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Epinephrine is used to treat anaphylaxis. It causes the heart rate to increase, blood vessels to constrict, and airways to open. Diphenhydramine stops the release of further histamines. Epinephrine reverses the signs of anaphylaxis, while diphenhydramine stops the reaction. Monitoring vital signs is important, and oxygen should be given if needed. Epinephrine is administered through the EpiPen in the thigh. Side effects of epinephrine include increased heart rate, hypertension, and pale skin. Epinephrine should not be given to patients without respiratory or hypertension symptoms. as a parasympathomimetic. It causes a parasympathetic response. So epinephrine tolerates the effect. So epinephrine will cause the heart rate to increase, blood vessels to constrict, bronchioles to dilate, it will clear up the wheezing and open up the airways, slow down swelling, increase GI motility which will fix that GI problem. And like she said, within a minute it starts working and it happens very quickly. But you have a lot of side effects from it. You get the rapid heart rate, hypertension, tremulous, cool, pale, flaming skin. So the epinephrine is the definitive treatment for it. What epinephrine does is reverses the sympathetic response, reverses anaphylaxis. But that doesn't stop it. What stops it is diphenhydranine. Diphenhydranine is an antihistamine. It stops the release of further histamines. It stops those granulocytes from degranulizing. So the diphenhydranine stops the reaction. The epinephrine counteracts the effects of the reaction. Does that make sense? So they both kind of work hand in hand. I can get epinephrine, but the epinephrine will wear off well before my body stops producing histamines. So I need the antihistamine to stop it from happening in the future. So the epinephrine reverses the signs and diphenhydranine stops the reaction. Okay? So systematic head to toe or a focused exam. I can focus on breathing and the skin, blood pressure. Also take breath sounds and inspect the skin for that urticaria, that swelling or rashes. Assess things like the pulse and respiratory rate, blood pressure, pupillary response. Skin will be unreliable as I said because of the swelling and the urticaria. You're not going to get a good view of the skin. Monitoring devices. Pulse oxygen should be used because it will tell you oxygenation levels. Decision to apply oxygen should be based on airy patency, work of breathing and abnormal lung sounds. If it's anaphylaxis they're going on oxygen. If it's anaphylaxis or if it's potential like an allergy and I don't know if it becomes anaphylaxis, I'm putting them on oxygen. I'd rather have them hyperoxygenated now. Repeat your primary assessment. Reassess vitals and repeat your focused assessment. You're going to do vitals every five minutes. Constantly reassess vitals every five minutes because these patients can go from zero to anaphylaxis in less than ten minutes and it can happen upwards of six hours. Determine the severity of the reaction. Modern reactions only require supportive care. Monitoring like those patients that I brought to the hospital. Yeah, I'm allergic to tomatoes. It was in the rice so I ate it. Not having any reaction. I'm going to transport, you know, maybe not even lightens the timer. Anaphylaxis requires epinephrine and ventilatory support. Call ALS. They need diphenyme. Transport to closest appropriate facility. Any ER can handle anaphylaxis. We check their interventions. Documentation and communication. Your documentation includes signs and symptoms, the reason you did what you did. Why did you give them epinephrine? Why did you do it? You can do a nebulizer treatment. If they're wheezing, you can give them epinephrine and a nebulizer treatment as a patient's response to the treatment. If a patient appears to be having a severe allergic reaction, administer BLS which includes epinephrine and prompt transport. Call ALS. Now, what they're doing there is they're removing the stinger. Now, you take a credit card, preferably the patient's, not yours, and you scrape away from the direction of the stinger. You don't pinch it and move it out. You don't use forceps or tweezers because you can squeeze the venom sac and push more venom in, only causing a bigger reaction. So, you want to scrape it to remove that and then you take the credit card and go to watch. But, what I don't recommend is doing this before you've got everything else done. Like, I'll do this after all my assessment is done. If I'm just sitting on the computer talking to the patient, punching in their number, their name and address, then I'll do this. But, if I have any treatments to do, I'm going to do this after. It says that the organ, the stinging organ of bees will keep pulsating, like honey bees will keep pulsating, so you'll find it only does it for a minute or two. So, this would be, this is the last thing I worry about. Wash the area with soap or antiseptic. You can take some hand sanitizer if you need to. Remove jewelry. I have seen people lose fingers because they left the ring on and they are swelling so much, they cut off the circulation, their fingers turn black and they remove their finger. So, do not, make sure you remove jewelry. That's why we carry ring cutters. Position the injection site below the heart. Apply ice or cold packs to kind of slow the swelling. Be alert to signs of airway swelling or signs of anaphylaxis. Anaphylaxis includes cardiovascular and respiratory compromise, wheezes, bronchoconstriction, stridor, blood pressure, drop in blood pressure, slowing heart rate. Monitor the patient's vital signs. Epinephrine, mimics the sympathetic fight or flight response. It's sympathomimetic, mimics the sympathetic nervous system fight or flight. It's a catecholamine, adrenogenic, stimulant. It all means the same thing. Causes blood vessels to constrict, reverses vasodilation and hypotension by causing vasoconstriction, increases cardiac contractility, causes heart to squeeze harder, relieves bronchospasms, it will rapidly reverse the effects of anaphylaxis. Epinephrine is prescribed by physicians. It comes in pre-dosed epinephrine auto-injector, the EpiPen. You have the EpiPen adult. What's the dose? 0.3 milligrams. What about for child? 0.15. What is the break up? What's the age? When do you go child to an adult? Maybe 13. It's 8 years, 55 pounds, 25 kilograms. So when my son was 8 years old, he was about 70 pounds. So go by the weight more than the age, but if you look at a child and you're like, I'm not sure if it's 55 or less, just give him the adult. It's perfectly fine. We only give him the child if you look at it, oh yeah, he's definitely less than 55 pounds. The dose in Massachusetts is you can give two to one adult, five minutes apart. Usually you can get seven to ten minutes out of the EpiPen. Usually it's about seven to ten before the symptoms come back. For a child, it's one dose, and then you call medical control for the second. So for an adult, you can give two doses, and if let's say you're still ten minutes out, you can't link up with ALS, the patient's signs are coming back, you can call medical control to give a third. With a child, you can give the first dose, and then you have to call for the second dose. And it's always in the thigh because that's like the thickest? Like why? Well, the auto-injector is in the thigh because the auto-injector has an inch and a quarter, inch and a half needle that's spring-loaded, so we put it in the thigh, that's the thickest tissue. And will it work if it hits the femur? Yeah, well it'll still work, it'll still put fluid in the epinephrine in the muscular. But the problem is that again, if you push too hard, if you really jam it in, you can push through the muscle and actually hit the bone. I've seen needles bend, the needles stick in the bone, I've seen the legs, people pull their legs away and make big lacerations in the leg. Look it up, if you want to look up on YouTube or Google epiPen injuries, I don't like them. So we use check and inject. I draw up 0.3 or 0.15 of epinephrine and I inject it into the deltoid, remember? We talked about that? And that is a much better way to administer. It comes with a little vial? It comes with a little vial, yeah, and you draw it up and inject it, and we'll talk about that. The difference is epiPen, $300-$500 per dose can cause massive injuries. The check and inject, $30, and it's just a 22-gauge IM needle. You're not going to cause any damage. So which one do I want to use? Check and inject all day. You guys can do that, you guys can give IM injections. As a matter of fact, I told you that there are companies, like Brewster was doing it in Boston, Basics were giving COVID vaccinations. It's one of the skills that you can do. So this is the epiPen, and again, you push it against the leg, support, and I mean hold that leg, baby. Have your partner hold that leg, because if they move that leg, especially kids, it slices right open. 0.3 for an adult, 0.15 for a child infant, you can give 65 pounds for the break-off. You can give 2 for an adult, then you have to call medical control, you can give 1 for a child, then you have to call medical control. Both 5 minutes apart, but you can usually get 7-10 minutes out of the dose. Side effects of epinephrine, so that blood pressure is going to go, the blood pressure is going to tank with anaphylaxis. It's going to drop into the 90s, so this is going to bring them back into the 140s. Epinephrine brings your blood pressure up 50-60 points. The pulse rate is going to increase significantly. You're going to have anxiety, cardiac, you're not going to have cardiac arrhythmias. The only cardiac arrhythmia is flatline. Epinephrine is not going to cause flatline. You're going to get cardiac dysrhythmias, things like TBCs and such. Pallor, which is pale skin, dizziness, chest pain, headache, nausea, vomiting from the halting of GI motility. That's all signs and symptoms of epinephrine. So a patient is working. Do not give an epinephrine to a patient without respiratory or hypertension. I'm not going to give it just because you've got urticaria. I'm going to wait to see cardiovascular or respiratory compromise. You also want to give it to a patient that has hypertension. So if you're like 180 over 100, even if you haven't brought those spasms, I'm not giving you epinephrine because it's going to bring your blood pressure up to like 230, 240, and you're going to freaking blow a blood vessel and have an aneurysm. Don't want to do that. Judo for the heart. So in review, the signs and symptoms of an allergic reaction are caused by the release of D, histamines, leukotrienes, and also cytokines. The negative effects associated with anaphylactic shock are the result of... Which one? You say D? C. Vasodilation and bronchial constriction. You'll call the baseball park for a 23-year-old man with difficulty breathing and states that he ate a package of beans 30 minutes ago and denies allergies or past medical history. It may not be the peanuts. It may be an oil it was cooked in. Your assessment reveals widespread urticaria, tachycardia, a blood pressure of 90 over 60, and you can hear him wheezing even without a stethoscope. We call that audible wheezing. What are you going to do for this guy? What's he going to get right now? God bless you. Epinephrine. He's going to get epinephrine. What's he having? D. That's absolutely anaphylactic reaction. Absolutely. He's getting EpiPen. If I can throw it across the room, he's going to get it. Like darts? Like darts. What is a wheel? No, it's not the thing that goes round and round on the bus. It's a hard form, like a hard... A raised, swollen, round, defined area of the skin, which is A. Very good. You are treating a woman who was stung numerous times by hornets. Unassess me to note that the stingers are embedded in the skin. You should scrape the stinger from your skin after everything else is done. A young male is experiencing signs and symptoms of anaphylactic shock after being stung by a scorpion. His level of consciousness is diminished, his breathing is labored, and he has stridor, inspiratory stridor. His face is cyanotic, blue. The patient has a prescribed auto-injector. What should you do first? Wrap him up like a mummy. Look at his presentation. What's the first thing we're going to do? Cyanotic, a ventilatory assistance. We're going to bag him. Right. It's just like Narcan for opiates. I don't just wait and hit him with Narcan. I want to start ventilating him right away. Then hit him with Narcan. So start ventilating right away. Then either you or somebody else can get that Vanessa. Oxygenate first. I always thought that because of the movie The Mummies that their scorpions were only in like Egypt and like over there and not in America. No they're not. We're going to talk about in the next chapter, we'll talk about scorpions down in Arizona. Yeah, I've seen them in Arizona. And it's not the big ones. You know the big nasty black ones that everybody's afraid of? Those, it's like a bee sting. It's the little ones. The little brown ones that kill you. And they don't really kill you. Anaphylaxis will soften it up. The most reliable indicator of upper airway swelling during severe allergic reaction is? Spriterus. Spriterus respiration, the high-pitched whistling sound. The fusion of the upper airway. The most common trigger of anaphylaxis is? Food. Food, D. About 30%, between 30 and 40% actually. An adult EpiPen delivers blank milligrams of epinephrine and the child delivers blank. 0.3 and 0.5. When administering epinephrine, do you want to hold the injector in place for? 10 seconds. Because it's spring-loaded. The first two seconds, 90% of the medication comes out, but then the rest of it kind of slowly comes out. Any questions? All right, take a break.