Myocardial stunning secondary to erroneous administration of intravenous epinephrine

Abstract

Epinephrine is a commonly used medication for emergent conditions, such as anaphylaxis, respiratory distress, and shock. However, its versatility can also lead to iatrogenic errors in dosages, concentrations, and routes of administration. In this case, a 47-year-old female experiencing anaphylaxis received an intravenous dose of 0.3 mg (1:1000) epinephrine formulated for intramuscular injection, resulting in cardiac arrest and acute heart failure due to myocardial stunning, as diagnosed by echocardiography. Management included invasive ventilation and hemodynamic support until cardiac function recovered. This case highlights the potential dangers of epinephrine overdose, and to our knowledge, is the first reported case of iatrogenic epinephrine-induced Takotsubo cardiomyopathy in a rural area. In addition, we review the literature on iatrogenic epinephrine toxicity-associated cardiomyopathy and the epidemiology of epinephrine errors. Safety measures must be considered for improving communication in emergencies, increasing awareness via training, and changing epinephrine’s antiquated packaging design.

Myocardial injury secondary to adrenaline toxicity

“…These changes are associated with raised troponin, cardiac impairment and usually (but not always) followed by a negative coronary angiogram. After an initial period of hypertension and tachycardia, some patients develop hypotension and catecholamine-induced (Takutsobu) cardiomyopathy [4]. In this series, left ventricular impairment (developing over minutes to hours) was associated with cardiogenic shock in 31% and pulmonary oedema in 21% of patients [3].…”

“…anaphylaxis the benefit of early use is likely to vastly outweigh the risks. With regards to adrenaline toxicity, no published guidelines exist despite multiple case series of life-threatening and fatal reactions [3,4]. In one, cardiac arrest occurred in 17% of patients, most caused by errors in dose (68%) and route of administration (18%) [4].…”

Inappropriate use of intravenous epinephrine leading to atrial fibrillation during prehospital anaphylaxis treatment: a case report

“…Haewon Jung, et al A case of cardiac arrest occurred following intravenous administration of 0.3 mg epinephrine (1:1,000) in a patient with computed tomography contrast-induced anaphylaxis [9]. In a study comparing routes of epinephrine administration in anaphylaxis, intravenous bolus epinephrine had significantly higher risk of overdose and adverse cardiovascular events compared to intramuscular epinephrine administration [6].…”