A 26-year old female seeks your care for a bee sting to her thumb that occurred just prior to her arrival.
She states that she reached into her purse looking for her car keys and felt a sting to the pad of her thumb. She came directly to the emergency department after the incident because she is allergic to bees … and she always carries an EpiPen with her (shown below).
She’s currently having moderate pain in her thumb, but no other symptoms.
What’s your diagnosis and how would you treat this patient?
And take a guess how much it will cost the patient to refill her EpiPen.
Scroll below the pictures for the answer.
UPDATE NOVEMBER 28, 2013
The answer was more obvious than the treatment. This was obviously an epinephrine autoinjector injury and not a bee sting. After making the diagnosis, the question was what to do to treat the injury.
Many options exist, but in most cases no treatment is needed.
A 2002 review of 28 autoinjector injuries showed that minimal treatment usually resulted in relief. Soaking the affected area in warm water resulted in symptomatic relief in most patients. This review also noted that injection of phentolamine is not without risk. Injecting phentolamine into an already closed space may increase the pressure and diminish blood flow to the affected digit. When administered parentally, phentolamine can cause hypotension and tachycardia.
A 2009 review of reported epinephrine autoinjector injuries showed that despite our best efforts, patients get better. Out of 69 reported cases, various treatments including observation, warming of the affected area, nitroglycerin paste application, phentolamine injection, and other unidentified treatments resulted in the same outcomes: No permanent sequelae were reported.
A 2007 review in the journal Hand reviewed all literature from 1900 to 2005 and found no instances of finger necrosis, but a few cases of neuropraxia and reperfusion pain. This study was interesting in that one of the study authors actually injected three of his own fingers with varying concentrations of epinephrine so that he could document the outcomes. The description of the symptoms was interesting, and the author had significant reperfusion pain in one of his fingers and developed neuropraxia lasting 10 weeks in the finger injected with 1:1000 epinephrine.
In this patient, we used an infant heel warmer to warm the finger and observed the patient for symptoms. Her pain resolved after about an hour and she was discharged with a new prescription for an EpiPen.
How much did that prescription cost?
One online pharmaceutical sales company lists the wholesale price for two epinephrine autoinjectors (0.6 mg total) and a trainer as $426.
A syringe of 1:10,000 epinephrine (1 mg) costs $7.69.