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CDA Oasis Conversation: EpiPen Efficacy & Safety – What Every Dentist Needs to Know with Dr. Mark Donaldson

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Dr. Mark Donaldson, Director at VHA, US health care network of not-for-profit hospitals, speaks about the safety and efficacy of the long-used EpiPen.


Epinephrine is one of the most important medications in an emergency kit. It is the reversal agent required for anaphylactoid reactions.


  • In most cases, there should be 3 EpiPens or EpiPen, Jr. in the office if treating an adult or pediatric patient, respectively.
  • An ampule of epinephrine has a longer shelf life than an EpiPen.
  • There is a high risk and incidence of auto-injection of health care professionals when attempting to administer the medication to the patient
  • Epinephrine is administered intramuscularly into the vastus lateralis because it has very good vasculature and its uptake is quick
  • The needle of the EpiPen is too short to effectively deposit the medication intramuscularly – as a result, the EpiPen must be held with continuous pressure for 10 seconds.

Allerject® auto-injector (Auvi-Q® in the United States)

  • Needle length is not improved in this autoinjector
  • It was recalled due to 26 device malfunctions in October 2015

Single 1:1000 1mg/mL dose

  • Most effective for patients
  • Break open with 2×2 gauze
  • Draw up 0.3mL from the ampule for the adult patient (3 doses are contained within one ampule)
  • Adrenalin can also be purchased as 1:1000 1mg/mL vials

Watch the video



  1. I would consider not drawing up a full 1ml from the vial as it may be difficult to administer only 0.3 ml in a patient in duress. Rather draw up 0.3 ml, inject completely, then draw up a second dose to administer if needed. I would just be concerned with accidentally injecting too much epi, possibly even the full 1 ml, which could have significant negative outcomes.

  2. The chart did not include comparative efficacy of sub-lingual epinephrine administration. Is the advice that the dose should be administered preferentially in the vastus lateralis or sub-lingual?

    • The vastus lateralis is definitely preferred over the sub-lingual administration of epinephrine during a medical emergency.

  3. Candice Wakulich

    What gauge of needle should we use to inject the epinephrine IM?

    • Using either 23 G or 25 G for intramuscular injections into the thigh reduces the occurrence of pain and local reactions. While not specific to epinephrine IM injections, the Cochrane Database recently published a systematic review on this topic (Beirne PV, Hennessy S, Cadogan SL, Shiely F, Fitzgerald T, MacLeod F. Needle size for vaccination procedures in children and adolescents. Cochrane Database Syst Rev. 2015 Jun 18;6:CD010720.)

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