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Letters: EpiPens

November 07, 2016
In the Oct. 3 My View “EpiPens: Dental Necessity or Extravagance,” by Dr. Larry Sangrik, he discusses the exorbitant pricing of the EpiPen Auto-Injector and questions its importance in dental offices.1

The EpiPen Auto-Injector contains 0.3 mL of 1:1,000 epinephrine in the adult (>30 kg, >66 lb.) and 0.3 mL of 1:2,000 epinephrine in the pediatric (up to 30 kg) syringe.

The EpiPen, or a less expensive generic autoinjectors,2 is used to treat anaphylaxis — a life-threatening allergy where the prompt administration of epinephrine increases the chance of surviving the event.

As a dentist anesthesiologist, professor of anesthesia and medicine for 43 years, author of a textbook on emergency medicine3 and lecturer worldwide on emergency medicine, I strongly disagree with a number of Dr. Sangrik’s comments.

Epinephrine is the most important drug in the emergency kit, more so even than oxygen. Though oxygen may be administered in any emergency situation, including anaphylaxis, the prompt administration of epinephrine affords the anaphylactic victim a chance at survival.

Dr. Sangrik recommends stocking 1 mL(cc) ampules of 1:1,000 epinephrine in the emergency kit, with a 1 mL tuberculin syringe, as epinephrine is indicated not only in anaphylaxis, but in status asthmaticus and cardiac arrest. Recommended doses of epinephrine differ from those for anaphylaxis, thus his recommendation for the 1 mL ampule of 1:1,000 epinephrine.

Herein lies the problem. Dr. Sangrik writes: “First, the dentist should be responding to the medical emergency from a written emergency plan (i.e. response manual) that includes algorithms for a wide variety of medical scenarios. These algorithms should include detailed response directives, including dosages.” I absolutely agree. Unfortunately, It is my experience that most dental offices are not prepared to recognize and treat medical emergencies. Though 44 states mandate cardiopulmonary resuscitation (CPR) training for a dentist to maintain their license to practice, many — but far from all — dentists have emergency drug kits, automated external defibrillators (AEDs), and oxygen delivery systems. Two states — Massachusetts4 and West Virginia5 — publish lists of emergency drugs and equipment required in all dental offices.

Many dentists who have emergency drugs are untrained in their administration. Additionally, most dentists are not adept at establishing venous access — the recommended route for emergency drug administration — but not for anaphylaxis.

The most recent package insert for EpiPen states that the only site of administration of the epinephrine autoinjector syringe is the vastus lateralis muscle on the anterior lateral aspect of the thigh.6

Dr. Sangrik opines that in status asthmaticus a dose of 0.1 mg of epinephrine might be sufficient to break bronchospasm. Perhaps, but the recommended administration of epinephrine in status asthmaticus, for adults, is up to three doses of 0.3 mg at 20-minute intervals.7

In cardiac arrest, Dr. Sangrik mentions the intravenous administration of epinephrine. When administered intravenously in cardiac arrest, a preloaded syringe of 1:10,000 epinephrine is employed, allowing for a more controlled dosing, never 1:1,000. There are no indications in emergency medicine for the IV administration of 1:1,000 epinephrine.8

Opening a 1 mL glass ampule and loading a syringe with a drug (e.g. epinephrine), as Dr. Sangrik recommends is not difficult if the doctor is trained. Most dentists have not been trained to do this.

Consider what might happen if dentists did have 1 mL epinephrine ampules and tuberculin syringes. First, though — happily — a rare occurrence in the dental environment, anaphylaxis is terribly frightening, for the victim, the dentist and staff. The 2015 guidelines for recognition and management of anaphylaxis for health care providers states “the appropriate dose of epinephrine should be administered promptly at the onset of anaphylaxis”9 With a patient in extremis (e.g. wheezing, hypotensive, unconscious), would a dentist untrained in opening an ampule and loading a syringe be calm enough to put the correct dose into the syringe and administer the drug? Not only do I think not, I know not. I have personally seen well-trained health care providers (medical doctors, registered nurses) hands shaking while opening an epinephrine ampule, having the drug spill onto the floor, as well as seeing needle stick injury occur.

It is important to note that epinephrine autoinjector syringes are used both on emergency ambulances (e.g. 911) by paramedics,10,11 as well as in the emergency department of hospitals by well-trained critical care physicians.

The preloaded autoinjector epinephrine syringe is a critical component of the dental office emergency kit. I recommend having two 1:1,000 autoinjector syringes (a “2-Pak”) for the >30 kg patient and, if appropriate, two 1:2,000 autoinjectors for patients weighing less than but up to 30 kg.

I agree wholeheartedly with Dr. Sangrik that dentists should be better prepared to recognize and manage those medical emergencies that can, and do, occur in our offices.
Yes, EpiPens are a dental necessity.

Stanley F Malamed, D.D.S.
Los Angeles

1. Sangrik LJ. EpiPens: Dental necessity or extravagance? (MyView). ADA News October 3, 2016;4-5, 2016.
2. Good Rx. Epinephrine. Available at: www.goodrx.com/epinephrine. Accessed October 24, 2016.
3. Malamed SF. Medical emergencies in the dental office. 7th ed. St. Louis, MO: Mosby/Elsevier; 2015.
4. Massachusetts Court System. Board of Registration in Dentistry: 234 CMR 6.00 — administration of anesthesia and sedation, § 6.15: administration of local anesthesia only. Available at: http://www.mass.gov/courts/docs/lawlib/230-249cmr/234cmr6.pdf. Accessed October 24, 2016.
5. West Virginia Board of Dentistry. Anesthesia emergency drug requirements and equipment list. Available at: http://www.wvdentalboard.org/Anesthesia%20Emergency%20Drug%20List%202015.pdf. Accessed October 24, 2016.
6. EpiPen (package insert). Morgantown, WV: Mylan Specialty; 2016.
7. Higgins JC. The “crashing asthmatic.” Am Fam Physician. 2003;67(5):997-1004.
8. Smith D, Riel J, Tilles I, Kino R, Lis J, Hoffman JR. Intravenous epinephrine in life-threatening asthma. Ann Emerg Med. 2003;41(5):706-711.
9. Lieberman P, Nicklas RA, Randolph C. Anaphylaxis: a practice parameter update 2015. Ann Allergy Asthma Immunol. 2015;115(5):341-384.
10. Pennsylvania Emergency Health Services Council. Notices: approved and required medications lists for emergency medical services agencies and emergency medical services providers — [45 Ps.B. 5451] [Saturday, August 29, 2015]. Available at: http://pehsc.org/wp-content/uploads/2015/08/EMS-Approved-and-Required-Medication-List-08-28-2015.pdf. Accessed October 24, 2016.
11. American College of Emergency Physicians. Policy Resource Education Paper. Equipment for ambulances. June 2014. https://www.facs.org/~/media/files/quality%20programs/trauma/publications/ambulance.ashx.  Accessed 24 October 2016. n