Epinephrine Epinephrine Administration by the EMTAdministration by the EMT

Pilot Project for the Administration of Epinephrine by Washington EMTsPilot Project for the Administration of Epinephrine by Washington EMTsTamara Coulter BS, FF/PM and Captain/MSO Steven EngleTamara Coulter BS, FF/PM and Captain/MSO Steven Engle

North Kitsap Fire & RescueNorth Kitsap Fire & Rescue

ObjectivesObjectives• Recall the drug name and classification Recall the drug name and classification • Correctly identify the drug and its concentrationCorrectly identify the drug and its concentration• Define and describe the indications and contraindications Define and describe the indications and contraindications

for the administration of epinephrinefor the administration of epinephrine• Explain the routes of administration, dosing regimen, Explain the routes of administration, dosing regimen,

pharmacology, pharmacokinetics, and precautions for this pharmacology, pharmacokinetics, and precautions for this drugdrug

• Accurately locate and describe acceptable sites of Accurately locate and describe acceptable sites of administrationadministration

• Understand and explain the mechanism of action and Understand and explain the mechanism of action and effects of epinephrineeffects of epinephrine

• Anticipate possible side effects and adverse reactionsAnticipate possible side effects and adverse reactions• Precisely and accurately draw the medication and prepare Precisely and accurately draw the medication and prepare

it for administrationit for administration

What is epinephrine?What is epinephrine?

• A synthetic reproduction of the endogenous A synthetic reproduction of the endogenous hormone/neurotransmitter epinephrinehormone/neurotransmitter epinephrine

• Functions in “fight or flight” response of the Functions in “fight or flight” response of the sympathetic branch of the autonomic nervous sympathetic branch of the autonomic nervous systemsystem

What is epinephrine?What is epinephrine?

Indications for the use of Indications for the use of epinephrine by the EMTepinephrine by the EMT

1:1,0001:1,000• AnaphylaxisAnaphylaxis• Anaphylactic shockAnaphylactic shock

Contraindications to the use of Contraindications to the use of epinephrine by the EMTepinephrine by the EMTAbsolute Absolute

ContraindicationsContraindications• There are no absolute There are no absolute

contraindications in contraindications in the emergency settingthe emergency setting

RelativeRelativeContraindicationsContraindications

• Hypersensitivity to epi Hypersensitivity to epi preparations preparations

• Glaucoma (narrow-angle)Glaucoma (narrow-angle)• Cardiovascular diseaseCardiovascular disease• Use during labor/childbirthUse during labor/childbirth• Cases where vasopressors Cases where vasopressors

are contraindicated (are contraindicated (e.g., e.g., thyrotoxicosis, diabetes, thyrotoxicosis, diabetes, hypertension, toxemia of hypertension, toxemia of pregnancy)pregnancy)

• Patients taking monoamine Patients taking monoamine oxidase inhibitors (MAOIs)oxidase inhibitors (MAOIs)

Route of administration for Route of administration for the EMTthe EMT

• Intramuscular sites Intramuscular sites allow a drug to be allow a drug to be injected into the injected into the belly of a muscle so belly of a muscle so that the blood that the blood vessels supplying vessels supplying that muscle that muscle distribute the distribute the medication to its medication to its site of action via the site of action via the bloodstream. bloodstream.

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Dosing Regimen for Dosing Regimen for Epinephrine Administration by Epinephrine Administration by

the EMTthe EMT

Anaphylaxis and anaphylactic shockAnaphylaxis and anaphylactic shock• Adults - 0.3mg of 1:1,000 via Adults - 0.3mg of 1:1,000 via

Intramuscular injectionIntramuscular injection• Pediatrics - 0.01mg/kg of 1:1,000 via Pediatrics - 0.01mg/kg of 1:1,000 via

Intramuscular injectionIntramuscular injection

Epinephrine Pharmacology Epinephrine Pharmacology • Exerts both alpha and beta adrenergic Exerts both alpha and beta adrenergic

activity (alpha constrictor and beta dilation)activity (alpha constrictor and beta dilation)• Relaxes smooth muscle in the bronchial tree.Relaxes smooth muscle in the bronchial tree.• Antagonizes histamineAntagonizes histamine• Increases glycogenolysis and raises blood Increases glycogenolysis and raises blood

glucose levelsglucose levels• Raises heart rate, blood pressure (systolic in Raises heart rate, blood pressure (systolic in

particular), and myocardial oxygen demandparticular), and myocardial oxygen demand• Increases myocardial chronotropy, inotropy, Increases myocardial chronotropy, inotropy,

dromotropy, irritability, and automaticity.dromotropy, irritability, and automaticity.

Epinephrine PharmacokineticsEpinephrine PharmacokineticsContinuedContinued

• Approximate onset/duration times – Approximate onset/duration times –

IM: 3-5 min/1-4hrsIM: 3-5 min/1-4hrsSQ: 5-10 min/2-6hrsSQ: 5-10 min/2-6hrsInhaled: within 5 minutes/1-3hrsInhaled: within 5 minutes/1-3hrs

• Crosses the placenta and into breast milk; does Crosses the placenta and into breast milk; does not cross the blood-brain barriernot cross the blood-brain barrier

Precautions to consider during Precautions to consider during epinephrine administrationepinephrine administration

• BE CERTAIN you are administering the correct BE CERTAIN you are administering the correct concentration! It will be 1:1,000, or 1mg/1mLconcentration! It will be 1:1,000, or 1mg/1mL..

• Epinephrine IS NOT a substitute for fluid resuscitation in Epinephrine IS NOT a substitute for fluid resuscitation in hypovolemic patients!hypovolemic patients!

• May precipitate ACS in those with underlying cardiovascular May precipitate ACS in those with underlying cardiovascular disease, so be very cautious in older patients.disease, so be very cautious in older patients.

• Use drug with caution in elderly patients, patients with CV Use drug with caution in elderly patients, patients with CV disease, pulmonary edema, hypertension, hyperthyroidism, disease, pulmonary edema, hypertension, hyperthyroidism, diabetes, psychoneurotic illness, asthma, prefibrillatory rhythm, diabetes, psychoneurotic illness, asthma, prefibrillatory rhythm, or anesthetic cardiac accidentsor anesthetic cardiac accidents..

• Store epinephrine AWAY from light; leave it in its carton until Store epinephrine AWAY from light; leave it in its carton until ready to use. Also keep away from extreme heat and danger of ready to use. Also keep away from extreme heat and danger of freezing.freezing.

Site Selection and Site Selection and PreparationPreparation

• Choose the site appropriate for the route and patient Choose the site appropriate for the route and patient ( “Intramuscular” is the preferred by Washington State MPD’s)( “Intramuscular” is the preferred by Washington State MPD’s)• Prep the site with approved antiseptic by scrubbing vigorously Prep the site with approved antiseptic by scrubbing vigorously

and allowing to dry. DO NOT TOUCH, BLOW ON OR FAN THE and allowing to dry. DO NOT TOUCH, BLOW ON OR FAN THE INJECTION SITE! INJECTION SITE!

• For intramuscular injection, select the injection site, deltoid, For intramuscular injection, select the injection site, deltoid, dorsogluteal, vastus lateralis, and rectus femoris muscledorsogluteal, vastus lateralis, and rectus femoris muscle

• Align the syringe and needle above the injection site at a 90 Align the syringe and needle above the injection site at a 90 degree angle, with the bevel of the needle facing up.degree angle, with the bevel of the needle facing up.

From From Mosby’s Paramedic TextbookMosby’s Paramedic Textbook

Drug AdministrationDrug AdministrationIntramuscular InjectionIntramuscular Injection

• Insert the hypodermic needle bevel-up under the Insert the hypodermic needle bevel-up under the skin at a 90-degree angleskin at a 90-degree angle

• Retract the plunger of the syringe to assure you Retract the plunger of the syringe to assure you haven’t inadvertently placed the needle into a blood haven’t inadvertently placed the needle into a blood vesselvessel

• If there is no ‘flash’, slowly and smoothly depress If there is no ‘flash’, slowly and smoothly depress the syringe’s plunger to inject the medicationthe syringe’s plunger to inject the medication

• Remove the needle/syringe and place in a sharps Remove the needle/syringe and place in a sharps containercontainer

• Place an adhesive bandage over the injection sitePlace an adhesive bandage over the injection site• Complete required documentation: Medication, Complete required documentation: Medication,

site, time, bandage application, vitals before/after, site, time, bandage application, vitals before/after, and patient response to therapy.and patient response to therapy.

Assessment of Patient Assessment of Patient ResponseResponse

Document your findings upon assessment Document your findings upon assessment of patient condition after treatment: of patient condition after treatment:

• This includes appearance, work of This includes appearance, work of breathing, lung sounds, skin signs, vital breathing, lung sounds, skin signs, vital signs, and changes in ability to speaksigns, and changes in ability to speak

• Also document any adverse or Also document any adverse or idiosyncratic effectsidiosyncratic effects

Ongoing AssessmentOngoing Assessment• Continue to monitor and document Continue to monitor and document

the patient’s vital signs and condition the patient’s vital signs and condition for the remainder of your transportfor the remainder of your transport

• Record the patient’s vital signs every Record the patient’s vital signs every fifteen minutes if stable and every fifteen minutes if stable and every five minutes if unstablefive minutes if unstable

ReviewReviewEpinephrineEpinephrine

• Functions in “fight or flight” response Functions in “fight or flight” response of the sympathetic branch of the of the sympathetic branch of the autonomic nervous systemautonomic nervous system

Review ContinuedReview ContinuedClassificationsClassifications

• Sympathomimetic monamineSympathomimetic monamine• CatecholamineCatecholamine• ArylalkylamineArylalkylamine• Vasopressor used in shock Vasopressor used in shock

Review ContinuedReview ContinuedEpinephrine PharmacologyEpinephrine Pharmacology

• Exerts both alpha and beta adrenergic activity Exerts both alpha and beta adrenergic activity • Relaxes smooth muscle in the bronchial tree Relaxes smooth muscle in the bronchial tree • Raises heart rate, blood pressure and Raises heart rate, blood pressure and

myocardial oxygen demandmyocardial oxygen demand• Increases myocardial chronotropy, inotropy, Increases myocardial chronotropy, inotropy,

dromotropy, irritability and automaticitydromotropy, irritability and automaticity

Review ContinuedReview ContinuedSide Effects/Adverse ReactionsSide Effects/Adverse Reactions

• Anxiety, tremors, nausea, vomiting, Anxiety, tremors, nausea, vomiting, hypertension, cardiac dysrhythmias, hypertension, cardiac dysrhythmias, headache, and heart palpitationsheadache, and heart palpitations

• Necrosis at injection site may occur with Necrosis at injection site may occur with repeated injections at the same siterepeated injections at the same site

• Anginal pain (chest pain) may result from Anginal pain (chest pain) may result from administration in those patients with administration in those patients with underlying cardiovascular diseaseunderlying cardiovascular disease

Review ContinuedReview ContinuedAbsolute ContraindicationsAbsolute Contraindications

There are no absolute There are no absolute contraindications in the contraindications in the

emergency settingemergency setting

Review ContinuedReview Continued Intramuscular sites allow a drug to be Intramuscular sites allow a drug to be

injected into the belly of a muscle so injected into the belly of a muscle so that the blood vessels supplying that that the blood vessels supplying that

muscle distribute the medication to its muscle distribute the medication to its site of action via the bloodstream.site of action via the bloodstream.

“ “Intramuscular” is the preferred by Intramuscular” is the preferred by Washington State MPD’sWashington State MPD’s

Review ContinuedReview ContinuedDosageDosage

Anaphylaxis and anaphylactic shockAnaphylaxis and anaphylactic shock

• Adults - 0.3mg of 1:1,000 via Adults - 0.3mg of 1:1,000 via Intramuscular injectionIntramuscular injection

• Pediatrics - 0.01mg/kg of 1:1,000 via Pediatrics - 0.01mg/kg of 1:1,000 via Intramuscular injectionIntramuscular injection

Any questions?Any questions?