Retrieval of Additional Epinephrine from Adrenaclick-Style Epinephrine Autoinjectors

Anaphylaxis is a life-threatening allergic reaction involving multiple organ systems that can result in significant morbidity and mortality if left untreated. Epinephrine the mainstay of treatment. Most episodes anaphylaxis resolve after single dose epinephrine, but biphasic protracted courses are well described. The need for additional doses epinephrine poses challenge wilderness setting, because patients providers may only carry autoinjector. Prior work has demonstrated successful disassembly various brands autoinjectors to retrieve drug product repeat dosing. We describe 2 techniques from Adrenaclick-style autoinjectors. described off-label not approved by manufacturer or Food Drug Administration. Wilderness should familiarize themselves with retrieval light differences design. airway compromise, hypotension, death. If untreated, results mortality, potential causes an austere setting myriad.1Tejedor Alonso M.A. Moro M. Múgica García M.V. Epidemiology anaphylaxis.Clin Exp Allergy. 2015; 45: 1027-1039Crossref PubMed Scopus (76) Google Scholar,2Yu J.E. Lin R.Y. epidemiology Rev Allergy Immunol. 2018; 54: 366-374Crossref (31) Scholar treatment, primarily delivered through easy-to-use designed use. Although most described.3Pumphrey R. Anaphylaxis: we tell who at risk fatal reaction?.Curr Opin Clin 2004; 4: 285-290Crossref (265) Biphasic cases occur approximately 20% time, majority within 8 h.4Boyce J.A. Assa’ad A. Burks A.W. Jones S.M. Sampson H.A. Wood R.A. et al.Guidelines diagnosis management food allergy United States: report NIAID-sponsored expert panel.J 2010; 126: S1-S58PubMed To address redosing, intentionally sold as 2-packs. autoinjector owing weight space concerns, financial constraints, improper planning. needed unavailable, used be disassembled extra contained inside ampoule. past decade seen introduction, recall, discontinuation, redesign several US market. Currently, 4 styles available Auvi-Q (Kaléo), Adrenaclick (Amneal Pharmaceuticals), Symjepi (Sandoz), EpiPen (Mylan). Generic versions also available. dosing.5Robinson P.E. Lareau S.A. Novel technique removal new generation autoinjectors.Wilderness Environ Med. 2016; 27: 252-255Abstract Full Text PDF (5) Scholar,6Hawkins S.C. Weil C. Baty F. Fitzpatrick D. Rowell B. Retrieval auto-injectors.Wilderness 2013; 24: 434-444Abstract (9) (ASEAs) using pliers was similarly product, Twinject.5Robinson adapted one style another, construction different varies enough require detailed instructions specific each type detail techniques, 1 knife, ASEAs. our knowledge, knife been previously offers alternative when recommend following manufacturer’s deliver first caveat: do delivery thick clothing this damage needle prevent its reuse. Unlike EpiPen, ASEAs protect firing (Figure 1). Be mindful exposed avoid damaging it during needlestick injury. It important recognize used; intended treatment patients. Step 1: Using pliers, grab hold red cap just below twist off segment 2). This will amount force. 2: ampoule then removed 3). Remove sticker on outer plastic housing expose underlying components. Identify spring opposite end needle. Use cut where they meet. Do attempt groove between inner housings doing so risks syringe process 4). these made harder material than EpiPen. In experience, easier use sawing serrated blade rather incision straight edge 5). With either type, must pay close attention safety; hard creates slippage, resulting self-injury. Once fully cut, remove 6).Figure 5Cut housing.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Outer removed.View (PPT) 3: Cut 7). Before administering dose, necessary draw air into required specialized plunger allows administration prespecified restricted travel fills administered drug, which resets inject medication. pointing up, slowly withdraw desired careful completely plunger; losing drug. markings ensure accurate dosing (0.3 mL adults, 0.15 children) display how much 8). administer second insert lateral thigh inject. contains 3 total doses. A repeating steps. These steps outlined supplementary video. described.6Hawkins novel adds literature providing approach dual design requires disassemble knife. involves cutting removing stopper base autoinjector.6Hawkins contrast, ASEA separate housings. Cutting sites, including housings, allow easy access process. Based find methods. publication considered temporizing measures unavailable arrival prehospital personnel transport hospital delayed. viable means get ASEA, coupled exposure blades needles relegate practice exigent circumstances only. During disassembly, there could contaminated before person performing addition, higher level expertise core tenet medicine proper planning preparation superior emergency repurposing limited resources environment. Proper consideration hazards, evacuation would mitigate paper. knowledge justify carrying fewer seek care administration. Sufficient supplies carried those known allergies traveling remote settings settings. Consistent Medical Society guidelines, any patient advanced medical soon possible.7Gaudio F.G. Lemery J. Johnson D.E. guidelines outdoor education settings: 2014 update.Wilderness 2014; 25: S15-S18Abstract (4) Nevertheless, believe understanding here prove vital mitigating effects environment readily Despite containing same significantly among manufacturers. unique designs. As such, valid long commercially. injury body fluid exposure. all other options exhausted. endorse strategy sufficient quantities epinephrine. prompt recognition priority followed immediate hospital. enthusiasts history responsible maintaining adequate supply account possibility reactions prolonged times. When available,