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Epinephrine Administration for Anaphylaxis

OVERVIEW OF ANAPHYLAXIS

Anaphylaxis is an allergic reaction that has life-endangering effects on the circulatory and respiratory systems. Anaphylaxis is an almost immediate, rapidly progressive multi-system allergic reaction to a foreign protein injected into the body by stinging and biting insects, snakes, and sea creatures or ingestion or inhalation of food, chemicals, and medications. Early recognition and prompt treatment, particularly in a wilderness setting, is essential to preserve life.

The onset of symptoms usually follows quickly after an exposure (minutes after a sting or bite, within 30-60 minutes following ingestion). Rebound or recurrent reactions can occur within 24 to 72 hours of the original episode.

In addition to shortness of breath, weakness and dizziness, victims also frequently complain of a sense of impending doom, cough, chest tightness, trouble swallowing, abdominal cramps, or generalized itching. Physical findings include rapid heart rate, low blood pressure, and other evidence of shock, upper airway obstruction (stridor) and lower airway obstructions (wheezes) with labored breathing, generalized skin redness, hives, and swelling of the mouth, face, and neck.

Epinephrine should only administered to patients having symptoms suggestive of an acute systemic reaction (i.e. generalized skin rash, difficulty breathing, fainting, or facial swelling).

Visit www.wildsafe.org/protocols for the complete wilderness medical field protocol for anaphylaxis and other wilderness medical protocols.

ROUTES OF ADMINISTRATION

The subcutaneous is the preferred route of administration of epinephrine by vial or ampule. If given intramuscularly (as with an epinephrine auto-injector such as an Epipen), injection into the buttocks should be avoided as it has been proven nearly ineffective compared to administration to the lateral thigh ONLY. If administering epinephrine by vial or ampule, it is also recommended to do so ONLY subcutaneously on the lateral thigh, and NOT the arm if possible.

INJECTION LOCATION

It has been shown that intramuscular (IM) injection of epinephrine into the lateral thigh (using a 1 or 1½ inch needle such as an Epipen) results in the fastest and most effective reduction of swelling in the airway. The rate at which epinephrine levels in the blood peak when administered via IM injection to the upper arm is significantly slower than when administered to the thigh, and should be only used as an alternative injection site.

Subcutaneous (SC) injection (regardless of injection site) has been shown to have significantly delayed absorption rates of epinephrine into the bloodstream as compared to IM injection into the thigh. Avoid any injections to the buttocks, as this method has been rendered ineffective in a life-threatening situation.

CONTRAINDICATIONS

Although there are no contraindications stated for the use of epinephrine for anaphylaxis, epinephrine is not recommended for patients who are in labor or suffer from coronary insufficiency (angina).

ADMINISTRATION OF EPINEPHRINE BY SYRINGE

    1. Take proper scene safety & body substance isolation precautions such as donning non-latex gloves.
    2. Inspect the medication vial to ensure that it is not discolored or cloudy. Epinephrine should be clear like water.
    3. Check the label and expiration date of the medication. Do NOT use expired or discolored epinephrine.
    4. Select a sterile syringe with a proper gauge needle. A 25 gauge needle is recommended for adults.

AMPULES

    1. If using a glass ampule, carefully break off the tip and hold the ampule upside down at a 45° angle.
    2. Insert the syringe carefully into the liquid and slowly pull back on the plunger, pulling out slightly more epinephrine than required (.3 – .5 ml).
    3. Remove needle from ampule and expel any air from the syringe.

VIALS

    1. If using a vial, wipe the top of the bottle (the rubber) with an alcohol swab.
    2. Draw air into the syringe, equal to or slightly greater than the volume of epinephrine required.
    3. Turn the vial upside down and insert the syringe into the rubber top.
    4. Insert the air of the syringe into the vial by pushing the plunger until it is completely empty.
    5. Slowly pull the plunger back to the same level that it was filled with air moments ago.
    6. Remove needle from bottle and expel any air from the syringe.
    7. Clean the injection site (the patient’s lateral thigh) with an alcohol wipe.
    8. Using a “darting action”, insert the needle directly into the subcutaneous tissue of the skin and slowly push the plunger all the way down until the syringe is empty. Remove the needle and dispose properly. If bleeding should occur, apply triple-antibiotic ointment and place a Band-Aid over the site.
    9. Record the event (date, time, & location of injection) in your patient documentation or incident report.

ADMINISTRATION OF EPINEPHRINE BY AUTO-INJECTOR

    1. Take proper scene safety & body substance isolation precautions such as donning non-latex gloves.
    2. Inspect the auto-injector to ensure that it is not discolored or cloudy. Epinephrine should be clear like water.
    3. Check the label and expiration date of the auto-injector. Do NOT use expired or discolored epinephrine.
    4. Ensure that the auto-injector is the correct dose (adult or pediatric).
    5. Prepare the auto-injector for use and administer as soon as possible.
    6. Record the event (date, time, & location of injection) in your patient documentation or incident report.

ADULT auto-injectors: contain 0.3 mg of epinephrine, and are intended for patients weighing 55 lbs. or greater.Adult epinephrine auto-injectors and cases are typically YELLOW, BLUE, GREY and/or BLACK.

Pediatric auto-injectors: contain 0.15 mg of epinephrine, and are intended for patients weighing up to 55 lbs. Pediatric auto-injectors and cases are typically GREEN.

Beware of generic epinephrine auto-injectors may not be color-coded. Always check the dose!

These curricula recommendations have been adopted from NOLS Wilderness Medicine and have been edited to conform to the standards
set by Center for Wilderness Safety and the Wilderness Medical Society in accordance with the WMS National Practice Guidelines.

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