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.
Case Series: Accidental Epipen digital self administration
- Thread starter AUSEMT
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probably couldn't. Other answers just as reasonable as mine.
KellyBracket
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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!
Obstructions
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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:
VFlutter
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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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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.
TheLocalMedic
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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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Those stickers save lives! And the crews' ears.
VFlutter
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I want to be a junior paramedic :wub:
TheLocalMedic
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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:
Please...Winne the Pooh hasn't been relevant for a decade. Get with the times please, kthxbai.
mycrofft
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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.
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.
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.
mycrofft
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There you have it.
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.
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.