity often will reduce Sx Breath Sounds >47 % will wheeze History - Events Leading Up to Episode? Wheezing or Stridor Other Etiology

Conditions That Can Mimic Anaphylaxis ANAPHYLAXIS Other Resp Prob Hives >88 % of the time NO HIVES Tongue Swollen >50 % of the time NOT PRESENT Prior Episodes May Have Had Hx What is prior Hx? Progression Symptoms progress increased SOB OXYGEN often will reduce Sx Breath Sounds >47 % will wheeze Rales or Rhonchi? Look at the patients Meds & Prior History Other Respiratory Impairments Other Respiratory Impairments

Conditions That Can Mimic Anaphylaxis ANAPHYLAXIS Other Resp Prob Hives >88 % of the time NO HIVES Tongue Swollen >50 % of the time NOT PRESENT Substernal Chest Pain Only 6% of the time >70 % of the time Pain Radiates NOOFTEN ArrythmiasRAREOFTEN Look at the patients Meds & Prior History Acute MI

Conditions That Can Mimic Anaphylaxis Acute MI Chest Pain in >70% of MIs Only 6% of Anaphylaxis

Conditions That Can Mimic Anaphylaxis ANAPHYLAXIS Other Resp Prob Hives >88 % of the time NO HIVES Tongue Swollen >50 % of the time NOT PRESENT Breath Sounds >47 % will wheeze Rales (Wheeze early) Blood Pressure 33 % with BP Very High (Drops late) Pedal edema - + JVD Frothy Pink Sputum NOOFTEN History Orthopnia Sleeping Position (# of Pillows?) CHF

Conditions That Can Mimic Anaphylaxis CHF CHF Occurs Primarily in the Geriatric Population

Conditions That Can Mimic Anaphylaxis ANAPHYLAXISASTHMAHives >88 % of the time NO HIVES Tongue Swollen >50 % of the time NOT PRESENT Breath Sounds 50% will not wheeze Wheeze (Absent Late) Progression Only Epi Reduces Sx ! Inhaler or Humidity often will reduce Sx Area Effected Upper Airway Lower Airway Many Patients will also have History of Both Anaphylaxis and Asthma ASTHMA

ASTHMA This drawing shows a normal, relaxed airway and air sacs in the lungs By contrast, this drawing shows tightened airway and inflamed air sacs in the lungs

Myth: Prior Episodes Predict Future Reactions REALITY: No predictable pattern No predictable pattern Severity depends on: Severity depends on: Sensitivity of the individual Dose of the allergen

Anaphylaxis: Food Induced Food allergies are usually due to the protein component of the offending food Food allergies are usually due to the protein component of the offending food For some reason some of the food protein is absorbed from the intestine intact, instead of being digested as most proteins are For some reason some of the food protein is absorbed from the intestine intact, instead of being digested as most proteins are Once the intact protein is in the blood stream, it is recognized as a foreign protein to the body, or in other words as an ANTIGEN Once the intact protein is in the blood stream, it is recognized as a foreign protein to the body, or in other words as an ANTIGEN

35%55% of anaphylaxis is caused by food allergy 35%55% of anaphylaxis is caused by food allergy 6%8% of children have food allergy 6%8% of children have food allergy 1%2% of adults have food allergy 1%2% of adults have food allergy Incidence is increasing Incidence is increasing Accidental exposures are common and unpredictable Accidental exposures are common and unpredictable Anaphylaxis: Food Induced Immediate Treatment = Saved Lives

Food Induced Anaphylaxis: Common Triggers

Food-induced Anaphylaxis: Common Symptoms Oropharynx: Swelling of lips and tongue, throat tightening, slurred speech Oropharynx: Swelling of lips and tongue, throat tightening, slurred speech GI: Cramps, diarrhea, nausea, vomiting GI: Cramps, diarrhea, nausea, vomiting Cutaneous: Urticaria, angioedema Cutaneous: Urticaria, angioedema Respiratory: Shortness of breath, cough, wheezing or stridor Respiratory: Shortness of breath, cough, wheezing or stridor

Anaphylaxis: Venom-induced Common Culprits (Triggers) 13 million Americans are sensitive to insect venoms Culprit Bees Wasps Hornets Yellow jackets Geographical Honeybees and yellow jackets most common in East, Midwest, and West regions of US Wasps, fire ants common in Southwest & Gulf Coast Culprit Fire ants Marine life Spiders

Venom-induced Reactions: Common Symptoms Normal: Local pain, Redness, Mild swelling Normal: Local pain, Redness, Mild swelling Large local: Extended swelling, Redness Large local: Extended swelling, Redness Anaphylaxis: Usual onset within 1520 minutes Anaphylaxis: Usual onset within 1520 minutes Cutaneous: Urticaria, Flushing, Edema Respiratory: Dyspnea, Wheeze or Stridor Cardiovascular: Dizziness, Loss of Consciousness, Tachycardia or Bradycardia (late), Hypotension, 30%60% of patients have a systemic reaction with multiple stings

Anaphylaxis: Latex 1%6% of Americans (> 16 million) affected 1%6% of Americans (> 16 million) affected 8%17% incidence with health care workers 8%17% incidence with health care workers Repeated exposure leads to a higher risk Repeated exposure leads to a higher risk Incidence has increased since mid 1980s Incidence has increased since mid 1980s Proteins in natural rubber latex Proteins in natural rubber latex Component of ~40,000 commonly used items Component of ~40,000 commonly used items Latex Gloves

Anaphylaxis: Latex The sudden, large-scale increase in latex glove use by healthcare workers since the 1980s lies at the heart of the growing problem of latex allergy The sudden, large-scale increase in latex glove use by healthcare workers since the 1980s lies at the heart of the growing problem of latex allergy As health care workers protect themselves from AIDS and other bloodborne diseases, latex glove use became virtually universal in hospitals As health care workers protect themselves from AIDS and other bloodborne diseases, latex glove use became virtually universal in hospitals Healthcare workers, were exposed to more latex than ever - many have become sensitized to it Healthcare workers, were exposed to more latex than ever - many have become sensitized to it Latex Gloves

Anaphylaxis: Latex Irritant contact dermatitisIrritant contact dermatitis Dry, itchy, irritated hands Allergic contact dermatitisAllergic contact dermatitis Delayed hypersensitivity Latex allergyLatex allergy Immediate hypersensitivity Sx: hives, itching, sneezing, rhinitis, cough, wheezing or stridor, shortness of breath Greatest risk with mucosal contact Latex Gloves

Latex Anaphylaxis: Prevention Use latex-free products Use latex-free products Alert employer/health care providers, schools about need for latex-free products and equipment Alert employer/health care providers, schools about need for latex-free products and equipment Wear MedicAlert bracelet Wear MedicAlert bracelet Awareness of cross-sensitivity with foods: Awareness of cross-sensitivity with foods: AVOIDANCE Banana Avocado Chestnuts Kiwi Stone fruit Others

Other Causes of Anaphylactic Reactions Antibiotics Antibiotics Chemotherapeutic agents Chemotherapeutic agents Aspirin Aspirin Biologicals (vaccines) Biologicals (vaccines) Radiocontrast media (IV Dye) Radiocontrast media (IV Dye)

Epinephrine Epinephrine Auto Injector Maintaining the Auto Injector EPI Auto Injector Administration Now let us take a look at The Treatment of Anaphylaxis

Treatment of Anaphylaxis Immediate Treatment with Epinephrine Imperative No contraindications in Anaphylaxis Failure or delay = Fatalities Must be available at all times Immediate Treatment = Saved Lives

Epinephrine Auto Injector A Lifesaving Tool Now In the Hands of the EMT-B Immediate Treatment = Saved Lives = Saved Lives

What Is Epinephrine ? EPINEPHRINE = ADRENALINE Adrenaline is a natural hormone released in response to stress Adrenaline is a natural hormone released in response to stress It is a natural "antidote" to the chemicals released with severe allergic reactions triggered by a drug, food, or insect allergy It is a natural "antidote" to the chemicals released with severe allergic reactions triggered by a drug, food, or insect allergy It is destroyed by enzymes in the stomach, so must be injected It is destroyed by enzymes in the stomach, so must be injected When injected, it rapidly reverses the effects of a severe allergic reaction When injected, it rapidly reverses the effects of a severe allergic reaction

CLINICAL PHARMACOLOGY EPINEPHRINE = ADRENALINE Strong vasoconstrictor action Strong vasoconstrictor action Acts quickly to counteract both vasodilation and increased vascular permeability which can lead to loss of volume and hypotension Anaphylaxis Epinephrine causes smooth muscle relaxation of the bronchial walls in the airway Epinephrine causes smooth muscle relaxation of the bronchial walls in the airway air flow alleviates wheezing & dyspnea Epinephrine is a sympathomimetic drug Epinephrine is a sympathomimetic drug Heart beats stronger and faster = more effective

Side Effects ? EPINEPHRINE = ADRENALINE Side effects of epinephrine may include palpitations, tachycardia, apprehension, sweating, nausea and vomiting, pallor, respiratory difficulty, tremor, headache, dizziness, weakness, and nervousness Side effects of epinephrine may include palpitations, tachycardia, apprehension, sweating, nausea and vomiting, pallor, respiratory difficulty, tremor, headache, dizziness, weakness, and nervousness Cardiac arrhythmias may occur after the administration of epinephrine Cardiac arrhythmias may occur after the administration of epinephrine

Risks of anaphylaxis far outweigh risks of epinephrine administration Risks of anaphylaxis far outweigh risks of epinephrine administration Minimal cardiovascular effects in children (Simons et al, 1998) Minimal cardiovascular effects in children (Simons et al, 1998) Use caution when administering epinephrine in elderly patients or those with known cardiac disease Use caution when administering epinephrine in elderly patients or those with known cardiac disease The Reality! Myth: Epinephrine is Dangerous

THE AUTO INJECTOR Preloaded Unit Dose Spring Loaded Trigger AUTO INJECTORS ONLY THE EMT-B IS NOT PERMITTED TO USE A SYRINGE THE EMT-B IS NOT PERMITTED TO USE A SYRINGE X

CANNOT BE USED BY THE EMT-B The First Dose is an AUTO INJECTOR Second Dose is a SYRINGE TWINJECT CANNOT BE USED BY THE EMT-B AUTO INJECTORS ONLY AUTO INJECTORS ONLY THE EMT-B IS NOT PERMITTED TO USE A SYRINGE THE EMT-B IS NOT PERMITTED TO USE A SYRINGEX

The EpiPen Dismantled EpiPen The Spring The Needle The Syringe How Does It Work ?

Check the expiration date when you get the prescription - You should be able to obtain an expiration date 12 - 14 months out Return expired Auto Injectors to Pharmacy Expiration Dates Expiration Date and Lot Number MONITOR THE EXPIRATION DATES

Expiration Dates Join the Free EpiPenCenter for Anaphylactic Support! www.epipen.com/epipen_reminder

EpiPenCenter for Anaphylactic Support There is a free expiration reminder program Register every time you purchase EpiPen You get reminders before the expiration date Expiration Date and Lot Number

CHECK FOR CLARITY Improper storage of the Auto Injector can cause the Epinephrine to oxidize & go bad Improper storage of the Auto Injector can cause the Epinephrine to oxidize & go bad Check the Epinephrine periodically through the viewing window - be sure the solution is clear and colorless Check the Epinephrine periodically through the viewing window - be sure the solution is clear and colorless Replace Auto Injector immediately if solution is found to be clouded Replace Auto Injector immediately if solution is found to be clouded Storage of EpiPen Clear Window XX

CHECK FOR CLARITY Epi stable at room temp until expiration date Epi stable at room temp until expiration date Epinephrine should not be refrigerated - refrigeration may cause unit to malfunction Epinephrine should not be refrigerated - refrigeration may cause unit to malfunction Epi should not be exposed to high heat Epi should not be exposed to high heat Do not expose the EpiPen to direct sunlight for prolonged periods of time Do not expose the EpiPen to direct sunlight for prolonged periods of time Storage of EpiPen Clear Window XX

How is Epinepherine Given? Intramuscular (IM) Injection A shot where the needle goes into the muscle to deliver a certain amount of medicine A shot where the needle goes into the muscle to deliver a certain amount of medicine The drug is absorbed in the muscle and the bloodstream then carries it through the body The drug is absorbed in the muscle and the bloodstream then carries it through the body IM injections are made into the striated muscle fibers under the subcutaneous layer of the skin IM injections are made into the striated muscle fibers under the subcutaneous layer of the skin

Where Do I Give Epinepherine? VASTUS LATERALIS MUSCLE Forms part of quadriceps muscle group Forms part of quadriceps muscle group Located on anteriolateral aspect of thigh Located on anteriolateral aspect of thigh Used as the site for IM injections as it is generally thick and well formed in patients of all ages and is not located close to any major arteries or nerves Used as the site for IM injections as it is generally thick and well formed in patients of all ages and is not located close to any major arteries or nerves This site is readily accessed This site is readily accessed Middle third of muscle is the injection site Middle third of muscle is the injection site QUADRICEPS

Where is Epinepherine Given? ANTERIOLATERAL MID THIGH AREA Same site is used for both Adult and Pediatric The EpiPen should simply be pushed against the fleshy outer (lateral) portion of the thigh There is no need for more precise placement Do not attempt an injection into a vein or the buttocks Do not attempt an injection into a vein or the buttocks

EpiPen .15 mg.3 mg Use the EpiPen Jr For Patients Under 4 Years Old OEMS Policy

Epinephrine dosing is based on body weight Epinephrine dosing is based on body weight The EpiPen Auto Injector (0.3 mg) is for individuals weighing 66 lbs. or more The EpiPen Auto Injector (0.3 mg) is for individuals weighing 66 lbs. or more The EpiPen Jr Auto Injector (0.15 mg) is for those individuals weighing between 33 and 66 lbs The EpiPen Jr Auto Injector (0.15 mg) is for those individuals weighing between 33 and 66 lbs The OEMS Epinephrine Auto Injector Policy states to use a EpiPen Jr Auto Injector (0.15 mg) for patients Under 4 years of age The OEMS Epinephrine Auto Injector Policy states to use a EpiPen Jr Auto Injector (0.15 mg) for patients Under 4 years of age EpiPen.15 mg.3 mg

Determining Weight & Age PEDI - WHEEL BROSELOW SYSTEM Dont Forget the Obvious ASK THE PARENT !

The Patient Assessment Using the Auto Injector Common Errors Post Use Now let us take a look at Using the Epinephrine Auto Injector

Epinephrine Auto Injector How Do I Use It ? AUTO INJECTORS ONLY AUTO INJECTORS ONLY THE EMT-B IS NOT PERMITTED TO USE A SYRINGE THE EMT-B IS NOT PERMITTED TO USE A SYRINGEX

Epinephrine Auto Injector EMT CHECKLIST My BLS Agency is registered with and has been approved by OEMS My BLS Agency is registered with and has been approved by OEMS I have completed the mandated training program for Epinephrine Auto Injectors I have completed the mandated training program for Epinephrine Auto Injectors I am a current NJ EMT-B I am a current NJ EMT-B I have a current CPR card I have a current CPR card The patient does not have his own The patient does not have his own ALS has not yet arrived on location ALS has not yet arrived on location

Remember Safety First Look Around! Be Alert!

The Scene Size-Up Remember crew safety and BSI! Remember crew safety and BSI! You already have Off Line Medical Control You already have Off Line Medical Control Check environment for source of the reactioninsects, foods, medications Check environment for source of the reactioninsects, foods, medications Call ALS immediately Call ALS immediately How many patients? How many patients? Do you need additional resources? Do you need additional resources? S T O P L O O K

Initial Assessment As you approach develop a General Impression As you approach develop a General Impression Assess mental status Assess mental status Assess A irway Assess A irway Assess the adequacy of B reathing Assess the adequacy of B reathing Assess C irculation Assess C irculation Identify patient priority Identify patient priority

Initial Assessment Identify the patient priority If unresponsive, then immediately evaluate and treat life threats If unresponsive, then immediately evaluate and treat life threats ABCs ABCs Provide 100% oxygen Provide 100% oxygen

Provide 100% OXYGEN Provide 100% oxygen via NRB, but be ready to assist ventilations if necessary with a BVM High Con O2 Nonrebreather mask @ 10-15 liters per min Nonrebreather mask @ 10-15 liters per min 10-15 lpm BVM for Ventilations For inadequate tidal volume or resp rate For inadequate tidal volume or resp rate Set @ 15 lpm

General Impression & Chief Complaint Consider the need for an Epinephrine Auto Injector if any of the following are present: Generalized urticaria (Present >80% of the time) Swelling of the face, tongue, or lips Chief Complaint of respiratory distress or arrest A tightness in the chest and or throat Wheezing or Stridor Altered mental status Restlessness, Anxiety, Confusion Restlessness, Anxiety, Confusion Seizure, Unresponsiveness Seizure, Unresponsiveness

Initial Assessment Look for indications of any circulatory distressLook for indications of any circulatory distress Indications of HypoperfusionIndications of Hypoperfusion Rapid heart rate Cool, moist skin Delayed capillary refill times If unable to palpate a pulse, then begin CPR and AED resuscitation immediatelyIf unable to palpate a pulse, then begin CPR and AED resuscitation immediately

Focused History and Physical Exam Obtain Baseline Vital Signs Obtain Baseline Vital Signs Look for Medical Alert Tags Look for Medical Alert Tags Check environment for source of the reactioninsects, foods, medications Check environment for source of the reactioninsects, foods, medications Where is the ALS Unit ?? Where is the ALS Unit ?? Responsive patients - SAMPLE HISTORY Responsive patients - SAMPLE HISTORY Unresponsive patients need to receive a Rapid Physical Exam Unresponsive patients need to receive a Rapid Physical Exam Immediate Treatment = Saved Lives ALLERGY

SHOCK ?? Consider an Epinephrine Auto Injector if any signs or symptoms of shock are present: CHILD 1 TO 12 years old Heart Rate > 140 AND/OR BP < 70 Systolic INFANT UNDER 12 months Heart Rate > 180 AND/OR BP < 60 Systolic ADULT OLDER THAN 12 Heart Rate > 120 AND/OR BP < 80 Systolic Fast pulses and hypotension are ominous signs

S A M P L E S Signs and SymptomsS Signs and Symptoms What signs & symptoms occurred at onset? A AllergiesA Allergies Is patient allergic to meds, foods, or other? M MedicationsM Medications What medications is the patient taking? What medications is the patient taking? P Pertinent Past HistoryP Pertinent Past History Does the patient have any medical history? L Last Oral IntakeL Last Oral Intake When & What did patient last eat or drink? E Events Leading Up ToE Events Leading Up To What events led to this incident? A S K L I S T E N

Transport Decision GO STAY Transport Promptly Take patient medications and the Epinephrine Auto Injector with you Treat respiratory distress and shock, then transport immediately TRANSPORT

Auscultate Breath Sounds WHEEZING WHEEZING STRIDOR STRIDOR RALES (CRACKLES) RHONCHI L I S T E N

Focused History and Detailed Physical Exam Consider if: Consider if: Complaint or history is confusing There is extended transport time You need to clarify findings In severe Anaphylaxis reactions the Focused & Detailed Physical exams may be omitted In severe Anaphylaxis reactions the Focused & Detailed Physical exams may be omitted Immediate Treatment = Saved Lives

Do I Use the Patients or Mine ? MINE HIS WHAT IF THE PATIENT HAS HIS OWN EpiPen ? If the patient has a prescribed Epinephrine Auto Injector then ASSIST the patient with theirs

EpiPen /EpiPen Jr: Directions for Use Storage Tube Remove the Auto Injector from the Storage Tube Check the Expiration Date & Color of the Epi

EpiPen /EpiPen Jr: Directions for Use Remove the Safety Cap AFTER THE SAFETY CAP IS REMOVED KEEP YOUR FINGERS AWAY FROM THE END The device is now LOADED X

EpiPen /EpiPen Jr: Directions for Use Insert in the Lateral Mid Thigh Place auto injector firmly against lateral portion of the thigh, midway between the waist and the knee Place auto injector firmly against lateral portion of the thigh, midway between the waist and the knee Firm pressure activates spring mechanism in the auto injector and forces the needle into the thigh muscles Firm pressure activates spring mechanism in the auto injector and forces the needle into the thigh muscles

EpiPen /EpiPen Jr: Directions for Use Hold in place for 10-15 seconds while the epi is injected in muscle Hold in place for 10-15 seconds while the epi is injected in muscle Remove auto injector from the thigh - careful the needle will now be projecting Remove auto injector from the thigh - careful the needle will now be projecting Massage the injection site this will enhance absorption of the epi Massage the injection site this will enhance absorption of the epi Hold For 10 Seconds and Remove

COMMON ERRORS MISTAKE NUMBER 1 The black tip contains the needle and needs to be placed against the mid-thigh. The black tip contains the needle and needs to be placed against the mid-thigh. Holding the wrong end and injecting the thumb (blue line) is painful and not very effective... Holding the wrong end and injecting the thumb (blue line) is painful and not very effective...

COMMON ERRORS MISTAKE NUMBER 2 Unless the safety cap is removed (blue line), the EpiPen will NOT work, no matter how hard you push... Unless the safety cap is removed (blue line), the EpiPen will NOT work, no matter how hard you push...

COMMON ERRORS MISTAKE NUMBER 3 This photograph is more subtle. The patient is pressing the white end very hard (blue line), assuming there is a "button" at the white end. There is not! This photograph is more subtle. The patient is pressing the white end very hard (blue line), assuming there is a "button" at the white end. There is not!

EpiPen /EpiPen Jr: Directions for Use Place the used Auto Injector in a sharps container for Safety Place the used Auto Injector in a sharps container for Safety Note: Most of the liquid (about 90%) stays in the auto-injector and cannot be reused - The correct epinephrine dose was given if the RED FLAG appears in clear window Note: Most of the liquid (about 90%) stays in the auto-injector and cannot be reused - The correct epinephrine dose was given if the RED FLAG appears in clear window Needle is Exposed BE CAREFUL ! Clear Window

The Ongoing Assessment You should have already initiated your patient TRANSPORT to the hospital DO NOT DELAY You should have already initiated your patient TRANSPORT to the hospital DO NOT DELAY Take the Epinephrine Auto Injector with you Take the Epinephrine Auto Injector with you Where is ALS ? Consider meeting the ALS unit Line of Sight en route to the hospital Where is ALS ? Consider meeting the ALS unit Line of Sight en route to the hospital Notify Receiving Hospital (If NO ALS) Notify Receiving Hospital (If NO ALS) Immediate Treatment = Saved Lives TRANSPORT

The Ongoing Assessment Monitor with Vigilance Level of Distress, Level of Consciousness, Blood Pressure, Respirations, Pulse, Breath Sounds Monitor with Vigilance Level of Distress, Level of Consciousness, Blood Pressure, Respirations, Pulse, Breath Sounds Repeat a second Epinephrine dose if the signs and symptoms still persist after 10-15 minutes Repeat a second Epinephrine dose if the signs and symptoms still persist after 10-15 minutes Maintain Normal Body Temp Maintain Normal Body Temp Where is the ALS unit? Where is the ALS unit? Immediate Treatment = Saved Lives TRANSPORT

Biphasic Reactions Immediate Treatment = Saved Lives TRANSPORT Biphasic reactions - Sx occur again after the initial anaphylaxis Sx have completely resolved Biphasic reactions - Sx occur again after the initial anaphylaxis Sx have completely resolved Biphasic reactions can occur several hours after the initial Anaphylactic episode Biphasic reactions can occur several hours after the initial Anaphylactic episode Biphasic reactions happen in up to 20% of cases Biphasic reactions happen in up to 20% of cases Biphasic reactions are treacherous more difficult to treat than initial episode Biphasic reactions are treacherous more difficult to treat than initial episode Patients often require intubation

DOCUMENTATION REQUIRED ON PCR Location of the Injection SiteLocation of the Injection Site Medication Name and DoseMedication Name and Dose Time Epi was AdministeredTime Epi was Administered Vital Signs Pre and Post EpiVital Signs Pre and Post Epi Any changes in the patients conditionAny changes in the patients condition Immediate Treatment = Saved Lives

DOCUMENTATION REQUIRED Leave a copy of the Patient Care Report (PCR) at the hospitalLeave a copy of the Patient Care Report (PCR) at the hospital Complete the MONOC QA FormComplete the MONOC QA Form Send a copy of the PCR toSend a copy of the PCR to MONOC within 7 days after the call OEMS within 45 days after the call Immediate Treatment = Saved Lives FINISH THE PAPERWORK!

Medical Director DR. MICHAEL MARCHETTI You administered the Auto Injector under his Off-line Medical Control You administered the Auto Injector under his Off-line Medical Control Responsible for all clinical aspects of the MONOC EpiPen Program Responsible for all clinical aspects of the MONOC EpiPen Program Will review documentation provided for Quality Assurance purposes Will review documentation provided for Quality Assurance purposes

Now let us take a look at AHA 2010 Guidelines for CPR and Emergency Cardiac Care Assessing Ventilations C-A-B Sequence Quality CPR Interfacing With ALS

Check Responsiveness Tap the patients shoulder ask are you all right? Tap the patients shoulder ask are you all right? Check for movement / chest rise and fall. Check for movement / chest rise and fall. Check for breathing / adequate breathing. Check for breathing / adequate breathing.

AGONAL Breathing Occasional gasps = agonal breathing Will soon lead to cardiac arrest Called Guppie Breathing This is NOT effective breathing Assess For Effective Breathing

Pulse Check Check the carotid artery for at least 5 seconds and no longer than 10 seconds to determine presence of a pulse. Check the carotid artery for at least 5 seconds and no longer than 10 seconds to determine presence of a pulse. If no pulse, perform 5 cycles of compressions and breaths (ratio 30:2) beginning with chest compressions. If no pulse, perform 5 cycles of compressions and breaths (ratio 30:2) beginning with chest compressions.

Compress at a rate of at least 100/min. Compress at a rate of at least 100/min. Ratio of compressions to breaths same for 1 rescuer or 2 rescuers 30:2 Ratio of compressions to breaths same for 1 rescuer or 2 rescuers 30:2 Each set of 30 compressions should take 18 seconds or less. Each set of 30 compressions should take 18 seconds or less. Chest Compressions Compress HARD & FAST

Ventilations delivered TOO FAST or with TOO MUCH VOLUME are NOT beneficial and may even be HARMFUL Deliver just enough volume to make the chest rise Each breath should be delivered over one second Each time you ventilate intrathoracic pressure increases and the flow of blood through the heart and the blood vessels in chest decreases Avoid the Urge To Ventilate TOO FAST or TOO HARD! Ventilate TOO FAST or TOO HARD! Ventilations This is much too FAST

Rate of Ventilations Child or Infant in respiratory arrest with a pulse: Deliver 12 - 20 effective breaths per minute Resist the urge to ventilate faster or harder! This is much too FAST Adult patient in respiratory arrest with a pulse: Deliver about 10 - 12 breaths per minute Give just enough volume to allow the chest to rise Resist the urge to ventilate faster or harder! Each rescue breath should be delivered over one second

A Word About Advanced Airways Once the ET is in place ventilate at: 8 times per minute Once every 7 seconds DO NOT PAUSE your cardiac compressions to give breaths DO NOT PAUSE your cardiac compressions to give breaths This will optimize blood flow This will optimize blood flow When ALS arrives on scene the paramedics will secure the airway with an Endotracheal Tube 211 MICU

AGE GROUP Breaths Per Min ADULT 10 per min CHILD 15 per min INFANT 20 per min ADULT with ET 8 per min Delivery of Ventilations Each rescue breath should be delivered over one second

AIRWAY EQUIPMENT Provide 100% oxygen via NRB, but be ready to assist ventilations if necessary with a BVM High Con O2 Nonrebreather mask @ 10-15 liters per min Nonrebreather mask @ 10-15 liters per min 10-15 lpm BVM for Ventilations For inadequate tidal volume or resp rate For inadequate tidal volume or resp rate Set @ 15 lpm

Best Use of the BVM 2 Rescuer Bag Valve Mask Technique is Preferred Minimizes the chance of the 2 most common BVM errors - Poor Seal Loss of Volume - Squeezing bag inadequately One rescuer seals the mask and opens the airway with an E C clamp The second rescuer squeezes the BVM with both hands - for good tidal volume (chest rise) Note the PADDING Note the E C Clamp

Best Use of the BVM 2 Rescuer Bag Valve Mask Technique is Preferred Sellick Maneuver is done by a third rescuer with ventilations of an unprotected airway BLS can provide the Sellick Maneuver early & continually until a ET tube is inserted by the Paramedics Note the padding under the head for this adult patient What if this were a child or infant? Note the PADDING Note the E C Clamp

The Sellick Maneuver The routine use of the Sellick Maneuver is no longer recommended for use American Heart Association

The Sellick Maneuver BLS Providers can help with the Sellick Maneuver Used to help line up the airway structures in ET intubation will help to visualize the vocal cords Used to help line up the airway structures in ET intubation will help to visualize the vocal cords Also will help to prevent gastric distension and vomiting as you ventilate an unprotected airway Also will help to prevent gastric distension and vomiting as you ventilate an unprotected airway

The Sellick Maneuver BLS Providers can help with the Sellick Maneuver Performed by applying gentle pressure to the anterior neck at the Cricoid Cartilage Performed by applying gentle pressure to the anterior neck at the Cricoid Cartilage BLS can provide this maneuver early and continually until an ET tube is inserted BLS can provide this maneuver early and continually until an ET tube is inserted

PEDI AIRWAY EQUIPMENT Variety of Sizes OPA OPA BVM BVM BROSELOW SYSTEM All BLS Ambulances must have airway adjuncts all age groups of patients of all types available for all age groups of patients

SUCTION EQUIPMENT Suction Equip READY TO USE READY TO USE Rigid tip catheter Rigid tip catheter 15 seconds 15 seconds On Board Equip Oxygen Oxygen Suction Suction Suction should be set up READY FOR USE BLS Ambulances must have SUCTION available for all patients Suction should be set up READY FOR USE

2010 Guidelines Focus on Maintaining CPP Maximizing delivery of quality compressions Minimizing the delivery of ventilations and other hands off time Coronary Perfusion Pressure (CPP) HIGH QUALITY CPR SAVES LIVES

The Need for The Need for Quality CPR Maintain compression rate at - least This rate is same in all AHA age groups - for both one and multiple rescuers PUSH HARD PUSH FAST MAKE EVERY COMPRESSION COUNT! Every compression done improperly decreases CPP Per Minute

All rescuers acting alone should deliver Compressions to Ventilations Compressions to Ventilations for all victims except newborns Adequate blood flow is needed to provide delivery of oxygen to the vital organs Adequate blood flow is needed to provide delivery of oxygen to the vital organs Scientific studies measured blood flow to the heart muscle in the coronary arteries Scientific studies measured blood flow to the heart muscle in the coronary arteries Coronary Perfusion Pressure (CPP) Coronary Perfusion Pressure (CPP) A Major Change -

Coronary Perfusion Pressure and the CPR Cycle first 5 - 10 compressions Scientific data shows that CPP builds up to the maximum with the first 5 - 10 compressions of the CPR cycle CPP will be maintained by well delivered uninterrupted cardiac compressions When cardiac compressions are interrupted CPP falls to almost zero immediately It will then take the next several compressions to build the CPP back up to the optimal level again MINIMIZE INTERRUPTIONS

Coronary Perfusion Pressure Over a CPR Cycle PUSH HARD PUSH FAST Per Minute

Compressions to Ventilations One Lone Rescuer Multiple Rescuers ADULT 30 : 2 CHILD 15 : 2 INFANT 30 : 2 15 : 2 MINIMIZE INTERRUPTIONS

Hand Position AGE GROUP Place Your Hands ADULT Center of chest between nipples 2 hands - Heel of hand on chest other on top CHILD Center of chest between nipples 1 hand - Heel of one hand on chest INFANT One Rescuer Just below nipple line 1 Rescuer 2 Fingers INFANT Multiple Rescuers Just below nipple line 2 Rescuers 2 Thumbs NO LANDMARKING Eyeball the correct spot and place your hands Minimize Hands Off Time

Two Thumb Compression Technique For Multiple Rescuer Infant CPR Encircle the infants chest with both hands Encircle the infants chest with both hands Spread your 4 fingers across the thorax and place your 2 thumbs together on the lower half of the sternum Spread your 4 fingers across the thorax and place your 2 thumbs together on the lower half of the sternum Note the PADDING

Two Thumb Compression Technique For Multiple Rescuer Infant CPR Squeeze the thorax with your 4 fingers as you compress over sternum with your 2 thumbs Squeeze the thorax with your 4 fingers as you compress over sternum with your 2 thumbs Second rescuer provides ventilations (15:2 Ratio) Second rescuer provides ventilations (15:2 Ratio) This technique has been proven to achieve higher CPP in studies This technique has been proven to achieve higher CPP in studies Note the PADDING

NJ Epinephrine Auto Injector Policy Allows NJ EMT-B to carry the Epinephrine Auto Injector in the ambulance & administer under off-line medical control Anaphylaxis Anaphylaxis is a condition that progresses through several phases very rapidly Anaphylaxis can be triggered by several things Food, Stings, Latex most common Other conditions can mimic Anaphylaxis SUMMARY

The EpiPen The EpiPen is a safe easy device that can rapidly reverse the effects of Anaphylaxis EMT-B should understand the actions, the side effects, dose, and site to use for EpiPen Using the Epi-Pen The EMT-B needs to perform an accurate rapid patient assessment Proper documentation required per policy Transport should not be delayed SUMMARY

Airway and CPR Skills It is essential the EMT-B delivers proper ventilations and compressions to all ages The EMT-B must be proficient in AHA 2010 Quality CPR is an essential skill Conclusion The Epinephrine Auto Injector is a new lifesaving tool now in the hands of the EMT IMMEDIATE TREATMENT = SAVED LIVES SUMMARY

Additional Information For Anaphylaxis -- WEB SITES FOR INFORMATION --

EpiPen Auto Injector A Lifesaving Tool Now In the Hands of the EMT-B Immediate Treatment = Saved Lives = Saved Lives

Thank You For Your Participation For More CEUs www.MONOC.ORG Thank You For Your Participation For More CEUs www.MONOC.ORG

Epinephrine Auto Injector A Lifesaving Tool Now In the Hands of the EMT-B New Jersey’s Hospital...

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