%0 Journal Article
%T Two Cases of Accidental Injection of Epinephrine into a Digit Treated with Subcutaneous Phentolamine Injections
%A Ryan P. Bodkin
%A Nicole M. Acquisto
%A Holly Gunyan
%A Timothy J. Wiegand
%J Case Reports in Emergency Medicine
%D 2013
%I Hindawi Publishing Corporation
%R 10.1155/2013/586207
%X Accidental injection into the digit from an epinephrine autoinjection device can cause discoloration, pain, and paresthesias. Although loss of digit is rare, treatment in the emergency department is commonly aimed at vasodilation of the affected tissue. We report two cases of accidental injection of epinephrine into the digits that were successfully treated with subcutaneous phentolamine injection with no adverse events. 1. Introduction An intramuscular injection of epinephrine is currently the gold standard of treatment for severe anaphylaxis reactions. Autoinjection devices (i.e., EpiPen and Twinject) have been commercially available for the treatment of self-diagnosed anaphylaxis in the outpatient setting for over 30 years. Although education is provided to patients on the proper administration of these devices, the anxiety of the acuity of an anaphylaxis event compounded by the infrequency of use leads to accidental digital injections during administration. It is reported that this occurs in approximately one in 50,000 attempts at injection [1]. The Ruth Lawrence Poison and Drug Information Center covering the Finger Lakes Upstate Region of New York (14 counties) reports 27 cases of accidental injection over the past 10 years, and the Upstate New York Poison Center (54 counties) reports a total of 48 cases in 2011 making this a rare presentation. The prescribing information advises patients to go to the emergency department immediately for treatment directed at vasodilation if there is inadvertent administration to the digits, hands, or feet [2]. Epinephrine causes severe vasoconstriction through agonism of alpha1 and alpha2 receptors on the vascular smooth muscle. Based on this mechanism, it is believed that a direct injection of concentrated epinephrine 1£¿:£¿1,000 into the digit could lead to ischemic necrosis of the area. However, there is a lack of available reports showing that this in fact occurs [3¨C5]. Since symptoms including digital pain and paresthesias are reported to last as long as 10 weeks in those left untreated, vasodilatory treatment is commonly used [4]. 2. Case Presentations Case 1. A 29-year-old female presented to the emergency department approximately 30 minutes after an accidental injection of epinephrine (0.3£¿mg/0.3£¿mL, 1£¿:£¿1,000 concentration) into the pad of her right thumb. She complained of pain and numbness and noted pale coloration tracking up the palmar and dorsal surface of her right thumb. Initial therapy in the emergency department consisted of nitroglycerin ointment 2%, applied with a transparent dressing, after
%U http://www.hindawi.com/journals/criem/2013/586207/