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Indian Pediatr 2013;50: 247 |
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Epinephrine Induced Digital Ischemia After
Accidental Injection from an Auto-injector Device
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Ramnik Patel and Hemant Kumar
Department of Paediatric Surgery, Directorate of
Children’s Services, University Hospitals of Leicester NHS Trust,
Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, United
Kingdom.
Email:
[email protected]
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The use of epinephrine auto-injectors for prehospital
treatment of severe allergic reactions in children has
become increasingly common [1], widely accepted and
prescribed [2]; 5% of the pediatric population in the United
Kingdom has some form of food allergy [3].
An 11-year-old girl accidentally injected
her right thumb with the EpiPen. This injection caused
immediate ischemic changes in the distal right thumb and
developed paraesthesia, pain, pallor, prolonged peripheral
capillary refill time and cold blue right thumb. Examination
of the right thumb revealed a puncture wound centrally on
the volar pad. She received warm water immersion and local
nitroglycerin paste. A mixture of 0.5 mg of phentolamine,
1.0 mL of normal saline with 1.0 mL of 2% lidocaine was
prepared and kept ready for half of this mixture to be
infiltrated subcutaneously at the puncture site, and the
rest to be infiltrated along the course of the digital
arteries should her symptoms worsen or her clinical
condition deteriorates. She had an uneventful recovery
following a period of observation.
There is a greater incidence of
accidental auto-injection into digits [1]. Epinephrine is a
sympathomimetic agent and has both
a-adrenergic
and b-adrenergic
responses. Several methods have been tried to reverse the
effect of epinephrine accidentally injected into a digit
including spontaneous reversal, warm water immersion,
systemic or topical nitroglycerin, topical infiltration with
terbutaline, topical and /or systemic phentolamine.
Topical infiltration of phentolamine is
the most appropriate treatment as it is easy to perform,
reverses ischaemia quickly and efficiently, has no reported
adverse reactions, and is effective in late presentations
[1, 4-5]. Phentolamine, a short acting
a-blocker
used mainly to control blood pressure during surgical
resection of phaechromocytoma, has been used as an effective
a-
adrenergic antagonist appropriately. Phentolamine at
puncture site, digital block and intra-arterial
administration have proved beneficial in reversing the
vasoconstrictive effect of epinephrine induced digital
ischaemia. However, a further injection may be required to
completely restore perfusion.
The most appropriate evidence-based
management for this situation was reviewed. If on assessment
there is adequate peripheral perfusion of the digit; patient
may be discharged. If the peripheral perfusion is
compromised, the intradigital sequential administration of
phentolamine into the puncture wound and along the course of
digital arteries on both sides is the preferred management
at any age, and even in delayed cases not responding to
conservative management.
References
1. Velissariou I, Cottrell S, Berry K,
Wilson B. Management of adrenaline (epinephrine) induced
digital ischaemia in children after accidental injection
from an EpiPen. Emerg Med J. 2004;21:387-8.
2. Macdougall CF, Cant AJ, Colver AF. How
dangerous is food allergy in childhood? The incidence of
severe and fatal allergic reactions across the UK and
Ireland. Arch Dis Child. 2002;86:236-9.
3. Watura JC. Nut allergy in school
children: a survey of schools in the Severn NHS Trust. Arch
Dis Child. 2002;86:240-4.
4. Mc Govern SJ, Treatment of accidental
digital injection of adrenaline from an auto-injector
device. J Accid Emerg Med. 1997;14:379-80.
5. El Maraghy MW, El Maraghy AW, Evans HB. Digital
adrenaline injection injuries: a case series and review. Can
J Plast Surg.1998; 4:196-200.
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