Wilderness Medical Society Summary of WMS Clinical Practice Guidelines for the Use of Epinephrine in Outdoor Education and Wilderness Settings: 2014 Update

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The treatment of anaphylaxis with injected epinephrine is a life-saving procedure. It is also time sensitive. In order to be effective, epinephrine must be administered soon after symptoms develop. In wilderness settings, access to standard medical care may be very delayed due to remote locations, weather, or geographical constraints. Therefore, we support the use of epinephrine in the field by properly trained, nonmedical professionals. The relevant laws and regulations regarding nonmedical professionals administering epinephrine vary from state to state. Where such practice is not supported by legislation, we encourage and support all efforts to change existing laws or introduce legislation supportive of this concept.

Legal background

The legality of nonmedical professionals administering epinephrine, an injected prescription medication, varies from state to state. The majority of states allow trained teachers or nurses in public schools to administer epinephrine by auto-injector to students in anaphylaxis, although such laws may not apply outside school settings. Certain states, however, do extend permission to individuals in private organizations, such as in outdoor education, to administer epinephrine for anaphylaxis. In North Carolina, for example, physicians may legally train lay people to administer epinephrine in the field. In states that do not specifically allow nonmedical individuals to administer epinephrine, the administration of a prescription drug by a layperson may be prohibited or considered negligence, regardless of benevolent intent.

Incidence of anaphylaxis in general public and outdoor education

Anaphylaxis is considered an underdiagnosed condition and therefore numbers may be higher than recognized and reported. The majority of fatalities in young adults and adolescents are caused by food allergies and insect stings. In the United States, there are approximately 150 recognized deaths from anaphylaxis secondary to food allergies or insect stings per year. Medication-induced fatal anaphylaxis typically occurs in an older, adult population—often in hospital or healthcare settings. When medications are considered along with food allergies and insect stings, there may be up to 1500 deaths per year. Overall, the risk of anaphylaxis in the general population is estimated at 0.05% to 2%.

Methods of epinephrine administration

Epinephrine may be administered via auto-injector or drawn from a vial into a syringe with an attached needle and administered intramuscularly. Injection into the anterolateral mid-thigh by either method achieves higher serum drug concentration than intramuscular or subcutaneous injection into the deltoid. Auto-injectors minimize the possibility of dosage error and can be administered through clothing. On the other hand, drawing from a vial or ampule is far less expensive. Regardless of the delivery method, historical evidence has suggested that up to 25% -35% of anaphylaxis victims may require a second dose, either within minutes of the first dose, or hours later, as part of a biphasic presentation of anaphylaxis. Recent evidence, however, suggests that the biphasic rate in emergency department patients treated early with epinephrine, antihistamines, and steroids may be <1%. Nonetheless, because of the life-threatening nature of anaphylaxis, as well as the possibility of a biphasic reaction, field victims of anaphylaxis should be evacuated if possible to definitive or hospital-based care.

Adverse outcomes from field epinephrine

The literature reports dysrhythmias, myocardial infarctions, and strokes as adverse side effects in individuals who received epinephrine. The majority of these adverse events occurred in the elderly, individuals with pre-existing heart conditions, patients who did not actually have anaphylaxis, or in cases in which excess epinephrine was inadvertently administered. In life-threatening anaphylaxis, there is no absolute contraindication to properly dosed epinephrine. Anaphylaxis itself may lead to ischemic electrocardiographic changes and dysrhythmias even in the absence of epinephrine administration.

Future directions

An outdoor organization with responsibility for students at risk for anaphylaxis—particularly children with asthma or food allergies, who may also be a long way from standard medical care—should require that such students carry personal auto-injectors and that outdoor instructors also be trained to administer epinephrine. Legal protection for this rests on having each state legislature or medical board approve the field administration of epinephrine by trained outdoor instructors. In time, continued legislative change on the federal level should establish uniform protection in all 50 states. The relevant law need only say that field administration of epinephrine is an approved practice and that physicians may train others to administer it. The roundtable panel endorsed the field administration of epinephrine under emergency conditions by wilderness instructors who have received adequate training in the field recognition and treatment of anaphylaxis.


Gaudio F, Lemery J, Johnson DJ. Wilderness Medical Society Practice Guidelines for the use of epinephrine in outdoor education and wilderness settings: 2014 update. Wilderness Environ Med. 25(4):15–48.

Published March 8, 2021

Volume 38, Issue 1