28
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Volume3 Issue6
S
upporting
Y
our
P
ractice
AdministrationofEpinephrine
Dr.MarkDonaldson, apharmacist andmember of
the
Journalof theAmericanDentalAssociation
editorial
board, says that epinephrine isoneof thedrugs that
shouldmakeup theminimal emergency kit of any
dental office. Epinephrineopensup theairways,
helpsdecrease swellingand increasebloodpressure,
and increasesheart rate (whichcanhelpprevent
cardiovascular events).
Auto-Injectors
Themost commonly knownepinephrineauto-injector
is theEpiPen® (Pfizer). Somemayalsohaveused the
Allerject® auto-injector, but it isno longer available
followingavoluntary recall of all lots in late2015as
“theywere found topotentiallyhave inaccuratedosage
delivery,” explainedSanofi inapress release.
4
While theyare theonlyoptionavailable to
patients themselves, auto-injectorsmight not
be thebest suitedoption for adental practice,
warnsDr. Donaldson. Additionally, theyare
themost expensiveoptionandhavea shelf
lifeof only18months.
• Manyunitsare required.
“Epinephrinehas a
half-lifeof about 2minutes,whichmeans that if
theemergencymedical teamcannot get toyour
officewithinminutes, youmayhave toadminister
a seconddose. And in somecases, especially if
youpractice ina remoteareaor if you’redealing
withapatientwho’s ahyporesponder (i.e., shows
little response toepinephrine injection), youmay
in fact needa thirddose. So Iwould recommend
that dentists carryat least 3EpiPen®devices at their
practice.”Dentists treatingpediatricpatients should
alsocarryat least 3EpiPen® Jr devices.
• Safetyofuse.
Toensure that peopleare
comfortableusinganEpiPen®, Pfizer created the
EpiPen® TrainingDevice. Thisdevice is identical in
shapeand size to the real injector, but it
doesn’t containaneedleormedication.
Although it comeswithadifferent colour
label and themention “trainingdevice”,
its similaritieswith theactual EpiPen® lead
manypeople toconfuseone for theother.
Trainingdevices shouldnever be kept in the
emergency kit orwith theactual EpiPen®.
Occurrencesof healthcareprofessionals
accidentally self-injectingepinephrine
inadigit because theyheld theEpiPen®
incorrectlyarealso fairlycommon, according
toDr. Donaldson.
• Efficacy.
“Auto-injectors all havea25-gauge,
½ inchneedle. Yet the literature shows that
youneedat least a3cm (~1.2 inches) needle to
correctlydeposit themedication into thevascular
bedwithin thevastus lateralis thighmuscle for the
epinephrine tobe takenup in theblood system
back to theheart. That iswhymanufacturers tell
patients tocontinue toholdandpress for at least
10 seconds after self-injecting.”And itmight be
evenmoredifficult to reach thevascular bed in
patientswhoareoverweight.Whencontacted
byDr. Donaldson, Pfizer responded that “the
EpiPen®Prescribing Informationdoesnot address
dosingconsiderations in thepediatricandadult
populations that areoverweight or obese. There
areuncertainties about appropriateneedle length
required for intramuscular dosing inpatientswho
areoverweight or obese.”
Ampules
The singleepinephrineampule1:1000 (1mg/mL)
might beabetter option for dentists, basedon
efficacy, safety, cost, and shelf life (about 2years).
Nevermanipulatedglass ampules?Given the
very lowcost of epinephrineampules, “you
cangetmany, practiseoftenandget skilledat
removing themedication ina timely fashion,”
saysDr. Donaldson. Tobreak intoanampule,
he suggestsplacinga2” x2” pieceof gauze
around theneckof theampuleandexerting some
pressure. Theneckwill snap, givingyouaccess to the
epinephrine. Usinga syringewithanappropriate length
needle, administer 0.3mL (0.3mg) [or 0.15mL (0.15mg)
for pediatricpatients] in thepatient’s vastus lateralis
muscleat a90-degreeangle. Should thepatient needa
secondor thirddose, simply inject another 0.3mLdose.
Vials
Althougha littlemoreexpensive than theampules,
1-mL (1mg) epinephrinevials canbeanalternative
for thosewhodonotwant tomanipulateglass
ampules.
a
R
eferences
1.HealthCanada[Internet].
SevereAllergicReactions
;2008Oct24[accessed2016Jan7].Available
from:hc-sc.gc.ca/hl-vs/iyh-vsv/med/allerg-eng.php
2.CanadianSocietyofAllergyandClinical Immunology.
Anaphylaxis inSchools&OtherSettings.3rd
Edition
[Internet].2014[accessed2016Jan7].Available from:csaci.ca/patient-school-resources/
3.FoodAllergyCanada[Internet].DidYouKnow?;2016[accessed2016Jan7].Available from:
foodallergycanada.ca/about-allergies/anaphylaxis
4,Sanofi[Internet].
SanofiCanada issuesvoluntarynationwiderecallofAllerject®duetopotential
inaccuratedosagedelivery
;2015Oct28[accessed2016Jan29].Available from:http://
sanoficanada.mediaroom.com/2015-10-28-Sanofi-Canada-Issues-Voluntary-Nationwide-
Recall-of-Allerject-Due-to-Potential-Inaccurate-Dosage-Delivery
To learnmoreabout
theadministration
of epinephrineand
theoptions available
todentists,watch
an interviewwith
Dr. Donaldsonat
