February 2, 2024

Welcome to UH EMS-I’s Pharmacy Phriday. In this installment, we continue to review changes within the 2024 UH EMS Protocols that directly involve medications and their administration. The focus this week will be on the use of Epinephrine in the 1 mg/ml concentration. The change of note with this medication is its use by EMT-level providers in anaphylaxis.

In the past, Epinephrine 1 mg/ml was permitted for administration by EMTs in cases of anaphylaxis using an Epinephrine Auto-Injector. A change within the OHIO EMS Scope of Practice, effective January 1, 2024, now allows EMT-level providers to draw up and administer Epinephrine 1 mg/ml intramuscularly using a standard syringe. (For the updated Scope of Practice, click HERE). This new “added competency” requires a medical director to provide a written protocol, specific education and training, continuing education, and a quality assurance program related to the skill. The UH monthly continuing education program in February 2024 will cover this training and provide hands-on practice.

It is important to quickly review the differences in the presentation and treatment of an allergic reaction compared to an anaphylactic reaction. When not recognized or undertreated, anaphylaxis can be life-threatening.

The typical allergic reaction is often viewed as a “local” reaction with symptoms such as a small rash, itching, watery eyes, etc. Anaphylaxis is defined as an extreme form of an allergic reaction involving two or more systems or a “systemic” reaction.   The classical presentation of anaphylaxis includes a quick onset and escalation of respiratory symptoms along with hypotension but can also include cardiovascular complaints, GI complaints, altered mental status, etc. Also, remember that a simple allergic reaction can quickly progress to anaphylaxis and a life-threatening event.

Epinephrine is viewed as the standard of care when anaphylaxis is recognized and should be administered as soon as possible. Our UH Protocol also indicates aggressive treatment in cases of even mild reactions when a history of anaphylactic reactions exists. Delayed Epinephrine administration is a major contributing factor leading to fatality in anaphylaxis.

Epinephrine’s properties make it the ideal medication in cases of anaphylaxis. It causes systemic vascular resistance and increased arterial pressures that will increase the blood pressure. Epinephrine also will affect the AV conduction in the heart, increasing the heart rate and contractility of the heart, raising cardiac output. The respiratory effects of the medication include smooth muscle relaxation that will cause bronchial dilation and relieve dyspnea.

In the case of anaphylaxis, all providers are encouraged to use Epinephrine Auto-Injectors if still available within the drug boxes. Eventually, Auto-Injectors will not be supplied, and manual IM injection will be the only option for the EMS providers (EMTs included, provided they have completed the required training). 

Epinephrine dosing for adults in cases of anaphylaxis is 0.3 mg – 0.5 mg IM or an Epinephrine Auto-Injector 0.3 mg. For the pediatric patient, the dosing is weight-based. A simple rule to remember is the 30 kg rule. If the pediatric patient weighs more than 30 kg (or 66 lbs.), the dosing is the same as the adult. When the patient weighs less than 30 kg, the dose is then 0.15 mg or an Epinephrine Auto Injector Jr.  Advanced EMTs and paramedics can calculate the dose of Epinephrine using the weight-based standard of 0.01 mg/kg to a maximum dose of 0.5 mg. Additional doses can be needed and may be repeated every 5 minutes as needed.

Be careful not to confuse the two different concentrations of Epinephrine provided in the drug box, the routes of administration for both, and the indications for both! The 0.1 mg/ml IV Epinephrine is only to be used by paramedic-level providers and only in cases of impending arrest during anaphylaxis.  

Besides its use in anaphylaxis, the 1 mg/ml concentration of Epinephrine can also be used by Advanced EMT and Paramedic providers in cases of respiratory distress when poor exchange persists even after aerosol treatments or stridor when racemic Epinephrine is not available. The IM dosing for these cases is the same as mentioned above. If used as an aerosol treatment in place of racemic Epinephrine, the dosing is 5 mg for the adult patient and pediatric patient weighing more than 10kg (approximately 22 lbs.) or 3 mg in cases when the pediatric patient weighs less than 10kg.

Side effects from the administration of Epinephrine can include anxiety, palpitations, headaches, tremors, restlessness, and dizziness. Symptoms rarely experienced may include arrhythmias, angina, myocardial infarction, pulmonary edema, sudden sharp increase in BP, and intracranial hemorrhage. Most resources indicate no absolute contraindications to Epinephrine use in anaphylaxis. However, our protocol does mention a known hypersensitivity and suggests caution in pregnant and cardiac patients.

Till the next installment, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals

July 15, 2023

Dear colleagues:

Welcome back to UH EMS-I’s Pharmacy Phriday. In last week’s installment, we reviewed Benadryl and its use with allergic reactions.  Once again, it is vitally important to recognize that the presentation and treatment of an allergic reaction as compared to an anaphylactic reaction is different.  When not recognized or when under-treated, anaphylaxis can be life-threatening.

The typical allergic reaction is often viewed as a “local” reaction with symptoms such as a small rash, itching, watery eyes, etc.  Anaphylaxis is defined as an extreme form of an allergic reaction involving two or more systems or a “systemic” reaction.   The classical presentation of anaphylaxis includes a quick onset and escalation of respiratory symptoms along with hypotension but can also include cardiovascular complaints, GI complaints, an altered mental status, etc.  Remember that a simple allergic reaction can quickly progress to anaphylaxis and a life-threatening event.

While Benadryl is the first-line treatment for a mild allergic reaction, Epinephrine is viewed as the standard of care as soon as anaphylaxis is recognized and should be administered as soon as possible to prevent the progression to life-threatening symptoms.  Our UH Protocol also indicates aggressive treatment when a history of anaphylaxis exists with a patient.  Delayed Epinephrine administration is a major contributing factor leading to fatality in anaphylaxis.

At the onset of an anaphylactic episode, it is not possible to predict how severe it will become, how rapidly it will progress, and whether it will resolve promptly and completely. Reassessment of the respiratory and cardiovascular systems as well as the level of consciousness, is critical to prevent a life-threatening event.  Trending downward should lead the provider to aggressive treatment.

Be aware of rare cases where symptoms may present, improve, and then return without an additional exposure to the antigen.  This is referred to as a biphasic reaction and can occur up to 8 or more hours following the exposure.  Such instances are estimated to occur in up to 23% of all anaphylaxis cases. 

Another rare presentation, occurring in up to 28% of anaphylactic reactions, is a protracted reaction.  In these instances, the anaphylactic episode can last hours to days without clearly resolving completely. Though these situations are rare, they are worth additional consideration when treating the anaphylactic patient and considering transport.  A patient with a history of anaphylaxis denying transport should be encouraged to seek further assistance.  Many medical articles recommend observation periods in the ED when an anaphylactic reaction has occurred.

As mentioned earlier, Epinephrine is the preferred treatment for anaphylaxis.  Epinephrine’s Alpha, Beta 1, and Beta 2 properties make it the ideal medication as it decreases release from mast cells that reduce the release of histamines, prevents or reverses obstruction to airflow in the upper and lower airways, and prevents or reverses cardiovascular collapse. 

Epinephrine used in anaphylaxis is the 1 mg/ml concentration administered IM, preferably in the outer aspect of the thigh.    Be careful not to confuse the two different concentrations of Epinephrine provided in the drug box, the routes of administration for both, and the indications for both! (Use of the 0.1 mg/ml IV dosing for impending arrest in anaphylaxis was covered in the 2023 Week #12 edition this year.)

As mentioned above, early administration of Epinephrine is crucial to a positive outcome for the patient.  Keeping this in mind, some agencies may be supplied Epinephrine auto-injectors to reduce time to administration.  Manufacturers’ recommendations for the use of these auto-injectors indicate the use of the adult device for patients weighing >30 kg or 66 lbs and use of the pediatric device for patients weighing 15-30 kg or 33-66 lbs. In the pediatric patient weighing less than 15 kg or 33 lbs., the provider should consider other forms of injectable Epinephrine. Second and subsequent doses will also require the provider to draw up and prepare the medication.

As a quick safety break, remember this! If using the auto-injector, be sure to hold the device correctly and keep your fingertips off the ends of the device!!  Also note that the injection time is now recommended as three seconds, reduced from the old ten-second standard many may have been taught.  (For detailed use instructions of the common auto-injector EpiPen click HERE).

For the adult patient, dosing of the 1 mg/ml Epinephrine per protocol is 0.3 to 0.5 mg IM every 5 minutes as needed.  The 0.5 mg dose is often considered for the larger adult patient. For the pediatric patient, the dosing is 0.01 mg/kg (max dose of 0.5 mg) every 5 minutes as needed.  Most patients respond to a single dose, particularly if it is given promptly after the onset of symptoms. Some studies indicate that a second dose is necessary in 12 to 36 % of cases.

Side effects from the administration of Epinephrine can include anxiety, palpitations, headaches, tremors, restlessness, and dizziness.  Symptoms rarely experienced may include arrhythmias, angina, myocardial infarction, pulmonary edema, sudden sharp increase in BP, and intracranial hemorrhage. Most resources indicate no absolute contraindications to Epinephrine use in anaphylaxis; however, our protocol does mention a known hypersensitivity.

Till the next installment, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals