Management options for accidental injection of epinephrine from an autoinjector: a case report

Abstract

IntroductionEpinephrine autoinjector devices are used with increasing frequency to treat severe anaphylactic reactions. Accidental injection, usually involving a finger, is a potential complication.Case presentationA physician in a Family Practice training program accidentally injected epinephrine into his left thumb while reading the operating instructions of an autoinjector (Epipen®). He developed swelling, pallor, and pain in the thumb. Treatment included topical nitroglycerin, oral vasodilators and warming of the thumb. As expected, none caused an immediate response; however, after 8 hours, the thumb was pink and warm. There was full recovery 2 months after the accident. We reviewed the treatment of accidental epinephrine injection, and found that the use of parenteral adrenergic alpha blocker phentolamine would have produced immediate recovery.ConclusionsAll health professionals concerned with the use of epinephrine autoinjectors should receive adequate instruction on their use. A regimen for management of accidental epinephrine injection, in particular the use of phentolamine, should be emphasized.

Reversal of Digital Ischemia with Phentolamine After Accidental Epinephrine Injection

“…Globally, the accidental injection rate of epinephrine has risen because of the increased use of autoinjectors, and has been found to occur once for every 50,000 EpiPen ® units sold [ 9 ]. The EpiPen® trainer was self-injected by about 16% of doctors who read the EpiPen ® device instructions and injected it into their thumbs [ 7 ]. This increases the risk of painful necrosis due to extreme local vasoconstriction, even though no case of digital loss has been recorded [ 7 ].…”

“…There have been reports of finger necrosis after accidental low-dose (1: 100,000) epinephrine injection [ 6 ]. Myocardial infarction has also been reported from injected epinephrine [ 7 ].…”

Use of phentolamine in the treatment of Epipen induced digital ischaemia

“…Hinterberger suggested direct local infiltration is the most effective as this allows phentolamine to access the affected receptors and any residual norepinephrine directly 9. Local infiltration into the puncture site has been successful in restoring perfusion within 1 h in most cases and it has been recognised that the treatment is effective up to 13 h after the accidental digital injection 10. Unfortunately, phentolamine is not routinely available in accident and emergency departments and treatment advice remains poorly publicised.…”

Using a Computer Module to Teach Use of the EpiPen®

“…A surprisingly common complication of EpiPen® use is digital ischemia: there is a series of case reports in which the patient held the EpiPen® in an inverted manner and injected the epinephrine into a finger, creating a second emergency. 15,16,17,18 Physicians frequently fail to instruct their patients on use of the EpiPen®. It is likely that physicians' lack of familiarity with the device is contributing to the lack of patient instruction.…”