Intra-Muscular Administration of Epinephrine

1. Connecticut Department of Public Health
Keeping Connecticut Healthy
EMT IM Epinephrine
Administration
Connecticut State Education and Training Committee
2019
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2. Goals and Objectives (1 of 2)
• EMT will review signs/symptoms of allergic/anaphylactic reactions.
• EMT will review the actions, indications and contraindications of
epinephrine.
• EMT will review OEMS epi administration protocol with “IM”
administration update.
• EMT will learn & demonstrate how to properly select “IM” injection
site for epi.
• EMT will learn & demonstrate how to properly select and prepare
injection syringe.

3. Goals and Objectives
• EMT will learn & demonstrate proper drawing up
and dosing of epi for selected patient age.
• EMT will learn & demonstrate correct “IM”
injection with provided equipment
• EMT will review the signs/symptoms that require
re-dosing of epi.
• EMT will successfully complete state provided quiz.

4. Connecticut Department of Public Health
Keeping Connecticut Healthy
The Check and Inject
Program
Connecticut State Education and Training Committee
2019

5. Check and Inject – Why?
• Decreased availability of auto injectors
• Rising cost of auto injectors
• Demonstrated success:
• King County, Washington
• New York State
• Massachusetts
• New Hampshire

6. Terms/Abbreviations
• Circumoral – surrounding the mouth
• IM – Intramuscular
• mg - Milligrams
• mL - Milliliter
• SQ - Subcutaneous
To convert Lbs to Kgs
Lbs / 2.2 = Kgs

7. Connecticut Department of Public Health
Keeping Connecticut Healthy
Identifying Allergic Reactions
Connecticut State Education and Training Committee
2019

8. Types of Reactions
• Minor Allergic Reaction
• Major Allergic Reaction – Anaphylaxis

9. THE “MYTH”
“You can’t have a reaction to something you haven’t been
exposed to before”
NOT TRUE!!!
If it looks like a duck, walks like a duck and quacks like a duck
It’s a duck!!! Treat it!!!

10. Minor Allergic Reaction
• Isolated body system reaction
• Itching
• Hives - isolated
• Runny nose
• Sneezing
• Watering eyes

11. Major Allergic Reaction
(Anaphylaxis)
• Two or more body systems affected
• Airway/breathing compromise
• Rapid onset of symptoms
• Systems often affected:
• Respiratory
• Cardiovascular
• Integumentary
• Gastrointestinal

12. Connecticut Department of Public Health
Keeping Connecticut Healthy
Signs & Symptoms
Major Allergic Reactions
Connecticut State Education and Training Committee
2019

13. Respiratory System
• Dyspnea
• Hoarse voice/Stridor
• Wheezing, Rales or Rhonchi
• Swelling of lips and tongue
Any respiratory system compromise validates
treatment for anaphylaxis!!

14. Cardiovascular
• Tachycardia
• Hypotension
• Circumoral cyanosis
NOTE: Hypotension isn’t a pre-requisite for
treatment. Some anaphylaxis patients experience
hypertension, or normal blood pressures.

15. Integumentary System
• Itching
• Hives
• Flushing of skin (decreased vascular tone)
• Angioedema
• Especially around face, mouth, eyes, tongue

16. Gastrointestinal system
• Nausea
• Vomiting
• Diarrhea

17. Connecticut Department of Public Health
Keeping Connecticut Healthy
Properties of Epinephrine
Connecticut State Education and Training Committee
2019

18. Epinephrine
Actions
Constricts skin blood vessels
• Improved central circulation, decreased GI upset
Increases heart rate and force
• Increases dropping blood pressure
Dilates bronchioles
• Decreases dyspnea, increases oxygenation
• Inhibits histamine release (cause of hives, itching)

19. Epinephrine
Indications
• Signs and symptoms of anaphylaxis
• Progression of allergic reaction
Contraindications
• In anaphylaxis – NONE
Side effects
• Palpitations
• Chest pain
• Anxiety/Jitteriness (tremor)
• Headache

20. Epinephrine
Risk of overdose
• Tachycardia
• Myocardial ischemia (heart muscle damage)
• Not a reason to withhold medication
FACT: Do Not change the protocol dose of 0.3mg for the
adult patient, no matter their age.

21. Connecticut Department of Public Health
Keeping Connecticut Healthy
Connecticut EMS Protocol
Connecticut State Education and Training Committee
2019

22. EMT Level – Adult Patient
• Oxygen
• May still use auto-injector or
• May select “Check and Inject” method
• Over 25 kg (55lbs) – 0.3 mg of 1 mg in 1 ml epinephrine
(1:1000), administered IM (intramuscular) in the lateral thigh.
• If in 5 minutes symptoms not resolving or worsening contact
medical control for potential second dose.
• No other meds at this level (antihistamines, bronchodilators,
steroids, etc.)

23. EMT Level – Pediatric Patient
• Oxygen
• May still use auto-injector
• May select “Check and Inject” method
• Under 25 kg(under 55lbs) – 0.15 mg of 1 mg in 1 ml
epinephrine (1:1000) administered IM (intramuscular) in the
lateral thigh.
• If in 5 minutes symptoms don’t resolve or worsen contact
medical control for potential second dose of epi.
• No other meds at this level (antihistamines, bronchodilators,
steroids, etc.)

24. Assessment
• Scene Safety
• BSI
• Primary Assessment
• Oxygen Administration
• Secondary Assessment
• Respiratory
• Cardiovascular
• Integumentary
• Gastrointestinal

25. Selection of Injection Site
Lateral mid-thigh
• Vastus lateralis muscle
• Muscle tissue remains well perfused during shock
• Current evidence supports this site over others for IM or
SQ
• Reduces risk of injection in vein or artery which can
cause:
• Tachycardia
• Cardiac compromise

26. Adult Lateral Thigh

27. Pediatric Lateral Thigh

28. 6 Rights of Medication
Administration
• Right Patient
• Right Medication
• Right Route
• Right Dose
• Right Time
• Right Documentation

29. Right Patient
Does this patient meet the protocol for anaphylaxis?
• Signs and symptoms of severe allergic reaction
• Suspected history of allergy
• Suspected exposure to allergen
• Previous use of epinephrine

30. Right Medication
• Confirm label
• 1 mg in 1 ml (1:1000 concentration)
• Not cardiac epinephrine

31. Right Route
• IM Intramuscular – Lateral Mid-Thigh
• Avoid blood vessels
• Prevent injection directly into circulation
• Avoid superficial layers of skin
• Prevent delayed absorption
• Avoid distal extremities
• Decreased perfusion in shock state

32. Right Dose
Pediatric
<55lbs/25kgsP
Adult
>55lbs/25kgs
= 0.3 mLs = 0.15 mLs

33. Right Time
• Administer 1st dose promptly
• If symptoms don’t improve or resolve w/ in 5 minutes
call medical control.

34. Connecticut Department of Public Health
Keeping Connecticut Healthy
Drawing Up Medication
Connecticut State Education and Training Committee
2019

35. Medication Containers
Ampule
• Break top
• Do NOT inject air
• Tilt sideways or upside
down
• Consider using a filter
needle
• Replace filter needle w/
a injection needle (if
filter needle used)
Vial
• Remove lid
• Do inject air
• Can be done w/
vial standing upright
or tilted upside down.

36. Aseptic Technique
• Handling, preparing and storing medications and injection
equipment to prevent microbial contamination
• Use a new syringe and needle every time
• Store equipment in sterile packaging until use
• Swab containers and skin with antiseptic
• Avoid touching contact points
• Needle
• Vial lid
• Skin
• Syringe connector

37. Using an ampule
1. Confirm medication
2. Tap contents to bottom
3. Wipe with antiseptic swab
4. Break neck (use gauze or swab wrapper)
5. Insert filter/injection needle
6. Withdraw medication
7. Replace filter needle w/ a new needle for injection (if filter
needle used)
8. Discard ampule safely in sharps container

38. Needle Size
• Appropriate gauge for intramuscular injection is 22-25
gauge
• Appropriate length for intramuscular injection:
• Infant (0-12mos) - 5/8 (16mm)
• 1y/o-2y/o - 5/8-1” (16-25mm)
• 3y/o-10y/o - 1” (25mm)
• 11-Adult - 1-1.5” (25-38mm)

39. Drawing from an Ampule
*Disregard comment concerning larger epi in ACLS bags*

40. Using a Vial (1 of 2)
1. Confirm medication
2. Remove plastic lid
3. Wipe stopper with antiseptic swab
4. Fill syringe with air (equal to volume of medication
wanted.)
5. Insert needle, inject air. (There is no need to change
needle when using a vial for injection)
6. Withdraw medication, remove needle.
7. Discard vial safely in sharps container

41. Drawing from a Vial
*Please always use a syringe with a safety capping feature!*

42. Using a Vial (2 of 2)

43. Confirm medication
• Speak out loud
• Ask partner to confirm
• If no partner – still state medication out loud
• “I have 0.3 mL’s of epinephrine. Does that look
correct?”

44. Prepare Syringe for Injection
• Hold syringe upright
• Allow bubbles to rise
• Push out remaining air
• Use caution – do not lose
medication when ejecting air

45. Prepare the injection site
• Select location (lateral mid thigh)
• Swab with alcohol or chlorhexidine wipe
• Avoid touching site after cleaning

46. Insert at 90 degrees (straight in)
(Make sure you are NOT using filter needle)
Pull back plunger ¼ inch (i.e. aspirate) – look for
blood
• If visible blood, stop injection
• If no visible blood, continue injection
Press plunger all the way in
Remove needle (using safety device to cap it)
Press on or massage injection site
Dispose of needle properly in sharps container

47. IM Injection (Video)

48. Additional Doses
• Reassess patient
• Should see improvement within 2 minutes of epi dose
• Is there improvement in respiratory symptoms?
• Has angio-edema reduced or resolved?
• Are vital signs improving?
• Vomiting/Diarrhea ceased?
If the answer is NO! Re-dose (every 5 minutes) with Medical
control permission.

49. Documentation
• Document accurately in ePCR
• List initial findings
• Vital signs
• Work of breathing
• General appearance
• Lung sounds
• Airway patency
• Document dose and route
• Document any errors
• Document reassessment

50. Documentation Tips
• Use correct medication box or tab on ePCR
• Data driven reports cannot read from narrative
section
• Include in narrative also
• Medication documented as listed below:
• 0.3/0.15mg epinephrine administered “IM” (location)

51. • Incorrect dose given (too much, too little)
• If too little, consider additional dosing
• Incorrect route of administration
• Too shallow – subcutaneous
• Venous delivery – prevented by aspirating prior to injection
• Unnecessary administration
• Routine minor allergy
• Different diagnosis
• Mechanical failure
• Needle breaks
• Ampule or vial shatters
Medication Errors

52. Thank you to the State of NH for
developing this chart.

53. PEARLS
• Ensure injection syringes have self-sheathing needles.
(Per Needle stick Safety and Prevention Act).
• Ensure provider is using 2x2 or alcohol prep to “crack”
open ampule. (Helps prevent cuts)
• Ensure provider changes out filter needle once
medication is withdrawn from ampule – and changed out
for proper injection syringe
• Ensure “pre-made” kits from manufactures have proper
self-sheathing needles.

54. Next Steps
• Take Quiz
• Schedule and successfully complete skills station

55. References
[Angioedema]. Retrieved from
https://www.google.com/search?rlz=1C2KDEC_enUS827&tbm=isch&q=angioedema&chips=q:angio
edema,g_1:tongue:apQ7QL_-1jc%3D&usg=AI4_-
kQ61iMMQ_L3Er7OzSQ9M_U5nKdoPQ&sa=X&ved=0ahUKEwiM1_S94KXfAhWIllQKHfgpBbMQ4lYILi
gA&biw=934&bih=658&dpr=1.25
CDC. (n.d.). Vacccine administration. Retrieved from CDC website:
https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html
Have Dummy Will Travel, Inc. (2018). Epi 1:1000 draw [Video file]. Retrieved from
https://www.youtube.com/results?search_query=drawing+meds+from+a+vial
[Hives]. Retrieved from
http://www.google.com/search?q=hives&rlz=1C2KDEC_enUS827&source=lnms&tbm=isch&sa=X&ve
d=0ahUKEwjYgr-i36XfAhVDyFQKHbQIDr4Q_AUIDigB&biw=1536&bih=674&dpr=1.25
Kroger, A., Atikinson, W., Marcuse, E., & Pickering, L. (2006). General recommendations on
immunization. Retrieved from CDC website:
https://www.cdc.gov/MMWR/PREVIEW/MMWRHTML/rr5515a1.htm#tab7

56. References
Monroe Livingston EMS Council. (2017). Check & inject NY training materials. Retrieved from
https://www.mlrems.org/check-inject-ny/check-inject-ny-training-materials
Schramm, J. (2016). Epi ampule training [Video file]. Retrieved from
https:https://www.youtube.com/results?search_query=drawing+meds+from+an+ampule//www.
mlrems.org/chec k-inject-ny/check-inject-ny-training-materials
Simula, T. (2017, October 15). Vastus Lateralis injection [Video file]. Retrieved from
https://www.youtube.com/watch?v=e0BRa8exQjQ