Epi pen mishap

Discussions of the best (or worst) equipment to have on hand for use in the event of an injury during an emergency.

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Ricky Romero
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Epi pen mishap

Post by Ricky Romero » Fri Feb 29, 2008 7:58 pm

I wasn't there when this happened, but let me tell you a story. Last week at the clinic, the lead nurse had a patient that needed an epinephrine injection for a severe allergic reaction. Our emergency box had an Epi pen in it, and when she went to administer the shot she inadvertently held the device upside down. I guess she was in a hurry. She ended up shooting her thumb full of epi. Another nurse who was nearby and had actually seen this same mishap occur at another facility was quick to slather the lead nurse's thumb with nitroglycerine paste. After everything had settled down, she explained that the massive vasoconstriction that the epi would cause could result in the nurse losing a digit. For those not in the know, think of this as an accidental internal tourniquet. The nitro paste would counteract by vasodilating, thus saving the thumb. This makes sense on a very basic level theoretically, but I have yet to hear from either nurse, so I don't know how the nitro trick worked.

I suppose there's not a whole lot to discuss here, but I thought I'd share two tips with y'all.

1. Make sure you watch how you hold an Epi pen
2. Anecdotal evidence indicates that nitroglycerin paste may work as an antidote for this sort of mishap.

If anyone here has seen, done, or heard anything about the nitro thing; please weigh in. I'm curious to know if this is a standard practice. I had never heard of it, but I've also never heard of someone shooting themselves accidentally with an Epi pen, so....
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Post by roscoe » Sat Mar 01, 2008 12:44 am

OK - now I know not to hold my thumb over the end of an epipen.

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Post by JIM » Sat Mar 01, 2008 3:18 am

Well, that's just stupid, because A: the patient who needs it didn't recieve the epi, and B: That nurse needed attention for her 'injurie'

You NEVER hold the ends of any type of auto-injector...

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Post by Scaramedic » Sat Mar 01, 2008 3:40 am

I have responded to two of these accidental epi-pen in the thumb calls. The first was a teenage girl who put the needle through the tip of her thumb completely causing the needle to bend slightly as it came through the thumbnail. We had an EMT student with us at the time who I thought we were going to lose as he almost passed out after seeing the girls thumb. The second was a middle aged woman who stuck the needle into the pad portion of her thumb where it became lodged. In the ED she did get her thumb coated in NTG paste to counteract the local effects of the epi.

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Post by Grin Reaper » Sat Mar 01, 2008 10:31 am

I've always wondered just how the heck this can happen. I typically put it in the same category of 'I was cleaning my gun, and it just went off'-stories.

Good info, though.

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Post by Gunny » Sun Mar 02, 2008 12:32 am

Um...how? She had to remove the safety from the blunt end...how....?

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Post by Lurch » Sun Mar 02, 2008 2:33 am

I'm glad this was brought up, because I'd have never thought of it. We recently had to get epi-pens because of my son. I can totally see someone twisting off the safety, laying it down to wrestle with the kid, picking it up wrong, and getting stuck. Thanks for the warning.

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Post by Gunny » Mon Mar 03, 2008 12:08 am

Lurch wrote:I'm glad this was brought up, because I'd have never thought of it. We recently had to get epi-pens because of my son. I can totally see someone twisting off the safety, laying it down to wrestle with the kid, picking it up wrong, and getting stuck. Thanks for the warning.
The thing is, they're not THAT pressure sensitive. I'm still scratching my head over this one.

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Post by Ricky Romero » Mon Mar 03, 2008 9:32 pm

Well, I still have yet to hear from the unfortunate nurse (hopefully I'll see her tomorrow) but I was still struggling to figure this out. My best guess is that she made the mistake of thinking that since the needle end (black end) is blunt and smooth, and the safety is removed from the non-needle end; that the black end was safe to place her thumb over. When you've given thousands of injections with conventional syringes, it might be second nature to expect there to be a plunger of some sort. It is odd that a safety device is found on the inactive end. I can see why someone who is inexperienced or under stress might make this mistake.
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Post by thorian » Mon Mar 03, 2008 9:55 pm

I will attest to the nitro trick working for a vascular constrictor.

I got bit in the ass by a brown recluse. They have a vascular constricting venom the RN prescribed a six day cource of nitro patches to be applied specificallyl to the bite. after it was done I was fine with no necrosis of my ass and no scar. the only downer was that I would get light headed and needed to lay down anytime I got sexually aroused.
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Post by throwback » Tue Mar 04, 2008 11:40 am

We had a trainee accidentally hit himself in the hand with an auto-injector a couple year ago. we monitored him and didn't really worry about the vasoconstriction, because epi has a really short time of action in the body. It's rapid on and rapid off. Not that it couldn't cause a problem, but we didn't have one with our guy. He was just in sever tachicardia for a bit. :wink:
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Post by southalabama » Tue Mar 04, 2008 2:19 pm

Don't want to derail the thread but.........."bit in the ass by a brown recluse" deserves further explanation.

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Post by Erik » Tue Mar 04, 2008 5:35 pm

Yes, please elaborate.

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Post by Jamie » Tue Mar 04, 2008 5:48 pm

thorian wrote:I will attest to the nitro trick working for a vascular constrictor.

I got bit in the ass by a brown recluse. They have a vascular constricting venom the RN prescribed a six day cource of nitro patches to be applied specificallyl to the bite. after it was done I was fine with no necrosis of my ass and no scar. the only downer was that I would get light headed and needed to lay down anytime I got sexually aroused.
I prefer it when my wife gets light-headed and has to lie down anytime I get sexually aroused...just sayin' :twisted:

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Post by Lurch » Tue Mar 04, 2008 10:50 pm

nfa wrote:
thorian wrote: I prefer it when my wife gets light-headed and has to lie down anytime I get sexually aroused...just sayin' :twisted:

nfa
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Post by Ricky Romero » Tue Mar 04, 2008 10:57 pm

So I talked to the unfortunate nurse today and she chalks the mishap up to frazzled nerves and bad packaging. She explained that the incident occurred at the end of the shift (a notoriously busy time) which meant she was exhausted enough to make a mistake like this even though she has used the Epi pen several times previously. She also commented that the way the injector slides out of the outer packaging tube (needle end first) led to an improper grip, the black end should be red to indicate the presence of a hazard, and the outside of the injector itself should be emblazoned with a huge directional arrow. Can't say I disagree with any of that. For those of you that carry an epi autoinjector, it might be a good idea to remove it from the outer packaging and apply the directional arrow tip yourself with a Sharpie or something and reinsert it into the outer packaging so that the non-needle end slides out first.

Above all, be careful and deliberate when using these things. The patient was lucky we had two injectors on hand, otherwise things could have gone very badly for him. Most folks don't carry two, so a mistake like this could turn an emergent situation involving one person into a total mess. And she said it hurts like a bitch. The needle (which is huge, like 14g) actually got stuck in her bone, 10/10 on the pain scale, and was described as a "crushing" pain that went all the way to her elbow. Not fun. She's fine now, but she said it still hurts a little almost a week later and her tissue perfusion to the entire hand is still compromised. Capillary refill is way slower on the affected side. I guess it takes a while to fully recover.
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Post by Gunny » Wed Mar 05, 2008 5:53 pm

Her story stinks.

The epi-pen comes out of the tibe safety end first, not injector.

The injector tip is black with clear markings. The safety end is clear with a gray safety plug.

Hell the thing even has pictoral instructions on the side.

The needle's not terribly huge, 18 gauge or so.

Least she's okay.

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Post by Ricky Romero » Wed Mar 05, 2008 8:22 pm

Gunny wrote:Her story stinks.

The epi-pen comes out of the tibe safety end first, not injector.

The injector tip is black with clear markings. The safety end is clear with a gray safety plug.

Hell the thing even has pictoral instructions on the side.

The needle's not terribly huge, 18 gauge or so.

Least she's okay.

Maybe she's just looking to absolve herself of doing something stupid. I'm going to break into the E-kit tomorrow at work and see if her story checks out. The needle gauge being 14 sounded funny, but what do I know?
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Post by Scott Skawronska » Thu Mar 06, 2008 12:54 am

Years ago in EMT class our instructors demoed a live (expired) one to demonstrate the needle - punched through a piece of thin cardboard. At the time, I had no idea how to measure a gauged needle, but it was pretty big. As I recall, it could have been a 14 or a 16.

We practiced with the dummy ones, and they're flat on the "safe" end and rounded (like a bullet) on the "needle" end, at least the ones we trained on were.

And if they were in an ER, why didn't they just establish IV access and administer that way? IM is kind of a "last resort" way to push epi, IMHO, because of its short half-life.

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Post by Cybrludite » Sat Mar 08, 2008 7:50 am

Scott Skawronska wrote:And if they were in an ER, why didn't they just establish IV access and administer that way? IM is kind of a "last resort" way to push epi, IMHO, because of its short half-life.
Perhaps they were having trouble establishing a line, or the patient was bad enough off that they didn't have time to start the IV so he got the shot to stabilize him long enough to get the IV going.
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Post by Jeriah » Sat Mar 08, 2008 8:54 am

Gunny wrote:
Lurch wrote:I'm glad this was brought up, because I'd have never thought of it. We recently had to get epi-pens because of my son. I can totally see someone twisting off the safety, laying it down to wrestle with the kid, picking it up wrong, and getting stuck. Thanks for the warning.
The thing is, they're not THAT pressure sensitive. I'm still scratching my head over this one.
Not knowing anything about epi pens, it sounds easier to to than putting in an AR mag backwards, and apparently that's possible, too.

How the hell they got those rounds in the HK mag backwards, I'll never know. Maybe the pointy end made 'em go in easier?
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Post by Ricky Romero » Mon Mar 10, 2008 6:31 pm

Ok, so I checked out the "bad" packaging, and while it's not preschool level simple with big red arrows and pictures of thumbs under the universal "no" symbol, it's not that confusing. Oh, and this didn't take place in an ED, it was at a correctional facility clinic, hence the use of IM over an IV line.
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Post by 19kilo » Mon Mar 10, 2008 6:44 pm

Ricky Romero wrote:Ok, so I checked out the "bad" packaging, and while it's not preschool level simple with big red arrows and pictures of thumbs under the universal "no" symbol, it's not that confusing. Oh, and this didn't take place in an ED, it was at a correctional facility clinic, hence the use of IM over an IV line.
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Post by Scott Skawronska » Tue Mar 11, 2008 12:19 am

Oh, and this didn't take place in an ED, it was at a correctional facility clinic, hence the use of IM over an IV line.
Ah! Ok now I understand.

Well, in EMT school they taught us to administer it rounded-end against the patient, but NOT to have anything over the other end, either. It was more of a "stab-thrust" motion, and I never had my hand or any of my digits anywhere near EITHER end.

Just how I was taught. I suppose it could happen, but thank goodness not to me.

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