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Q. I am a school nurse and our school system stocks vials of epinephrine in the event of an anaphylactic reaction. Under current policy, we are asked to administer epinephrine subcutaneously (subQ or under the skin) when the student does not have his or her own epinephrine auto-injector. I have researched that delivering the epinephrine in the muscle (IM) has advantages over the subQ approach. Which delivery is preferred, and could you give specifics so I might discuss this further with our policymakers?

A. Your question could not be a more timely one, as anaphylaxis is the focus of the World Allergy Organization, for World Allergy Week this April. The current recommendation is for epinephrine to be administered in the muscle (IM) in anaphylaxis. While the last American Academy of Allergy, Asthma, and Immunology/American College of Allergy, Asthma, and Immunology/Joint Council of Allergy, Asthma, and Immunology practice parameter published in 2010 (published in indicated that epinephrine could be administered IM or subQ, updated anaphylaxis practice guidelines in progress will indicate IM is preferred. A recently developed practice parameter (soon to be published) for treatment of anaphylaxis in the emergency room also indicates IM . Finally, the World Allergy Organization guideline ( also says IM.The best location to administer IM epinephrine is the anterolateral (outer) aspect of the thigh, where studies have shown absorption is best. Only RNs should be using the epinephrine vials, as it is rather easy to err and administer too large a dose. It would be much better, even for nurses, to have epinephrine auto-injectors available for use. Please keep up your efforts and help us save lives at school!