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Breaking News: ‘Cutting’ the Most from an EpiPen

Staff, EMN

doi: 10.1097/01.EEM.0000453159.50729.6f
Breaking News
Figure. C

Figure. C

Natalie Giorgi loved reading, Disneyland, and her twin sister, though not necessarily in that order. She also had a peanut allergy, but she and her family were vigilant about what she ate. Until last July.

Natalie was 13 when she died after eating a snack containing peanuts, even though her father, a physician, injected her with multiple epinephrine auto-injectors.

Food allergies aren't uncommon; they cause some 200,000 ED visits every year, according to the organization Food Allergy Research & Education. And the FDA says food anaphylaxis results in 30,000 ED visits, 2,000 hospitalizations, and 150 deaths each year. Natalie was one of those 150.

Natalie's story and others like it are all too familiar to Seth Hawkins, MD, the medical director of Burke County (NC) EMS and Western Piedmont Community College and an adjunct assistant professor at UNC-Chapel Hill School of Medicine. They made him wonder why EpiPen users experiencing anaphylaxis and long EMS arrival times couldn't use a technique he and colleagues had taught over and over in wilderness medicine classes.

The technique? Cut open the auto-injector. Hidden inside are another two or three doses that often just go to waste. Whether this technique would have saved Natalie Giorgi is unknown, but it certainly begs the question.

This ad hoc method of extracting additional epinephrine from auto-injectors has been taught to military and wilderness personnel for about 20 years, but Dr. Hawkins said he recognized the need to make it general knowledge for any emergency situation. He teamed up with Carl Weil, the founder and owner of Wilderness Medicine Outfitters (WMO) and an original developer of the technique, as well as others who refined the technique. The published study was made open access for the public by the journal Wilderness & Environmental Medicine because of its potentially widespread significance. The process has undergone several small modifications over the years, such as in 2010 when the EpiPen manufacturer changed its packaging, but the basic idea has remained the same.

“We know that early epinephrine is very important, and having adequate epinephrine to reverse a severe episode is just as important,” Dr. Hawkins said. “The EpiPen solves the first problem, but since it's a single dose it doesn't address the chance that multiple doses are needed. We know that about 30 percent of the time more than one dose is needed, and then in about five percent of these cases three or more doses are needed.”

Anaphylaxis can be fatal in minutes, he noted, making it all the more important that extra doses are available if an ambulance is delayed or only one auto-injector is available. “You have to consider using that second dose to improve the survival rate,” Dr. Hawkins said. “The technique is accepted in the wilderness because it's the extreme case, but in reality, hundreds of fatalities are not in the wilderness but instead the additional epinephrine carried by EMS was too far away to help in time.”

A WMO graduate experiencing protracted anaphylaxis effectively administered numerous doses of epinephrine from her auto-injector using the technique. Another doctor reversed a biphasic anaphylactic reaction using the technique after the first dose from an auto-injector failed to be sufficient. The technique does not have FDA approval, but safety is not an issue when done properly, Dr. Hawkins said, noting, however, that anecdotal success abounds.

The technique can pose a risk to new operators because a knife must be used to open the auto-injector. They need to know how to use their knife properly and to cut only with the knife in a locked position on a stable surface.

“Even if you were to take all of the additional doses at once, it would be less than twice the recommended maximum dose. The risk to an adult would likely be minimal because of epinephrine's rapid clearance and the average patient weight in this country,” Dr. Hawkins said. “Someone with a cardiac condition could have a negative reaction because of the strain that it could put on the heart.

Dr. Hawkins emphasized, however, that it is important to follow the instructions for the technique precisely. He noted that the risks of incorrect teaching or usage were a major impetus for publishing the technique in the medical literature rather than depending on oral teaching or word of mouth.

“This increased need for epinephrine is not going away, and the line of thinking that lives could be saved suggests that there's room to consider other delivery systems,” Dr. Hawkins said. “This has the chance to save more lives than anything else I've written simply because its application is so broad. I can only hope that this reaches the right people.”

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Cutting Open an Auto-Injector

Read about this technique and watch a video showing how to open an auto-injector at

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