Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

A Mistaken Bolus of Epinephrine Given to a Living Patient

This is an example of some of the complications of the routine IV (IntraVenous) administration of epinephrine to people not expected to be pronounced dead after arriving at the hospital.

The man, who does not want to be named, said he was running to work when he was bitten by a dog and started to go into anaphylactic shock.[1]

Anaphylaxis is routinely treated with epinephrine 0.3 mg IM (IntraMuscular) injection. We used to give it subcutaneously, but it works better IM. When was the last time most of us gave any medicine subcutaneously? All that does is lead to administration errors and delays in treatment.

True anaphylaxis does not do well with delays. This is one of the reasons for epinephrine autoinjectors that I wrote about in Schools and Asthma/Anaphylaxis.

He said: “In the back of the ambulance the paramedic gave me some more medication in my left and right arm… I didn’t question what it was.

“I thought my heart and my brain were going to explode and moments after that I can’t remember any more.

“I could have died… this is by far the most frightening and horrific experience that I have ever been through.”[1]

This is not at all surprising.

The 39-year-old patient, who was being treated for anaphylactic shock, said he thought his heart and brain were going to “explode”.[1]

Maybe he is just a very anxious individual?

Warnings
Inadvertently induced high arterial blood pressure may result in angina pectoris, aortic rupture or cerebral hemorrhage. Epinephrine may induce potentially serious cardiac arrhythmias in patients not suffering from heart disease and in patients with organic heart disease or who are receiving drugs that sensitize the myocardium.
[2]

he thought his heart and brain were going to “explode”.

may result in . . . aortic rupture or cerebral hemorrhage.

Epinephrine may induce potentially serious cardiac arrhythmias in patients not suffering from heart disease

OK. Maybe he is not just a very anxious individual. Maybe this is just the difference between giving epinephrine IV and giving epinephrine IM. Patients frequently still get cardiac symptoms and head aches when epinephrine is given IM, but generally not this bad.

A drug that is toxic to the heart and toxic to the brain that we routinely give to patients who are not capable of refusing, but are often having heart problems to begin with. In other words, cardiac arrest patients. An important consideration with patients resuscitated from cardiac arrest is neurological function, so why should we be concerned about giving a drug that is also toxic to the brain?

Epinephrine also contains a chemical that some people are allergic to, but shouldn’t worry about –

Epinephrine is the preferred treatment for serious allergic or other emergency situations even though this product contains sodium metabisulfite, a sulfite that may in other products cause allergic-type reactions including anaphylactic symptoms or life-threatening or less severe asthmatic episodes in certain susceptible persons. The alternatives to using epinephrine in a life-threatening situation may not be satisfactory. The presence of a sulfite in this product should not deter administration of the drug for treatment of serious allergic or other emergency situations.[2]

Some unintended humor in that description or just the understated way the British would present this?

The alternatives to using epinephrine in a life-threatening situation may not be satisfactory.

Is it appropriate to deliver such a line without a British accent? 😉

Maybe I need to get Medic999 to record this warning, so that I can play it back for patients, in order to explain the risks and benefits properly.

Footnotes:

[1] Apology after Devon paramedic’s error
29 November 2010 Last updated at 07:27 ET
BBC News
Article

[2] EPINEPHRINE injection, solution
[General Injectables & Vaccines, Inc]
FDA Label
DailyMed
Warnings
Label with link to PDF download of FDA Label

.

Comments

  1. A friend, and occasional casualty, of mine has a severe sulphite allergy. She gets an epinephrine inhaler imported from the US, which is of some use though often the ability to breath it in is somewhat impaired. Unfortunately there aren’t really any other options 🙁

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