WhiteCoat

What’s The Diagnosis #17

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.

Thumb Sting

EpiPen

 

 

 

 

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.

Older studies recommended phentolamine injection for treatment of adrenaline autoinjector injuries.

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.
Ouch.

EpiPen Auvi-Q cost

Epinephrine 1mg cost

 

11 Responses to “What’s The Diagnosis #17”

  1. Greg says:

    She injected herself in the thumb with the EpiPen. Monitor for short time and send home.

    I bet $250 for the epipen.

    Greg

  2. Peter says:

    I agree with Greg on the diagnosis. The pen will be free to her since she’s on medicaid as will the visit to see you in the ED. It will cost the taxpayers several hundred dollars. Also, she wants a sandwich and a cab voucher and some more blankets.

    • Ed says:

      I’m with Greg as to the diagnosis, and with Peter as to the cost. Only a Medicaid patient who feels entitled to all-you-can-eat “free” healthcare would front up to the ER with just “moderate pain in her thumb, but no other symptoms”.

  3. Paul says:

    I would guess the same, but my colleagues precede me. Was there a wheal or any puncture mark on the other side of the thumb? The one time I set off an epipen (it was expired) I was shocked by the force of the needle deploying. I would have expected a DP fracture. Damn, that thing was scary.

    Apparently Epipens can now only be sold as a 2 pack, because 20% of people who need one dose need a second. Costco prices a 2 pack at $357.81. Want to buy one? Tough. That would be like buying a junk health insurance policy, from the scourge of which Obama protects us.

    What is the cash price of a vial of epinephrine, a 3cc syringe, and a needle?

    • Ed says:

      They make a generic Adrenaclick pen, you can get a 2-pack at Walmart or Sam’s Club for just under $185. Or if you must have the brand name Epipen and you’re cash/self-pay (uninsured or HSA), there’s a free card they’ll send you for $100 off, you can use it up to three times, so then if you get your 2-packs at K-Mart for $290-$298 (they’re cheaper than Costco on this one) and show the card you only have to pay $190.

      ^ ^ ^ as a side-note, I’ll point out that having a Major Medical (Catastrophic) policy just for big stuff, and self-paying for routine stuff out of your HSA, you learn to shop around and find the best deals like this. Because it’s your own money you’re spending!

      You know, I have never once felt like I had a “junk policy” with my MM+HSA – it was through a reputable company, no lifetime limits, no hassles the one time I had to make a claim, and it was exactly what I wanted, for an extremely reasonable price. I’m really ticked off that the paternalistic wankers in Washington who think they’re so much smarter than me and so much better at knowing what I “need” have legislated my policy, and others like it, out of existence.

      But hey! Free* birth control** pills! WHEEEEE!!!

      *for only $4,500 more per year
      **which are kind of pointless anyway, as I’m a vasectomized 49-year-old male

      • Ian Random says:

        My group policy went-up $1,200/year when in the past it went-up $60/year. I’m wanting to send a bill to the whitehouse, but I fear the SS showing-up on my front lawn.

  4. DefendUSA says:

    Hmm. She must have used the pen is my educated guess. If she’s talking, no difficulty breathing, then there is no shock. Assuming she did the pen, I bet she’s got the shakes, too. I would give tylenol and an ice pack.
    I had to have an epi injection for unknown swelling of my lips causing throat to swell and man, in 10 seconds, I swear, cured!! Didn’t give any haircuts that night to my squad boys! :)

  5. ThePack says:

    My daughter accidentally injected herself (had never touched it in the 4 years she had carried it around…opened the container one day and ouch).

    Called the pediatrician who had us go to the ED as it was in the base of her thumb and his concern was decreased blood flow to that area. Her BP was a little off, minimal edema, numbness, but other than that she was fine in a couple of hours (and learned a whole new respect for the instructions to not open the outer container unless needed).

    Epi-pen is now offering a coupon on their website (probably related to the release of the Auvi-Q injector).

  6. Dr. N says:

    If she had no symptoms I would just discharge her. And a vial of epinephrine costs somewhere in the range of $5.

  7. Wshay says:

    Agree with the self injection, had a pt come in 2 days ago with allergic reaction fire ants. Seen 3 days prior with acute anaphylaxis , did not fill her script for epi due to cost $300+, because they only come in packs of 2.

  8. Dr. Defensivemedicine says:

    “Nevertheless, because is has been well shown that phentolamine decreases the duration of epinephrine-induced vasoconstriction time in the human finger, it is the opinion of the authors that treatment of high-dose epinephrine injuries with 1 mg/kg of phentolamine may be of value to decrease ischemia reperfusion pain and possible neuropraxia, as well as possibly decreasing the possible risk of ischemic injury in patients with preexisting finger vascular insufficiency.”

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526033/

    Now doctor, why on earth did you discharge this patient without treatment when it’s CLEAR that treating her would have reduced her pain and spared her from a lifetime of neuropathy? Ladies and gentlemen of the jury, you can clearly see based on Dr. FMG the Neurologist’s testimony that Dr. XYZ violated the standard of care.

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