MABEES. MFR & Basic EMT Epinephrine Study

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1 MABEES MFR & Basic EMT Epinephrine Study

2 Acknowledgements This program is a State of Michigan approved special study designed by members of the Oakland County Medical Control Authority American CME developed the training program The State of Michigan originally approved the Basic EMT Epinephrine Study (BEES). They recently approved the Washtenaw/Livingston MCA to expand the study to include MFRs. The study is now the MFR & Basic EMT Epinephrine Study (MABEES).

3 Objectives Understand the intent and purpose of MABEES. List and describe the indications for the administration of intramuscular (IM) epinephrine. Recall the adult and pediatric dosages of epinephrine when given IM and cite relevant protocols. List and describe the 5 rights of medication administration.

4 Objectives Discuss techniques to minimize risk of needle stick injury. Describe relevant W/L MCA and LSA procedures in the event of an exposure. Describe the contents and use of the W/L MCA Epi-Kit. Identify the MFR and BLS units that will carry the W/L MCA Epi- Kit. Describe and demonstrate how to draw up epinephrine from a vial and administer via IM injection using the W/L MCA Epi-Kit.

5 Objectives Describe how to document epinephrine indications, effects, and administration. Describe and demonstrate how to complete an W/L MCA MFR or BLS Medication Kit Exchange Form. Describe the LSA s procedure that assures a copy of the Patient Care Report (PCR) and a copy of the W/L MCA MFR or BLS Medication Exchange Form are submitted to the W/L MCA.

6 Introduction Understand the intent and purpose of MABEES. Epinephrine auto-injectors represent a significant expense.

7 Introduction MABEES Special Study Protocols: 1-4 Anaphylaxis/Allergic Reaction 1-15 Respiratory Distress 3-2 Pediatric Anaphylaxis/Allergic Reaction 3-4 Pediatric Bronchospasm 6M-1 BLS Medication Kit Contents and Exchange Procedure 6M-6 MFR Medication Kit Contents and Exchange Procedure Modified to meet study criteria

8 Introduction Intramuscular injection (IM) of epinephrine. Eliminates expense of epinephrine auto-injectors. Same drug, same dose.

9 Epinephrine Review Describe the effects of epinephrine. Vascular effects: Reverses vasodilation Causes vascular constriction Pulmonary effects: Effective bronchodilator Pulmonary vasodilator

10 Epinephrine Review Describe the effects of epinephrine. Pharmacokinetics: Onset time of 3-5 minutes when administered IM. Remains in the body 1-4 hours. Best effect when administered IM into the vastus lateralis. (Lateral Thigh)

11 Epinephrine Review Side effects Vary from patient to patient and include: Tremors Chills Anxiety Nausea Vomiting Tachycardia Palpitations Angina Hypertension

12 Epinephrine Review Indications for IM Epinephrine: Adult Anaphylaxis Asthma/COPD Pediatrics Anaphylaxis Severe respiratory distress or failure resulting from bronchospasm

13 Epinephrine Review Indications for IM Epinephrine Adult: Anaphylaxis sudden onset, systemic allergic reaction that can cause rapid death if not immediately identified and appropriately treated. Causes: Food, drug, latex, insect stings

14 Anaphylaxis Signs and Symptoms Vary greatly from patient to patient Hives, itching, flushing of the skin Tachycardia Wheezing Hypotension Anxiety Shortness of breath Nausea Vomiting

15 Anaphylaxis WHEN IN DOUBT, GET THE EPI OUT!

16 Epinephrine Review Indications for IM epinephrine: Adults with impending respiratory failure from: Asthma COPD

17 Asthma/COPD Indications for IM epinephrine: Impending respiratory failure. Exacerbation of asthma/copd. History should support suspicion Inability to tolerate nebulizer therapy.

18 Asthma Asthma patients received epinephrine before albuterol became the drug of choice.

19 Asthma/COPD Patients with impending respiratory failure should receive epinephrine IM. Benefits of epinephrine: Bronchodilation occurs throughout lung tissue. Rapid onset. No patient coaching (as with nebulizer treatment).

20 Contraindications There is no absolute contraindication for epinephrine. A patient that cannot breathe may have elevated vital signs: Tachycardia Hypertension ASK YOURSELF WHY?

21 Epinephrine Dosing Recall the adult and pediatric dosages of epinephrine when given IM and cite relevant protocols. Adult: Anaphylaxis/Allergic Reaction Respiratory Distress

22 Epinephrine Dosing Adult Anaphylaxis: In cases of severe allergic reaction, wheezing or hypotension, Administer epinephrine 1 mg/ml, 0.3 mg (0.3 ml) IM OR via adult auto-injector. Vial brand and labeling may vary

23 Epinephrine Dosing Adult Anaphylaxis Post-Medical Control: Administer additional epinephrine 1 mg/ml, 0.3 mg (0.3 ml) IM OR via adult epinephrine auto-injector.

24 Epinephrine Dosing Adult Asthma/COPD: Administer epinephrine 1 mg/ml, 0.3 mg (0.3 ml) IM in patients with impending respiratory failure unable to tolerate nebulizer therapy. Vial brand and labeling may vary

25 Epinephrine Dosing Adult Asthma/COPD Post-Medical Control: Consider additional epinephrine 1 mg/ml, 0.3 mg (0.3 ml) IM in patients with impending respiratory failure unable to tolerate nebulizer therapy.

26 Epinephrine Dosing Pediatric patients: What do they weigh? Utilize standardized length based tool to accurately estimate weight. Ask parents for accurate weight Never estimate weight

27 Epinephrine Dosing Pediatric Anaphylaxis Allergic Reaction < 10 kg (approx. 20 lbs.): Contact medical control prior to epinephrine administration if possible.

28 Epinephrine Dosing Pediatric Anaphylaxis Allergic Reaction kg (approx lbs.): Administer epinephrine 1 mg/ml 0.15 mg (0.15 ml) IM OR via pediatric epinephrine auto-injector.

29 Epinephrine Dosing Pediatric Anaphylaxis Allergic Reaction > 30 kg (approx. 60 lbs.): Administer epinephrine 1 mg/ml 0.3 mg (0.3 ml) IM OR via adult epinephrine auto-injector.

30 Epinephrine Dosing Pediatric Anaphylaxis Allergic Reaction Post-Medical Control Additional Epinephrine IM: If child weighs between kg (approx. 60 lbs.), administer Epinephrine 1 mg/ml, 0.15 mg (0.15 ml) IM OR via pediatric epinephrine auto-injector. If child weighs greater than 30 kg, administer Epinephrine 1 mg/ml 0.3 mg (0.3 ml) IM OR via adult epinephrine auto-injector.

31 Epinephrine Dosing Pediatric Bronchospasm < 10 kg (approx. 20 lbs.): Contact medical control prior to epinephrine administration if possible.

32 Epinephrine Dosing Pediatric Bronchospasm kg (approx lbs.): Administer epinephrine 1 mg/ml 0.15 mg (0.15 ml) IM OR via pediatric epinephrine auto-injector.

33 Epinephrine Dosing Pediatric Bronchospasm > 30 kg (approx. 60 lbs.): Administer epinephrine 1 mg/ml 0.3 mg (0.3 ml) IM OR via adult epinephrine auto-injector.

34 Epinephrine Dosing Pediatric Bronchospasm Post-Medical Control Additional Epinephrine IM: If child weighs between kg (approx. 60 lbs.), administer Epinephrine 1 mg/ml, 0.15 mg (0.15 ml) IM OR via pediatric epinephrine auto-injector. If child weighs greater than 30 kg, administer Epinephrine 1 mg/ml 0.3 mg (0.3 ml) IM OR via adult epinephrine auto-injector.

35 Considerations for Medication Administration Medication errors are preventable! A study found Michigan paramedics have an error rate of 60.9% when administering epinephrine to pediatric patients. Do not estimate weight!

36 Considerations for Medication Administration List and describe the 5 rights of medication administration: 1. Right Patient 2. Right Medication 3. Right Dosage/Concentration 4. Right Route 5. Right Documentation

37 Considerations for Medication Administration List and describe the 5 rights of medication administration: 1. Right Patient 2. Right Medication 3. Right Dosage/Concentration 4. Right Route 5. Right Documentation

38 Considerations for Medication Administration List and describe the 5 rights of medication administration: 1. Right Patient 2. Right Medication 3. Right Dosage/Concentration 4. Right Route 5. Right Documentation

39 Considerations for Medication Administration List and describe the 5 rights of medication administration: 1. Right Patient 2. Right Medication 3. Right Dosage/Concentration 4. Right Route 5. Right Documentation

40 Considerations for Medication Administration List and describe the 5 rights of medication administration: 1. Right Patient 2. Right Medication 3. Right Dosage/Concentration 4. Right Route 5. Right Documentation

41 Considerations for Medication Administration List and describe the 5 rights of medication administration: 1. Right Patient 2. Right Medication 3. Right Dosage/Concentration 4. Right Route 5. Right Documentation

42 Needle Stick Safety Discuss techniques to minimize risk of needle stick injury: Wear personal protective equipment. Have sharps container readily accessible. Place needle directly into sharps container.

43 Needle Stick Safety Discuss techniques to minimize risk of needle stick injury: Never pass a needle to another provider. Expose and prepare injection site prior to handling needle. Never set a used needle down. Never recap needles. Avoid IM injection in a moving ambulance. of transport is required Provides or the ER to prepare Notification of transport is NOT required LSAs should identify which ERs would like P3 notification of transport

44 Needle Stick Safety If an exposure occurs: Immediately wash the needle stick with soap and water.

45 Needle Stick Safety Follow W/L MCA Notification of Prehospital Personnel Regarding Potential Exposures to Communicable Diseases Section 6D-3. This will ensure the following: 1. A doctor will determine if an exposure occurred. 2. The hospital will test the patient for HIV/Hepatitis B and C surface antigen. 3. The exposed individual will be referred to their respective agency for follow-up, testing, logistics, and counseling.

46 Needle Stick Safety Follow your Life Support Agency s SOPs This will ensure YOU receive the appropriate care.

47 W/L MCA Epi Kit

48 W/L MCA Epi Kit Contents of the W/L MCA Epi-Kit: Medication/Item Concentration Packaging Quantity Epinephrine 1 mg/ml 1 mg/ml Vial 1 Luer Lock Syringe 1 cc Syringe 2 Intramuscular Needle 1 25 Gauge 2 Alcohol Prep Single Use 4 Dosing Card 1

49 W/L MCA Epi Kit Participating MFR units and all BLS units at participating LSAs will carry the Epi-Kit. The Epi-Kit will be contained within the W/L MCA MFR or BLS Medication Kit. Store in a secure cabinet Climate controlled storage Free from direct sunlight

50 BEES Dosing Card (Front)

51 BEES Dosing Card (Back)

52 Epinephrine Administration The injection site: Vastus lateralis (Lateral Thigh) Preferred site. IM injection offers significantly faster absorption.

53 Epinephrine Administration First things first: Expose the injection site.

54 Epinephrine Administration Locate the injection site Place little finger of one hand on the greater trochanter. Place little finger of the other hand on the lateral femoral condyle. The center of the space between thumbs is the injection site.

55 Epinephrine Administration Locate the injection site:

56 Epinephrine Administration Intramuscular (IM) injection: Cleanse the site with an alcohol prep.

57 Epinephrine Administration Draw up epinephrine from a vial: Prepare supplies 1 25G Needle Syringe Alcohol prep Vial containing 1 mg of 1 mg/ml epinephrine BEES Dosing Card One person can be exposing and preparing the site while the other draws up and prepares and performs the epinephrine injection.

58 Epinephrine Administration Draw up epinephrine from a vial: Clean rubber top with alcohol.

59 Epinephrine Administration Draw up epinephrine from a vial: Attach the needle to the syringe.

60 Epinephrine Administration Draw up epinephrine from a vial: Draw the syringe back to the appropriate dosage.

61 Epinephrine Administration Draw up epinephrine from a vial: Hold the vial with one hand and puncture the vial. Flip the vial upside down.

62 Epinephrine Administration Draw up epinephrine from a vial: Push the plunger to inject all air from the syringe into the vial.

63 Epinephrine Administration Draw up epinephrine from a vial: Draw up the appropriate dosage. Make sure the tip of the needle is at the very top of the vial as your draw up medication.

64 Epinephrine Administration Draw up epinephrine from a vial: Remove the needle from the vial. Remove air bubbles.

65 Epinephrine Administration Draw up epinephrine from a vial: Confirm correct dosage. Verify with partner.

66 Epinephrine Administration Intramuscular (IM) injection: Squeeze the muscle to increase the size and depth of the injection site.

67 Epinephrine Administration Intramuscular (IM) injection: Inform the patient they will feel a poke. Insert the needle in a smooth motion at a 90 degree angle.

68 Epinephrine Administration Intramuscular (IM) injection: Draw back on the syringe and verify blood is not present.

69 Epinephrine Administration Intramuscular (IM) Injection: The presence of blood indicates that the needle is in a vein. Administering epinephrine 1 mg/ml directly into a vein can cause cardiac dysthymias and even death. If blood is present simply remove the needle and dispose of the needle safely. A new needle is required. If no blood is present, inject the medication into the lateral thigh in one smooth motion.

70 Epinephrine Administration Intramuscular (IM) injection: Remove the needle and place it directly into a sharps container.

71 Epinephrine Administration Intramuscular (IM) injection: Place a bandage over the injection site.

72 Documentation Describe how to document epinephrine indications, effects, and administration. Documentation should include: Patient presentation Epinephrine administration information Positive/negative effects

73 Documentation Patient presentation: Signs and symptoms to support epinephrine administration. Indications at the scene. Clinical suspicion of anaphylaxis, asthma/copd. Medical alert bracelet. Prescription for an epinephrine auto-injector.

74 Documentation Epinephrine administration information: How was epinephrine administered? Correct medication Correct concentration Correct dosage Correct route Correct time Example: 00:22 hrs Epi 1 mg/ml, 0.3 mg IM in the right lateral thigh

75 Documentation Positive/negative effects How did the patient react to the medication? Document any change in patient condition. Record vital signs before and after epinephrine administration.

76 W/L MCA Epi-Kit Exchange Form Describe and demonstrate how to complete an W/L MCA MFR or BLS Medication Kit Replacement Form.

77 W/L MCA Epi-Kit Exchange Form Must be completed each time the W/L MCA Epi-Kit is used in the field. Used to maintain the tracking of W/L MCA Epi- Kit use in the field.

78 W/L MCA Epi-Kit Exchange Form EMS Agencies participating in MABEES are responsible for exchanging the W/L MCA MFR or BLS Medication kit. Initial exchange may be done with a spare MFR or BLS Medication kit at your agency. Used W/L MCA MFR or BLS Medication kits are exchanged at the pharmacy designated for your agency. Remember to call ahead to arrange for the MFR or BLS Medication kit exchange.

79 W/L MCA Epi-Kit Exchange Form A copy of the Patient Care Report (PCR) and the W/L MCA MFR or BLS Medication Kit Exchange Form must be submitted to the W/L MCA with 72 hours. Each LSA must develop their own strategy to satisfy this requirement. W/L MCA will accept the documents by Fax or Fax: cottrelj@ewashtenaw.org

80 W/L MCA Epi-Kit Discrepancy Form Must be completed if there is any discrepancy with the W/L MCA Epi-Kit contents.

81 QUESTIONS?

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