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Avoiding Epinephrine Auto-injector Injuries in Children

SEATTLE – Epinephrine auto-injectors can be a double-edged sword for children with severe allergies. They save lives during episodes of anaphylaxis but also sometimes cause severe injuries.

That’s according to a recent study in Annals of Emergency Medicine, which identifies potential injury-causing design features of EpiPens, the most commonly used auto-injector.

"We were surprised by the severity of some of these injuries, including thigh lacerations and embedded needles," said lead study author Julie Brown, MDCM, MPH, of Seattle Children's Hospital and the University of Washington in Seattle. "We can't think of anywhere else in pediatric medicine where we would hold a needle in an awake child's leg for 10 seconds. That's a set-up for injury, particularly in the uncontrolled, stressful setting of anaphylaxis. In addition, the instructions for use do not mention patient restraint, so parents are not appropriately prepared."

For the study, researchers identified 25 cases of epinephrine auto-injector-related injuries after using the device to treat a child’s allergic reaction. (An additional case involved a 5-year-old child who accidentally injected himself in the ankle with his older cousin's EpiPen, requiring removal of the bent needle at the ED.)

Lacerations, some up to 3-inches long, occurred in 20 children and one nurse injured during administration. In four cases, the needle stuck in the child's limb.

In most cases, EpiPens were administered by parents, including some medical professionals. In six cases, injuries occurred during treatment by nurses, with three others caused by educators.

To reduce injuries, Brown and her colleagues recommend immobilizing the child’s leg and keeping the site of delivery as controlled as possible. In addition, the needle, which should be strong enough that it doesn’t bend during use, should remain inserted in the thigh for as short a time as possible. Never reinsert the needle, they advise.

Of the three epinephrine auto-injectors currently available in North America, none include instructions to immobilize the child’s leg, the study points out, and only one has a needle that self-retracts in two seconds. The others have needles that remain in the thigh during the 10 seconds that the user is instructed to hold the device against the leg, yet their instructions do not caution against reinjection if the needle is dislodged during these 10 seconds.

The self-retracting Auvi-Q (Allerject in Canada) device “would appear to be a safer design for use in children," Brown said. “While EpiPen likely holds a larger share of the epinephrine auto-injector market, it is notable that we did not see any injuries associated with the use of Auvi-Q or Allerject devices, even in recent years."

She added, "We want to emphasize that these injuries are uncommon and should not deter parents and patients from using their epinephrine auto-injectors when needed. Epinephrine is a life-saving medication that must be given early in the course of anaphylaxis. Our goal in reporting these injuries is not to create fear of the EpiPen device but simply to identify limitations with the device, and hopefully motivate improvements in product design and instructions for use."

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