PWC Protocols

1
PWC Protocols

• Protocol 1
• Allergic Reaction

2
Objectives

• The provider will gain a basic understanding of
  the etiology of an allergic reaction.
• The provider will be able to identify the signs
  and symptoms of an allergic reaction reaction.
• The provider will be able to identify the
  different severities and appropriate treatment(s)
  of an allergic reactions.

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The Big Picture

• An allergy refers to a misguided reaction by our
  immune system in response to bodily contact with
  certain foreign substances
• Allergens
• These foreign substances (allergens) are usually
  harmless and remain so to non- allergic people
• When an allergen comes in contact with the
  sensitized body, it causes the immune system to
  develop an allergic reaction
• An allergen can be almost anything
• Including the sun
• An allergic reaction can develop at any age

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Allergic Reaction Scope

• Allergic reactions can be localized
• Hay fever
• Minor in nature
• Allergic reactions can be systemic
• Anaphylaxis
• Life threatening

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Severity Generalizations

• Mild (inherited)
• Pollen
• Mold
• Animal dander
• Dust mites
• Moderate to Severe (developed)
• Injected substances
• Venom, medications, etc.
• Oral substances
• Certain foods, medications, etc.
• Contact
• Latex

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Anaphylaxis

• The most severe form of an allergic reaction
• Is frequently life-threatening
• Most often develops within minutes of exposure to
  an allergen
• Can be delayed for up two hours
• Usually involves either respiratory or
  cardiovascular symptoms
• Same pattern of symptoms will evolve in
  subsequent episodes

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Histamine Release

• Signs and Symptoms are primarily due to a mass
  release of histamine and may include
• Generalized itching
• Increased capillary permeability
• Angioedema
• Hives and soft tissue edema
• Hoarseness and closing off of larynx
• Vasodilatation
• Flushed skin
• Decreased cardiac preload
• Hypotension
• Decreased cardiac output
• Cerebral hypoxia
• Anxiety and/or decreased LOC
• Bronchial constriction
• Wheezes
• SOB
• Hypoxia
• Coughing and sneezing
• A protective mechanism

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The Protocol

• All Providers
• ALS/BLS

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Initial Assessment

• Ensure the safety of yourself and your crew.
• Reduce the patients potential for further
  exposure to the allergen.
• Move patient to fresh air
• Remove the stinger
• Apply cold pack to site (if indicated)

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Assessment

• Perform a rapid initial (primary) assessment
• Be prepared to immediately intervene should
  deficits be present
• Perform focused history and physical assessment
• Pay particular attention to
• Past allergies
• Exposure time and progression of signs and
  symptoms
• Past severities
• Self treatments and the results
• Home medications

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Determine Severity

• Minor/Local
• Local edema and itching
• Most often a non-allergic sting or bite
• Moderate
• Formation of urticaria or generalized itching
• Severe
• Anxiety or decreased LOC, respiratory distress,
  wheezing, stridor or upper airway compromise,
  decreased perfusion, or hypotension
• Note treatment regimes and transport
  considerations are based on the above

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Establish and Maintain A Patent Airway

• Administer oxygen
• Rule of thumb
• N/C for SpaO2 gt 90
• NRB for SpaO2 lt 90
• BVM for patients who are inadequately ventilating

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Monitor Vital Signs Regularly

• If hypotension occurs, place patient in shock
  position
• This may on occasion be contraindicated owing to
  respiratory compromise

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BLS Providers Only

• Contact Medical Control for permission to assist
  the patient in administration of their prescribed
  Epinephrine Auto-Injector
• 0.3 mg maximum dose

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Transport Considerations

• BLS for mild/local reactions if
• No previous history of moderate or severe
  reactions
• Note The now stable patient who had received an
  epinephrine injection prior to your arrival, must
  be transported by ALS if available

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The Protocols

• ALS Providers

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Monitor

• Tachycardia is to be expected
• Compensation
• PVCs are not uncommon
• Dont become focused on them
• If capnography is available look for the presence
  of bronchospasm
• Long, slanted and peaked, exhalation phase
• Phase 1 3
• Note The up-rise is the exhalation phase!

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Epinephrine 1/1,000 For Severe Reaction

• Administer epinephrine 1/1,000
• Adult 0.3 mg Sq
• Ped 0.01 mg/kg up to 0.3 mg Sq
• Note epinephrine may be administered
  immediately after the primary survey is completed
  as it may be the means of maintaining a patent
  airway
• Halts bronchospasm
• Reduces soft tissue angioedema
• Constricts blood vessels
• Increases cardiac output
• Note If epinephrine was given prior to your
  arrival, contact Medical Control prior to
  administering an additional dose

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Establish IV

• Normal Saline using a Standard (10 gtt/ml)
  administration set
• If necessary fluid resuscitate to maintain an
  acceptable blood pressure
• Adult 100 mg/Hg systolic
• Ped. 70 2 times (age/yrs) systolic
• Note Fluid resuscitation must be monitored very
  closely for patients who have a history of CHF or
  are elderly. The increase in preload can rapidly
  send these patients into pulmonary edema
• Sometimes you just cant win!

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Diphenhydramine and Methylprednisolone

• Administer Diphenhydramine (Benadryl) for
  moderate and severe reactions
• Adult 50 mg IVP
• Ped. 2 mg/kg IVP, not to exceed the adult
  dosage
• Administer Methylprednisolone (Solu-Medrol) for
  severe reactions
• Adult 125 mg IVP
• Ped. 2 mg/kg IVP, not to exceed the adult dosage

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So You Cant Get That IV Huh?

• Administer Diphenhydramine (Benadryl) for
  moderate and severe reactions
• Adult 50 mg IM
• Ped. 2 mg/kg IM, not to exceed the adult dosage
• Administer Methylprednisolone (Solu-Medrol) for
  severe reactions
• Adult 125 mg IM
• Ped. 2 mg/kg IM, not to exceed the adult dosage

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The Protocols

• Medical Control

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Other Considerations, But Requires Medical
Control Permission

• Additional dosages of epinephrine 1/1,000.
• May be required every 10 20 minutes
• If patient is extremely hypotensive
• Epinephrine 1/10,000 slow IVP (over 10 minutes)
• 0.1 0.3 mg is usual dosage
• Risk of life-threatening ventricular dysrhythmias
  and myocardial ischemia

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What Are These?Are They Relevant?

• Acebutolol, Bisoprolol, Blocadren (Timolol
  Maleate), Cartrol (Carteolol), Lopressor
  (Metoprolol tartrate)
• These all common beta-blocking medications taken
  for home use!
• Guess what?
• They block the effect of our primary intervention
• Epinephrine
• Is there anything that we can do?

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Glucagon

• Positive Inotropic effects
• Does not use beta 1 receptor sites
• Can also be given for beta-blocker overdoses
• 1 mg (1 ml) IVP
• Requires Medical Control permission

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Last Words Of Caution

• Do No Harm!!!!!!!!
• Before committing to the treatment of
  anaphylaxis, take a few seconds out to review the
  possible differential diagnosis of the following.
  It might prove to extend both your patients life
  and your career
• Acute myocardial infarction
• Pulmonary embolism
• Vasovagal reactions
• Insulin shock
• Seizure disorder
• Intracranial bleed
• Food aspiration