EMT Standing Orders

Routine Patient Care:

• For anaphylaxis administer: (anterolateral thigh preferred administration site)
• Adult epinephrine autoinjector 0.3 mg IM OR Epinephrine (1: 1,000) (1 mg/mL): Administer 0.3 mg (0.3 mL) IM.
  • Contact Medical Direction for additional dosing.
• Do not delay transport. (Patients receiving epinephrine must be transported.)
• Call for AEMT/Paramedic intercept, if available & assist them in patient care.

AEMT/Paramedic Standing Order:

• May repeat epinephrine 0.3 mg (1: 1,000) IM every 5 – 15 min as needed for continued symptoms (maximum 3 doses.) Establish IV access. Administer 500 – 1000 mL bolus 0.9% NaCl for SBP < 90 mmHg.
• For bronchospasm, consider the administration of albuterol 2.5 mg via nebulizer. May repeat every 5 minutes for continued symptoms OR Ipratropium 0.5 mg and albuterol 2.5 mg via nebulizer (DuoNeb). May repeat every 5 minutes (maximum 3 doses). Contact Medical Direction for additional dosing.
• For anaphylaxis refractory to IM epinephrine, consider epinephrine infusion 2 – 10 mcg/min, titrated to effect (infusion pump required).
• Diphenhydramine 25 – 50 mg IM/IV/IO to treat pruritus.
• Methylprednisolone 1 mg/kg IV (max 125 mg) every 6 hours OR
• Dexamethasone 0.6 mg/kg IV/IO/IM/PO (maximum dose 10 mg)
• Diphenhydramine 25 – 50 mg IM/IV. May repeat every 4-6 hours as needed (maximum dose of 300 mg/24 hours).

CAUTION:

• Epinephrine is available in different routes and concentrations. Providers are advised to re-check the dosing and concentration prior to administration.
• In anaphylaxis, epinephrine should not be delayed by taking the time to administer second-line medications such as diphenhydramine.

PEARLS:

• Known/likely allergen exposure AND hypotension or respiratory compromise,
• Systemic allergic reaction (multi-system), including two or more of the following:
  • Respiratory distress
  • Airway compromise/impending airway compromise
• Wheezing/stridor, swelling of lips/tongue, any airway structures, throat tightness or difficulty/ inability swallowing
  • Widespread hives, itching, swelling, flushing
  • Gastrointestinal symptoms: vomiting, abdominal pain
  • Altered mental status, syncope, cyanosis, delayed capillary refill or decreased level of consciousness associated with known or suspected allergic reaction
  • Signs of shock refer to Shock Protocol (56 Medical)
• Do not delay transport for other than epinephrine administration.
• Patients can present with anaphylaxis without a prior history of allergy.
  • Wheezing may be caused by anaphylaxis but it is not the only sign.
  • Consider patients with a history of asthma as having a high risk of anaphylaxis.