How to Use an EpiPen: A Step by Step Guide

An EpiPen is an auto-injector device that administers epinephrine, a medication that can stop the symptoms of anaphylaxis. 

Anaphylaxis is a potentially fatal complication of a severe allergic reaction triggered by an exaggerated immune response to an allergen. During an anaphylactic allergic reaction, your immune system overreacts to the allergen resulting in a medical emergency.  

You can carry an EpiPen with you in a bag or pocket. It should be used immediately if symptoms such as low blood pressure, difficulty breathing, or swelling occur. 

Even after using an EpiPen, emergency medical help should be sought by contacting either 911 or the emergency services in the area. Keep reading to learn how to use an epinephrine auto-injector properly.

Severe Allergic Reaction (Anaphylaxis) Symptoms

Anaphylaxis symptoms may initially present with mild symptoms, but it can quickly worsen and become life-threatening when your blood pressure and breathing are compromised. If you or someone near you begins to experience symptoms of severe allergic reaction or anaphylaxis, use the EpiPen immediately and call 911, then seek emergency medical care at the closest urgent care or emergency department. An Initial anaphylactic allergic reaction may present differently among people. However, a severe allergic reaction is typically present with the following symptoms: 

• Fainting or collapsing
• Difficulty breathing
• Having a feeling of doom
• Dangerously low blood pressure and low pulse
• Having pale or clammy skin
• Swelling of the throat, face, or lips
• Having a rapid heart rate
• Feeling dizzy or light-headed
• Wheezing or hoarseness
• Anxiety and confusion
• Shock — your body can go into shock when there is not enough blood supplying the vital organs 

Other possible symptoms include:

• Diarrhea
• Nausea or vomiting
• Abdominal pain
• Hives and itching

The above symptoms can be present during different states of an allergic reaction. However, the following symptoms are indicative of anaphylaxis:

• Weakness, confusion
• Swelling of the face, tongue, or throat
• Paleness
• Dangerously low blood pressure with rapid heart rate
• Hives
• Shortness of breath, wheezing 

A Step-by-Step Guide to Use an EpiPen

When using an EpiPen, the following three steps are required, as outlined by the manufacturer:

Prepare

• The first step is to open the yellow cap to the auto-injector. Then tip the case and slide the EpiPen out. 
• Keep the EpiPen in your closed fist, with the orange tip pointing downward. One way to remember this is the phrase, "Blue to the sky, orange to the thigh."
• With the other hand, remove the blue safety cap by pulling it straight up. This won’t work unless the safety cap is removed.

Administer

• Position the point of the orange tip to rest on the outer thigh at a right angle to the thigh. If administering the EpiPen to a child, hold the leg firmly in place.
• Swing the EpiPen about 6 inches back and hold firmly against your outer thigh as you do so. The orange tip has the needle inside, pushing the orange tip into the leg until it clicks. Once you hear a “click,” the injection has begun.
• Keep this position for the next three seconds. Count slowly, keeping the needle in the muscle. If you don’t hear the click, the medication may not have been delivered.  
• Remove the EpiPen from your thigh.
• Massage the injection area for ten seconds.
•  If you or your child have severe allergies, it is highly recommended that you carry a second EpiPen with you in case the first injection fails. 

Get emergency medical help

An Anaphylactic allergic reaction can be life-threatening. You should immediately call 911 or seek medical care at the closest healthcare facility. In some cases, a second injection may be necessary. The first EpiPen injection works to give you additional time to get medical care.

If possible, someone should drive you to the nearest hospital emergency room. It is recommended to avoid driving unless absolutely necessary, as there is a chance that it may happen again. 

If you are using any epinephrine auto-injectors other than an EpiPen, read the manufacturer's instructions for administering the medication and consult with a doctor if you have any concerns or questions. 

If the first dose does not have the desired effect, a second dose may be necessary. This will require an additional auto-injector. If you need to give an injection of epinephrine to another adult using an auto-epinephrine injector, follow the steps outlined above. and give the injection into the upper outer thigh. For the best results, it is recommended to give the injection to the upper outer thigh while the person is seated or lying down for better results.

When to use an EpiPen

You should use an EpiPen any time you have reason to believe that you or another person is experiencing a severe allergic reaction. As soon as the symptoms of anaphylaxis or severe allergic reaction present themselves, it’s crucial that the patient use an EpiPen.

However, the EpiPen should only be used by people who have a prescription for it from a doctor.

In addition, the administration of epinephrine should never serve as a substitute for medical treatment or other medications. You absolutely must seek medical care as soon as possible.

What to do during a medical emergency

In the event that someone is having an anaphylactic reaction, what steps should you take? Adhere to the emergency protocols that are listed below.

1. Put in a call to 911 right away and ask for help from others if possible.
2. Ask if the person if they are in possession of an epinephrine auto-injector. If they are, you should ask if they need assistance giving the injection.
3. Give the patient an epinephrine injection in the outer thigh if requested.
4. Loosen any garments that are too close-fitting. However, remember that the EpiPen auto-injector is designed to deliver epinephrine through clothing, so removing clothing is not necessary to use an EpiPen.
5. Help the person roll over onto their back if they are having trouble doing so. If they are feeling sick, have just vomited, become unconscious, are having trouble breathing, or are pregnant, turn them carefully onto their side. 
6. If possible, eliminate any allergen triggers.
7. If possible, wrap the person in a blanket.
8. Do not give the patient anything to eat or drink.
9. If symptoms have not improved within 5 to 15 minutes after the first injection of epinephrine, a second injection should be given after at least 5 minutes if another auto-injector is available. However, the administration of more than two injections should only be done under the supervision of a doctor.
10.  If there are no signs of respiration, you should begin chest compressions.
11. Stay with the individual while you wait for assistance to arrive.

Other precautions

The following safety advice can help you avoid an anaphylactic or allergic reaction or prepare and protect you if you have one.

• Identify and avoid your allergy triggers. The following are some examples of common allergens:
  • Latex allergy
  • Contrast agents used in medical imaging
  • Medicine 
  • Food allergies, such as shellfish and peanuts
  • Venom from insect bites or stings
• Remember to always bring your epinephrine auto-injector with you and make sure it is not an expired EpiPen. 
• If you or your child is prescribed an EpiPen, you should familiarize yourself with the instructions on how to use it, in addition to being able to recognize the symptoms of anaphylaxis. 
• Check the epinephrine injector regularly to ensure that the liquid has not changed color. 
• Keep epinephrine auto-injectors at room temperature. 
• Be aware of the symptoms of anaphylaxis and learn how to administer the epinephrine auto-injector properly. 
• Make sure your loved ones and those who look after you know about your allergy, and consider carrying a medical identification card or wearing jewelry that displays your allergy information. 
• If your child has a severe allergy, make sure at least two EpiPen are available in the classroom or the nurse’s office. Parents should label a container with EpiPen with the child’s name, photo, and emergency contact information. 
• If you suspect anaphylaxis, call 911 or your local hospital services immediately. 
• Dispose of the EpiPen in a sharps container or an empty laundry detergent container with a lid.

References

• Reber, L. L., Hernandez, J. D., & Galli, S. J. (2017). The pathophysiology of anaphylaxis. The Journal of allergy and clinical immunology, 140(2), 335–348. https://pubmed.ncbi.nlm.nih.gov/28780941/
• Vijayaraghavan R. (2020). Autoinjector device for rapid administration of drugs and antidotes in emergency situations and in mass casualty management. The Journal of international medical research, 48(5), 300060520926019. https://pubmed.ncbi.nlm.nih.gov/32436421/
• McLendon K, Sternard BT. Anaphylaxis. [Updated 2023 Jan 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482124/
• Epipen. (n.d.). How to use Epipen Auto-Injector. Retrieved from https://www.epipen.com/-/media/files/epipen/howtouseepipenautoinjector.pdf
• Epinephrine Injection: MedlinePlus Drug Information. (n.d.). Epinephrine Injection: MedlinePlus Drug Information. https://medlineplus.gov/druginfo/meds/a603002.html
• Search List of Extended Use Dates to Assist with Drug Shortages. (2023, May 4). Search List of Extended Use Dates to Assist With Drug Shortages | FDA. https://www.fda.gov/drugs/drug-shortages/search-list-extended-use-dates-assist-drug-shortages
• Safely Using Sharps (Needles and Syringes). (2021, November 19). Safely Using Sharps (Needles and Syringes) at Home, at Work and on Travel | FDA. https://www.fda.gov/medical-devices/consumer-products/safely-using-sharps-needles-and-syringes-home-work-and-travel
• Posner, L. S., & Camargo, C. A., Jr (2017). Update on the usage and safety of epinephrine auto-injectors, 2017. Drug, healthcare and patient safety, 9, 9–18. https://pubmed.ncbi.nlm.nih.gov/28356773/
• https://kidshealth.org/en/parents/school-foodallergy.html#:~:text=Label%20the%20epinephrine%20container%20with,parents%20in%20your%20child's%20class.