Review
Hazards of unintentional injection of epinephrine from autoinjectors: a systematic review

https://doi.org/10.1016/S1081-1206(10)60332-8Get rights and content

Objectives

To ascertain the rate of occurrence of unintentional injections from epinephrine autoinjectors used in the first aid treatment of anaphylaxis and to provide information about the resulting needle stick injuries.

Data Sources

A systematic review was performed. The MEDLINE, Scirus, CINAHL, ISI Web of Science, and Google Scholar databases were searched by title and abstract to identify reports of unintentional injections from epinephrine autoinjectors published in peer-reviewed journals.

Study Selection

Publications were selected for inclusion based on predefined strict criteria.

Results

In 26 reports published during the past 20 years, we identified 69 people with an unintentional injection of epinephrine from an autoinjector. More than 68% of them were reported in the past 6.3 years, 58% were female, 42% were injured in the home, and 91% sustained injury to a finger or thumb. More than 65% of the 69 individuals were evaluated in an emergency department; 13% of the 69 were not treated or were treated only with observation. Warming of the injured part was used in 25%, nitroglycerin paste application in 9%, local injections of phentolamine and/or lidocaine in 22%, and other treatments in 20%; treatment, or lack thereof, was not described in 12%. No permanent sequelae were reported.

Conclusions

The true rate of occurrence of unintentional injection of epinephrine from autoinjectors is unknown but is increasing. People at risk for anaphylaxis need regular coaching in how to use epinephrine autoinjectors correctly and safely. Improved autoinjector design will address the safety concerns identified in this review.

Section snippets

INTRODUCTION

Anaphylaxis occurs frequently in the community, in settings where health care professionals are not present. First aid treatment focuses on prompt injection of epinephrine from an autoinjector, such as EpiPen (0.3 mg) or EpiPen Jr (0.15 mg) (Dey LP, Napa, California) or Twinject 0.3 mg or Twinject 0.15 mg (Shionogi & Co Ltd, Osaka, Japan).1, 2, 3, 4, 5, 6

The true rate of occurrence of unintentional epinephrine injections from autoinjectors is currently unknown. In the past, however, they have

METHODS

A systematic review was performed to identify reports of unintentional epinephrine injections from autoinjectors published in the English language in peer-reviewed journals. The MEDLINE (January 1966 to April 30, 2008), Scirus, CINAHL (1982 to April 30, 2008), ISI Web of Science (1965 to April 30, 2008), and Google Scholar (1950 to April 30, 2008) databases were searched by title and abstract. Keywords searched included accident epinephrine, accidental epinephrine, accident adrenaline,

RESULTS

The results of the systematic review are summarized in Table 1. After the additional exclusion criteria outlined in Figure 1 were applied, 26 reports published between 1989 and April 30, 2008, were identified for review. Eleven of these were published in the emergency medicine literature, 7 in the general medical literature, 6 in the surgical literature, and 2 in the allergy literature (Table 2).7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32

DISCUSSION

We identified 69 cases of unintentional injection of epinephrine from autoinjectors that have been published in peer-reviewed journals during the past 20 years,7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 most of them in the past 6.3 years.24 The rate of occurrence of unintentional injections, which was previously projected to be 1 in 50,000 injections,10 has almost certainly been underestimated. After this systematic review was completed,

ACKNOWLEDGMENTS

We thank Rita Mrvos, BSN, et al, for providing previously unpublished data from reference 24 and Erica L. Liebelt, MD, for helpful discussions regarding reference 34. We also thank Lori McNiven for her assistance.

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    Disclosures: Dr Simons has served on the Dey Advisory Board, Intelliject Advisory Board, and Alk-Abello Advisory Board. Dr Lieberman has served as a consultant and/or speaker for Dey, Intelliject, Meda, Alcon, Schering, Glaxo, UCB, Pfizer, Genentech, Novartis, and Teva and has served on the Dey and Intelliject Advisory Boards. Dr Read is a scientific advisor, investor, and member of Intelliject. Mr Edwards is an employee and shareholder (> $10,000) of Intelliject.

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