Intravenous epinephrine overdose in prehospital management of suspected anaphylaxis

Abstract

A 65-year-old woman called paramedics for stridor and neck swelling following an insect bite with a possible anaphylactic reaction. On arrival paramedics administered intramuscular epinephrine without any observed improvement in stridor. Paramedics then prepared 5 mg of 1:1000 epinephrine for nebulised administration, which was inadvertently given intravenously. The patient developed tachycardia, anxiety and a severe headache, with biochemical evidence of cardiac necrosis without any haemodynamic compromise. The patient recovered over the next 24 hours and no long-term sequelae were identified on CT coronary angiogram, electrocardiography (ECG) echocardiography or invasive angiography. This case highlights the risk of cardiac ischaemia during epinephrine administration and the importance of protocols to ensure appropriate dosing. This case also raises questions regarding appropriate management of epinephrine overdose and shines a light on the absence of guidelines on the prevention of complications from epinephrine administration.

Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis

“…Other side effects described included decreased ejection fraction, diagnosis of cardiomyopathy, and coronary artery thrombus that was diagnosed on cardiac catheterization 19–22 . The other case reports described 34 patients in total who received an intravenous bolus dose of epinephrine inadvertently, or an inappropriately high IM dose 23–52 . This led to a wide array of side effects including arrhythmias, cardiomyopathy, thrombus, and cardiac arrest.…”

Inappropriate use of intravenous epinephrine leading to atrial fibrillation during prehospital anaphylaxis treatment: A case report

“…Additional interventions by the EMS medical director would be needed in cases of anaphylaxis, wherein some patients are unresponsive to the initial treatment. A case was reported in Australia [14] wherein an error following intramuscular epinephrine administration by EMTs led to inadvertent administration of 5 mg intravenous epinephrine, which resulted in ventricular tachycardia. In our case, under the medical director's oversight, EMTs administered not only 0.5 mg of epinephrine intramuscularly without using an autoinjector, but also an intravenous epinephrine bolus.…”

CSACI position statement: transition recommendations on existing epinephrine autoinjectors

“…In the adult population, a rise in troponin levels have been seen predominantly after administration of intravenous bolus epinephrine [ 31 ]. Patients with pre-existing cardiovascular disease who take medications such as beta-blockers may be at higher risk of developing severe anaphylaxis.…”