# Case Series: Accidental Epipen digital self administration



## AUSEMT (Jan 6, 2013)

Case Series:
A care provider accidentally administers an Epipen containing 300ug to thier own thumb/ digit whilst trying to figure out how to administer to a patient.

Immediate effects are:
Local Vasoconstriction
Loss of circulation/ adequate perfusion with a cap refill >4 seconds
moderate 6/10 localized pain
Mild swelling and erythema 

How would you treat? 
i) at a BLS Level
ii) at an ALS Level
iii) at a Tertiary clinical / hospital level?

What are your primary concerns for the patient?

what co-morbidities or history would be relevant or pertinent in discussing this scenario?


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## AUSEMT (Jan 6, 2013)

Accompanying Radiology:


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## Clare (Jan 6, 2013)

My main concern would be sympathetic effects of the adrenaline causing myocardial ischaemia; but that could be treated with a small dose of GTN spray (0.4 mg).  Of lesser concern would be infection.  Digital ischaemia is not a concern, digits and limbs can go many hours with total loss of blood flow before ischaemia become irreversible.  

I'd be keen to see if we could remove the needle or at least cut the sharp protruding end off with a pair of pliers.  

Provide appropriate analgesia, put on stretcher and take to hospital where I imagine the orthopaedic surgeons will have a quick tinker and get it out.

I would classify this patient as status four (minor, not time critical or life threatening)


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## Anjel (Jan 6, 2013)

I classify them as a moron.


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## Handsome Robb (Jan 6, 2013)

Anjel said:


> I classify them as a moron.



:rofl:

I'm not real worried about this guy unless he has a cardiac hx, personally, and would gladly poke fun at him all the way to the ER.


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## Medic Tim (Jan 6, 2013)

I have had a few pts similar to this. One was a ped . The needle was not stuck in the bone or anything like that. The finger was pale cool and had a delayed cap refill. Pt also had paresthesia to finger. We submerged the hand in warm water and had the pt move his hand and fingers as mush as possible. We also used some nitro paste after consult with a doc. Pt was fine after a few hours.

Another one happened when I was on my internship. Pt similar to the first came in. The doc used Phentolamine injections. The pt has sensation in his thumb within 10 min or so.


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## EpiEMS (Jan 6, 2013)

Fairly sure you could send this in by a taxi  . Surely they should be evaluated by an ED MD/PA/NP. If adequate perfusion is present, then the patient can probably be quickly evaluated and discharged. In the absence of adequate perfusion, as in this case, it seems like the options are wait around for a couple hours or have a physician administer phentolamine (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2726472/). Apparently, nitro paste and warm water soaks don't work (ibid). And the good news is, it doesn't seem like there's any cases of loss of digits, though (at least, not in my PubMed search).


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## NYMedic828 (Jan 6, 2013)

I'd have minimal worry of cardiac ischemia. It is in a very distal region from the heart and furthermore it's not a big dose. 0.3mg in a younger patient is not that relevant.

Furthermore, the needle entirely transacted his thumb and came out the other side. 90% of the medication probably released outside of the body...


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## Veneficus (Jan 6, 2013)

Digital nerve block (because I am nice) Pull it out, control bleed as need, tetanus shot, 1g IV cephtriaxone. 

Remind him laughter is the best medicine and tell him how lucky he was he wasn't trying to figure out how to use a gun.


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## phideux (Jan 6, 2013)

By that pic it sure seems that the needle went through soft tissue, missed the bone, and squirted the epi in the air.


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## Veneficus (Jan 6, 2013)

NYMedic828 said:


> I'd have minimal worry of cardiac ischemia. It is in a very distal region from the heart and furthermore it's not a big dose. 0.3mg in a younger patient is not that relevant.
> 
> Furthermore, the needle entirely transacted his thumb and came out the other side. 90% of the medication probably released outside of the body...



Having some experience on this matter, I once treated a pt after a Basic stabbed a patient having only a cutaneous allergic reaction with an epi-pen. Aside from "feeling a little weird" and a HR of 140, there was no ill effect at all.

Additionally, some physicians prefer to use local anesthesia with epi in it. 0.3 mg in the soft tissue is not something to get worked up about in a patient with no history.

Furthermore, there is also a post surgical pain control technique of injecting an opioid like morphine locally SQ and then injecting SQ epi into the same region to limit the blood flow and prolong the absorbtion of the opioid.

While it may seem exciting, I don't see life and death here.


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## EpiEMS (Jan 6, 2013)

Veneficus said:


> While it may seem exciting, I don't see life and death here.



What is the worst way this could plausibly go downhill? That is, accidental Epi administration to a healthy young person?


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## NYMedic828 (Jan 6, 2013)

Veneficus said:


> Having some experience on this matter, I once treated a pt after a Basic stabbed a patient having only a cutaneous allergic reaction with an epi-pen. Aside from "feeling a little weird" and a HR of 140, there was no ill effect at all.
> 
> Additionally, some physicians prefer to use local anesthesia with epi in it. 0.3 mg in the soft tissue is not something to get worked up about in a patient with no history.
> 
> ...



Been given Xylocaine 1:100,000 a couple times to facilitate stitches.





EpiEMS said:


> What is the worst way this could plausibly go downhill? That is, accidental Epi administration to a healthy young person?



The epi pen lands directly in a vein (massively unlikely) and ends up giving an IV dose of 0.3mg and even still has minimal danger in a healthy younger patient. 

Going for an intense run probably releases more endogenous norepi/epi than the 0.3mg injection.


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## Tigger (Jan 6, 2013)

NYMedic828 said:


> Been given Xylocaine 1:100,000 a couple times to facilitate stitches.



This and Septocaine 1:200,000 are very common in dentistry and other minor procedures. 9/10 suturing procedures I've assisted with have been done with Septocaine or Xylocaine.


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## Veneficus (Jan 6, 2013)

EpiEMS said:


> What is the worst way this could plausibly go downhill? That is, accidental Epi administration to a healthy young person?



They could get an infection which compromises use of their digit.

They could get tetanus from a nonsterile needle. (sterile packaging is finite)

They could increase their heart rate high enough it reduces prefil to the point of shock from low output or consequent arrhythmia.

The distal digit could get necrotic from lack of blood flow, reducing quality of life.

A person with afib could throw a clot and have a stroke.

But all of these aside from infection (which is also not a major concern but is easily and cheaply preventable) are extremely unlikely. Especially in a healthy young person.


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## mycrofft (Jan 6, 2013)

Tigger said:


> This and Septocaine 1:200,000 are very common in dentistry and other minor procedures. 9/10 suturing procedures I've assisted with have been done with Septocaine or Xylocaine.



Dental and local injections for sutures and the like often contain epinephrine already. We were taught if that happens the digit may be lost, but we're talking a lot of local all over the digit versus the partial from the epipen...and the photo suggests the dose was partially sent aerially.

My atrial fib doesn't like epi at all, and reactions to the epi on dental shots was the first clue something was wrong. Plain carbocaine: fine but it wears off faster.

PS: nice illustration but it looks to me like the plunger on the syringe has not traveled to its stop near the needle, and the needle lies superior/towards the camera of the bones of the rt thumb in a dorsal view, which strongly suggests the needle is laying on top of the thumb entirely.


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## mycrofft (Jan 6, 2013)

PPS: how old is the subject? Nice hands.


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## VFlutter (Jan 6, 2013)

Pulp Fiction reference: You must have hit a bump or something

Not sure how someone does that


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## lightsandsirens5 (Jan 6, 2013)

EpiEMS said:


> What is the worst way this could plausibly go downhill? That is, accidental Epi administration to a healthy young person?



Vasovagal reaction. Pt's lights go out, falls over, cracks head on something, ends up with either: a) depressed skull fracture and massive bleeding into brain, or: b) closed TBI, increased ICP, brain herniation, and dies.

Well, you asked...


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## EpiEMS (Jan 6, 2013)

lightsandsirens5 said:


> Vasovagal reaction. Pt's lights go out, falls over, cracks head on something, ends up with either: a) depressed skull fracture and massive bleeding into brain, or: b) closed TBI, increased ICP, brain herniation, and dies.
> 
> Well, you asked...



I should know better than to ask a question that was so open ended

I was thinking more "How could this *realistically* go wrong?"


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## Veneficus (Jan 6, 2013)

EpiEMS said:


> I should know better than to ask a question that was so open ended
> 
> I was thinking more "How could this *realistically* go wrong?"



probably couldn't. Other answers just as reasonable as mine.


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## KellyBracket (Jan 6, 2013)

AUSEMT said:


> Case Series:
> A care provider accidentally administers an Epipen containing 300ug to thier own thumb/ digit whilst trying to figure out how to administer to a patient.
> 
> ...



Great topic! There is some interesting mix of the conventional/old thinking with newer data.

The older thinking suggests that the EMT should have their finger evaluated at the ED. For a long time providers and nurses were told never to use epinephrine when injecting anesthetics in the "fingers, nose, penis, or toes," for fear that the epi would cause necrosis of the finger (or other parts).

On the other hand, it turns out that while some doctors were fretting about epi in the fingers, other doctors weren't so worried. Hand surgeons, in particular, were using it all the time to get "bloodless fields" and better anesthesia.

By the same token, we used to worry about stabbing the finger with an Epi-Pen. (Even doctors do this sometimes!). However, it appears that these fears are overemphasized, and there is little evidence that any fingers have fallen off as a result of clumsy auto-injector handling.

All the same, let a doc take a look at it. It's your hand, after all!


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## Obstructions (Jan 7, 2013)

I'm surprised no one is as worried about the finger itself... Lots of physicians (I'm thinking of surgeons and gastroenterologists) use epinephrine as a vasoblocker to minimize bleeding during procedures. If herpy derpy Paramedic here just injected an anaphylaxis dose into his finger his blood vessels are going to be shriveled and closed like no other. Wouldn't we want to take a little more care into saving his thumb? It's kind of important...:huh:


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## VFlutter (Jan 7, 2013)

Obstructions said:


> I'm surprised no one is as worried about the finger itself... Lots of physicians (I'm thinking of surgeons and gastroenterologists) use epinephrine as a vasoblocker to minimize bleeding during procedures. If herpy derpy Paramedic here just injected an anaphylaxis dose into his finger his blood vessels are going to be shriveled and closed like no other. Wouldn't we want to take a little more care into saving his thumb? It's kind of important...:huh:



Epi is also used in conjuction with lidocaine for local anesthetic. The half life of Epi is like 2 minutes so I wouldn't be all that concerned about tissue necrosis. Hell they can even reattach fingers that have been severed for several hours and are still viable.


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## Handsome Robb (Jan 7, 2013)

Obstructions said:


> I'm surprised no one is as worried about the finger itself... Lots of physicians (I'm thinking of surgeons and gastroenterologists) use epinephrine as a vasoblocker to minimize bleeding during procedures. If herpy derpy Paramedic here just injected an anaphylaxis dose into his finger his blood vessels are going to be shriveled and closed like no other. Wouldn't we want to take a little more care into saving his thumb? It's kind of important...:huh:



We don't worry about removing a tourniquet until you start approaching 4 hours after application...epinephrine from an EpiPen is going to wear off long before that.


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## TheLocalMedic (Jan 7, 2013)

Had a call where a six year old was showing his 3 year old brother how his pedi epi-pen worked and shot the three year old in the leg with it.  Both of them were upset and crying (with dad glowering over them), but apart from local skin blanching and tachycardia the kid was fine.  Extra fine after we gave him some Junior Paramedic stickers!


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## Handsome Robb (Jan 7, 2013)

TheLocalMedic said:


> Extra fine after we gave him some Junior Paramedic stickers!



Those stickers save lives! And the crews' ears.


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## VFlutter (Jan 7, 2013)

I want to be a junior paramedic :wub:


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## Veneficus (Jan 7, 2013)

I always liked the ones that said "I am a star in the ER"


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## TheLocalMedic (Jan 7, 2013)

I carry a supply of funny bandaids on my ambulance as well.  I've got "bacon strip" ones for adults (hilarious) and Transformers and Sponge Bob too.  It's the small things, right?


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## AUSEMT (Jan 7, 2013)

TheLocalMedic said:


> I carry a supply of funny bandaids on my ambulance as well.  I've got "bacon strip" ones for adults (hilarious) and Transformers and Sponge Bob too.  It's the small things, right?



Please, my winnie the poo bandaids for kids KILL yours :lol:


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## Dwindlin (Jan 7, 2013)

AUSEMT said:


> Please, my winnie the poo bandaids for kids KILL yours :lol:



Please...Winne the Pooh hasn't been relevant for a decade.  Get with the times please, kthxbai.


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## mycrofft (Jan 7, 2013)

Chase said:


> Epi is also used in conjuction with lidocaine for local anesthetic. The half life of Epi is like 2 minutes so I wouldn't be all that concerned about tissue necrosis. Hell they can even reattach fingers that have been severed for several hours and are still viable.



Yeah, I want to rely on reattachment to correct an issue I caused! Like the head nurse who told us to go ahead and give an antibiotic injection to a pt who was allergic to a related drug, "We have epinephrine and benadryl".

Seriously, the manufacturers say not to use "lido with" on any dependent thing like tongue tip, ears, digits. I've heard stories for decades but not first hand..pun unintended.


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## jwk (Jan 7, 2013)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526033/

Good article here.  

Although likely innocuous in most cases, there are reported problems with inadvertent high-dose epi in the finger.  Although no cases of tissue necrosis were reported, neuropraxia was, meaning there was enough restriction of blood flow to the digital nerves to cause some intermediate term nerve problems that eventually resolved.

Just so y'all are clear how much epi is used for different purposes...

High concentration epi is generally 1:1000, or 1mg/cc.  This is what is frequently found in Epi-Pens (1:2000 in Epi-Pen Jr) and hospital crash carts.  EMS units may carry these as well to use subQ.  

Epi found in pre-filled syringes for ACLS use is usually 1:10,000, or 100mcg/cc.  That's still 1mg of epi for the whole syringe.

Epi used in conjunction with local anesthetics is at far lower concentrations, usually 1:100,000 or less (10mcg/cc).  There are still plenty of people around that will swear you should never use local anesthetics containing epi on fingers, toes, and the penis.  Those concerns have pretty well been discounted, but you won't find a lot of people testing the concept.


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## mycrofft (Jan 7, 2013)

*There you have it.*



jwk said:


> http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526033/
> 
> Good article here.
> 
> ...



From the link, in which two researchers looked online and in person for all cases (?) of inadvertent admin of injected high-concentrtion epi into fingers:

(AND I QUOTE, mods) 

"There is not one case of finger necrosis in all of the 59 reported cases of finger injections with 1:1,000 epinephrine in the world literature. The necessity or type of treatment of high-dose epinephrine injection injuries remains conjecture, but phentolamine is the most commonly used agent in the reported cases, and the rationale and evidence for its use are discussed" (red letters mine...mycrofft).

I am dubious about how thorough this search could be strictly speaking, but I think it is a pretty good effort covering *105 years.* 59 is a very low frequency. And outcomes were reported to be mostly ok.


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