PCTH - Analgesia & Allergic Reaction Flashcards
What is epinephrine?
- a catecholamine secreted by the adrenal medulla; is classified as a sympathomimetic
- aka adrenaline
- part of your fight or flight response (part of SNS)
What is the concentration of epinephrine carried on the trucks?
1:1000
1 gram: 1000ml (the ml of that current solution needed to make 1 gram of the drug) ⇒ this also equates to 1mg/ml
What receptors does epinephrine act on and what are the resulting effects?
alpha and beta effects
A1 receptor: Peripheral vasoconstriction
A2 receptor: dilation of coronary arteries
B1 receptor: increase HR and contractility (so increased BP)
B2 receptor: Bronchodilation
Delivery methods for epinephrine
injection
nebulized (for resp emergencies like croup, asthma)
What is diphenhydramine?
- aka Benadryl
- one of the first known anti-histamines
- used for tx of moderate allergic reactions
- found in OTC sleep aids (drowsiness a side effect of benadryl)
If moderate allergic reaction, a paramedic gives:
If severe allergic reaction, a paramedic gives:
moderate: benadryl
severe: epinephrine and then benadryl
Moderate to Severe Allergic Reaction Medical Directive
Indication
Conditions
Contraindications
Indications:
- exposure to a probable allergen; AND
- S/S of a moderate to severe allergic reaction (including anaphylaxis)
Conditions:
- Epinephrine: for anaphylaxis only
- Diphenhydramine: weight is ≥25kg
Contraindications
- Epinephrine: allergy/sensitivity to epinephrine
- Diphenhydramine: allergy/sensitivity to diphenhydramine
Moderate to Severe Allergic Reaction Medical Directive
Treatment
Clinical Considerations
Treatment:
-
Epinephrine
- __Route: IM
- Concentration: 1mg/mL (1:1000)
- Dose: 0.01mg/kg* (may round to nearest 0.05mg)
- Dosing interval: minimum 5 min
- Max # of doses: 2
-
Diphenhydramine
- __Weight ≥25kg to <50 kg ⇒ give 25mg IV/IM (max single dose 25mg, max 1 dose)
- Weight ≥ 50kg ⇒ give 50 mg IV/IM (max single dose 50mg, max 1 dose)
Clinical Considerations:
1) Epinephrine administration takes priority over IV access.
2) IV administration of diphenhydramine applies only to PCPs authorized for PCP autonomous IV
What body systems are involved with an allergic reaction and what signs and symptoms would present?
1) Integumentary: hives, itching, flushing, swelling, angioedema
2) Cardiovascular: Increased HR, decreased BP, syncope, decreased LOC, hypoxemia
3) Respiratory: SOB, wheeze, cough, stridor
4) GI: cramping, N/V/D
Primary treatment for a minor to moderate allergic reaction
- diphenhydramine - slow onset
- relieves Sx (itching, flushing, urticaria, angioedema, eye and nasal symptoms)
- DOES NOT prevent or relieve upper airway obstruction, hypotension shock
- Note: Severe symptoms to a single body system (resp system, CV system) should be considered as a severe allergic reaction
True or False. Some patients may present with a biphasic reaction within 72 hours of the initial symptoms having resolved without further exposure to an allergen
True
High risk patient groups for anaphylaxis
very young and very old
Hx of asthma
Hx of cardiovascular disease
Hx of mast cell disease
Treatment for anaphylactic reaction
PRIMARY
- epinephrine - 1:1000 IM
- fast onset - will increase BP, prevent and relieves hypotension, decreases upper airway obstruction, decreases wheezing, decreases urticardia and angioedema
SECONDARY TX:
- diphenhydramine IV/IM
Patient administrated epinephrine but both of his epipens prior to paramedic arrival, approximately 10 minutes ago. How many more is the paramedic allowed to give?
as many as your directive allows :)
you can always max out your directive BUT if you show up and say they literally JUST took their epi, maybe wait a bit and see how they respond
Steps to prepare giving epinephrine.
1) Go through your 5 rights and check epinephrine - dose, name, expiry etc.
2) open epi ampule
3) draw up epi
4) delivere - vastus lateralis or deltoid
If patient is 0 to 5 months, how much epinephrine are you administering (weight unknown)?
If patient is 6 months to 1 year, how much epinephrine are you administering (weight unknown)?
0 to 5 months: 0.05 mg
6 mos to < 1 year: 0.1mg
The trucks carry Benadryl in what form/concentration?
50mg/mL
Pt was showing mild allergic reaction S/S. After giving him benadryl, he deteriorates to anaphylaxis. You administer 2 rounds of epinephrine with marked improvement. Are you able to follow that up with diphenhydramine to help with symptoms?
No. You’ve already given your one dose prior to epi administration
If patient with anaphylaxis presents with wheezing, what other protocols should be considered?
Shortness of Breath Standard:
- Assess:
- Head/neck for cyanosis, nasal flaring, excessive drooling, JVD, trach deviation
- extremities for cyanosis, edema
- Chest: 12 lead (if chest pain), subQ ephysema, accessory muscle use, urticaria, indrawing, shape, symmetry, tenderness
- Lungs: air entry, sounds
- Abdomen: puslations, discolouration, scars, distension, masses, guarding, rigidity, tenderness
Respiratory Failure Standard:
- ventilate pt if needed
- maintain ETCO2 between 35-45; COPD/asthma patients who have initial ETCO2 >50mmHg, maintain at 50-60mmHg
True or False. Urticaria on its own does not constitute a severe reaction.
True. You need at least one other system affected
Skin findings in allergic reactions are most common however up to ____% of patients do not have hives or other skin symptoms.
20
that’s why it is vital that all body systems are assessed to determine the most appropriate treatment plan
Is VSA secondary to anaphylaxis a special consideration?
Yes. It is a reveresible cause so 1 analyze and start packaging and going (but after you give the epi)
What is the most common complaint in the pre-hospital setting?
pain (however often goes untreated in the pre-hospital setting)
What may be administered to relieve pain?
analgesic compounds
Downfalls of providing pain relief in pre-hospital setting, especially with narcotics?
- can cause respiratory depression and hypotension
- may mask progression of symptoms (or real pain S/S leading to changes in CTAS levels)
- Can complicate assessment after arrival in the receiving facility
Analgesic compounds include which 3 drugs that paramedics are allowed to give?
acetaminophen
ibuprofen
ketorolac
What is acetaminophen and how does it work?
- aka Tylenol
- non-opioid analgesic that works by inhibiting cyclooxygenase enzyme - this causes inhibition of prostglandin synthesis
- prostanglandins are usually synthesized in response to injury and illness, and promote fever and inflammation as well as protect stomach lining and prevent bleeding)
- goal: to control edema and body’s processes that are causing inflammation
- works primarily on the CNS - so likely more effective for complaints like headaches
What is ibuprofen and how does it work on the body?
- aka Advil
- similar mechanism to acetaminophen
- equal effect in both PNS and CNS so preferred for extremeity pain due to anti-inflammatory process
Which pain medications given by paramedics are adminsitered via the enteral route?
acetaminophen
ibuprofen
Which pain medication is given parenteral route (i.e. bypasses GI tract)?
Ketorolac
What is ketorolac and how does it work?
- aka Toradol
- similar mechanism as ibuprofen, being a nonselective COX enzyme inhibitor to reduce pain and inflammation
- more powerful than Tylenol
When is a pain assessment done and how is it administered?
prior to and post administration of any analgesic
on a scale of 0-10 or mild/moderate/severe
Analgesia Medical Directive
Indications
Conditions
Indications: pain
Conditions:
- Acetaminophen: ≥12 y.o., unaltered LOA
- Ibuprofen: ≥12 y.o., unaltered LOA
- Ketorolac: ≥12 y.o., unaltered LOA, normotension
Contraindications for Acetaminophen
- Acetaminophen use within previous 4 hours
- Allergy or sensitivity to acetaminophen
- Hx of liver disease - because it’s metabolized in the liver so if they have liver disease, then it can accumulate in the body
- Active vomiting - no PO meds
- Unable to tolerate oral medication - can’t swallow pills or if patient is supine
- Suspected ischemic chest pain - follow cardiac ischemia directive instead
Contraindications for ibuprofen
- NSAID use within the last 6 hours - takes longer to metabolize
- Allergy or sensitivity to NSAIDs
- Patient on anticoagulation therapy - due to increased risk of bleeding
- Current active bleeding
- Hx of peptic ulcer disease or GI bleed - bc we don’t want to limit prostaglandin production (helps with healing/lining stomach)
- Pregnant - ibuprofen has been shown to cause premature closure of the ductus arteriosus leading to cutting off blood flow
- If asthmatic, no prior use of ASA or other NSAIDs - chance of asthma exacerbation/bronchospasm
- CVA or TBI in the previous 24 hours - due to risk of bleeding
- Known renal impairment - because drug needs to eventually be eliminated (and can cause exacerbations to renal disease)
- Active vomiting
- Unable to tolerate oral medication
- Suspected ischemic chest pain
Contraindications for Ketorolac
- NSAID use within previous 6 hours
- Allergy or sensitivity to NSAIDs
- Patient on anticoagulation therapy
- Current active bleeding
- Hx of peptic ulcer disease or GI bleed
- Pregnant
- CVA or TBI in the previous 24 hours
- Known renal impairment
- Suspected ischemic chest pain
What is considered an “active bleed” when determining if a patient is contraindicated for ibuprofen?
- external trauma that is dressed and controlled IS NOT an active bleed
- occult bleeding should be considered active bleeding (hematuria, GI bleed, vomiting blood, stool blood)
- Trace blood in urine with suspected renal colic is not considered active bleed
True or False. Oral administration of pain medications (i.e. acetaminophen and ibuprofen) is as effective as parenteral analgesia (i.e. ketorolac).
True
True or False. Administration of acetaminophen and ibuprofen can provide analgesia similar to low-dose opioids without the euphoric effect.
True
Anticoagulation Therapy - Common anticoagulants
- Pradaxa (dabigatran)
- Coumadin (warfarin)
- Xarelto (rivaroxaban)
- Eliquis (apixaban)
- Lovenox (enoxaparin)
- Savaysa (edoxaban)
- Arixtra (fondaparinux)
Analgesia Medical Directive
Treatment
1) Consider Acetaminophen
- Age ≥12 years to <18 years
- Route: PO
- Dose: 500-650mg
- Max single dose: 650 mg
- Dosing interval: N/A
- Max # of doses: 1
- Age ≥18 years
- Route: PO
- Dose: 960-1000mg
- Max single dose: 1000 mg
- Dosing interval: N/A
- Max # of doses: 1
2) Consider ibuprofen:
- Age ≥12 years
- Route: PO
- Dose: 400mg
- Max single dose: 400mg
- Dosing interval: N/A
- Max # of doses: 1
3) Consider ketorolac
- Age ≥12 years
- Route: IM/IV
- Dose: 10-15mg
- Max single dose: 15 mg
- Dosing interval: N/A
- Max # of doses: 1
Analgesia Medical Directive
Clinical Considerations
Whenever possible, consider co-administration of acetaminophen and ibuprofen.
Suspected renal colic patients should routinely be considered for ibuprofen or ketorolac.
IV administration of ketorolac applies only to PCPs authorized for PCP Autonomous IV.
What is renal colic and what is the special consideration for these patients when administering pain medication?
Renal colic is a sudden, acute pain in the kidney area caused by the obstruction of urine flow from the kidney to the bladder
They should routinely be considered for NSAIDS (either ibuprofen or ketorolac) administration because of the anti-inflammatory action and smooth muscle relaxant effects (reduces the GFR which reduces renal pelvic pressure and stimulation of the stretch receptors) as well as its inhibition of prostaglandin production makes them ideal agents to treat renal colic. The only advantage of parenteral ketorolac over oral ibuprofen is the ability to administer an NSAID despite vomiting. The overall clinical effect of these drugs is almost identical.
