Adrenaline (Epinephrine) Autoinjectors and What School Staff Need to Know
What are adrenaline autoinjectors?
An adrenaline autoinjector is a device that injects a single, fixed dose of adrenaline. They are designed for use by everyone, even those with no medical training.
Adrenaline ampoules and syringes are not suitable for community settings, including schools.
What are adrenaline autoinjectors used for?
Adrenaline autoinjectors are used to deliver adrenaline to treat anaphylaxis (life-threatening allergic reactions). Signs of anaphylaxis can include difficulty breathing and talking, coughing or wheezing and/or dizziness/collapse. Refer to the ASCIA Action Plan for Anaphylaxis for all signs of anaphylaxis and actions to take in an emergency.
Adrenaline is the first line treatment for anaphylaxis and works within minutes to open the airway and maintain blood pressure. Withholding or delaying adrenaline may result in sudden deterioration and potentially death of an individual experiencing anaphylaxis.
Adrenaline is a hormone that is naturally released in the body, but in an emergency, such as anaphylaxis, the body needs more adrenaline to quickly reverse the signs and symptoms of anaphylaxis. It is safer to give adrenaline and not need it, than to give it too late.
Temporary side effects of adrenaline are to be expected and they include increased heart rate, trembling and colour draining from the face (pallor). These side effects resolve quite quickly.
Adrenaline is most rapidly absorbed when it is administered into the muscle of the outer mid-thigh by injection. An autoinjector is less likely to damage nerves or tendons at this site. It can be done through a single layer of clothing, but not pockets or seams.
Antihistamines do not reverse the signs and symptoms of anaphylaxis and must not be given as a first step for someone having a severe allergic reaction. Antihistamines help reduce the itch and make individuals having a mild to moderate allergic reaction more comfortable. They do not prevent or treat anaphylaxis. If someone has anaphylaxis and it resolves, it is because the anaphylaxis was self-limiting and not because antihistamines were taken.
If someone with both asthma and food/insect/medication allergy suddenly has severe breathing difficulty, give the adrenaline autoinjector first and then asthma reliever medication. Always follow instructions on the ASCIA Action Plan.
View the Allergy & Anaphylaxis video for step by step instructions on EpiPen administration.
What type of adrenaline autoinjectors are available?
In Australia, adrenaline autoinjectors are available on the Pharmaceutical Benefits Scheme (PBS) for patients diagnosed to be at risk of anaphylaxis. There are two doses of adrenaline autoinjectors available:
- EpiPen® – usually prescribed for children over 20kg (and adults)
- EpiPen® Jr– usually prescribed for children 10-20kg
Individuals are prescribed 2 adrenaline autoinjectors per prescription. The student must have at least one adrenaline autoinjector easily accessible at all times, however, as about 20% of cases need a second dose of adrenaline after 5 minutes, Allergy & Anaphylaxis Australia advises individuals at risk of anaphylaxis to have 2 adrenaline autoinjectors available at all times.
Purchasing general use adrenaline autoinjectors for schools
The Principal is responsible for arranging the purchase of the appropriate number of adrenaline autoinjectors for general use (i.e. for a first aid kit and not prescribed to an individual). This number should be determined by a risk assessment and consideration of issues such as the:
- number of children at the school
- number of students diagnosed at risk of anaphylaxis
- size of the school, and
- number of activities off school grounds at any one time.
These general use autoinjectors should not be used as a substitute for students at risk of anaphylaxis having their own prescribed adrenaline autoinjector/s at school.
Adrenaline autoinjectors for general use may be administered following instructions on the ASCIA Action Plan for Anaphylaxis for general use (orange) when:
- the student already prescribed an adrenaline autoinjector does not have their device quickly accessible, it is out-of-date or has been accidentally discharged
- a second dose is required before the ambulance arrives
- a student with a previously diagnosed mild allergy has their first anaphylaxis, or
- a student who has never been diagnosed with an allergy has their first anaphylaxis.
Another student’s adrenaline autoinjector can be used for someone having an anaphylaxis after checking the student that owns the device is not showing signs of an allergic reaction and when there is no adrenaline autoinjector for general use available. It is critical that the device be replaced immediately by the school and that further measures to reduce the risk of an allergic reaction are taken until the device is replaced (e.g. only eat fruit if milk, egg or peanut allergic, not packaged food).
Adrenaline autoinjectors for general use can be purchased by the school at any pharmacy without a prescription.
Adrenaline autoinjectors should be able to be accessed quickly and must be stored in an unlocked cupboard/classroom, out of reach of small children and away from direct light. They should be stored between 15-25 degrees Celsius and not placed in the refrigerator, freezer or next to ice packs, as this may damage the mechanism. Small temperature fluctuations are permitted but if they are going to be outside for an extended period on a hot day i.e. sports events, excursion etc consideration should be given to purchasing an insulated pouch.
Each individual’s adrenaline autoinjector should be clearly labelled with the student’s name and be stored with their individual ASCIA Action Plan for Anaphylaxis (red). Many individuals put the adrenaline autoinjector, ASCIA Action Plan and other required medications in a bag/pouch/pencil case they call a medical kit.
Adrenaline autoinjectors for general use should be clearly labelled and stored with a general ASCIA Action Plan (orange).
ASCIA Action Plans for Anaphylaxis have been developed as concise, easy to follow documents, to assist in the emergency treatment of an allergic reaction, including anaphylaxis. They contain instructions on how to use the adrenaline autoinjector and should always be stored together with the adrenaline autoinjector. ASCIA Action Plans for Anaphylaxis should be reviewed and reissued when patients are reassessed by their medical practitioner and when they obtain a new adrenaline autoinjector prescription.
To avoid confusion, adrenaline autoinjector trainer devices (which do not contain adrenaline or a needle and are used to practise administration of the device) are NOT to be stored in the same location as the current school medical kit.
The shelf life of adrenaline autoinjectors is approximately 12-18 months from the date of manufacture. The expiry date on the side of the device (not the box) should be noted and must be replaced by the end of that month.
Registration with a reminder service (e.g. www.epiclub.com.au) may be used to assist with keeping track of expiry dates. Schools and parents or guardians can also use an electronic reminder system on their phone or computer. The new Allergy Pal App which allows parents to share their child’s ASCIA Action Plan also has a reminder system.
Expired adrenaline autoinjectors are not as effective for treating allergic reactions, but if no other device is available, the most recently expired adrenaline autoinjector should be used if the adrenaline is not discoloured and there is no sediment. (The EpiPen® contains a clear window to view this).
An adrenaline autoinjector that has been used should be placed in a container with a label indicating what time it was used and then handed to paramedics. Expired adrenaline autoinjectors should be handed back to parents once they have been replaced. Adrenaline autoinjectors for general use that have expired can be given back to the pharmacy to dispose of safely.
All staff should know where the adrenaline autoinjectors are located. A designated school staff member should conduct regular reviews to ensure that all adrenaline autoinjectors are not out of date or discoloured. Adrenaline autoinjectors should all be accounted for – they should be signed in and out for excursions, camps, holidays etc.
Teachers taking students on excursions must check that the adrenaline autoinjector and ASCIA Action Plan are taken, even if the student is at an age where the medical kit is carried by the student.
The decision whether a child (usually not younger than 10 years old) should carry their own adrenaline autoinjector at school needs to be made in consultation with the student, parents and medical practitioner and be noted on their individual anaphylaxis management/healthcare plan. Younger children who travel independently on public transport/school bus should have their adrenaline autoinjector accessible. For those children who choose to carry their device, they may consider it convenient to carry their adrenaline autoinjector in a pouch. If a student carries their medical kit in their school bag, the school bag must be easily accessible at all times i.e. not in their locker or on a verandah with 30 other school bags. It is important to note that students who are capable of self-administering may not be able to do so due to the effects of a reaction, so a staff member has a duty of care to administer their adrenaline autoinjector for them.
About the author
Maria Said, CEO of Allergy & Anaphylaxis Australia, and Sally Voukelatos write on behalf of Allergy & Anaphylaxis Australia, the trusted charity for allergy support. We listen, guide and educate Australians living with allergic disease. We advocate on their behalf to ensure their voice is heard.
For more information on adrenaline autoinjectors go to:
Allergy & Anaphylaxis Australia www.allergyfacts.org.au