Lacerations and Embedded Needles Caused by Epinephrine Autoinjector Use in Children - 23/02/16

Doi : 10.1016/j.annemergmed.2015.07.011

Julie C. Brown, MDCM, MPH ^a,^⁎ , Rachel E. Tuuri, MD, FAAP ^b, Sabreen Akhter, DO ^a, Lilia D. Guerra, MD ^c, Ian S. Goodman, MDCM ^d, Sage R. Myers, MD, MSCE ^e, Charles Nozicka, DO, FAAP ^f, Shannon Manzi, PharmD ^g, Katharine Long, MD ^e, Troy Turner, MD, FRCPC ^h, Gregory P. Conners, MD, MBA ⁱ, Rachel W. Thompson, MD ^j, Esther Park, PharmD ^a
^a Seattle Children’s Hospital and University of Washington, Seattle, WA
^b Medical University South Carolina Children’s Hospital, Charleston, SC
^c Lawrence General Hospital, Lawrence, MA
^d Baystate Medical Center, Springfield, MA
^e Children’s Hospital of Philadelphia, Philadelphia, PA
^f Rosalind Franklin University, Chicago, IL
^g Boston Children's Hospital, Boston, MA
^h University of Alberta, Edmonton, Alberta, Canada
ⁱ Children's Mercy Hospitals & Clinics, University of Missouri Kansas City School of Medicine, Kansas City, MO
^j Boston Medical Center and Boston University, Boston, MA

^∗Corresponding Author.

Abstract

Study objective

Epinephrine autoinjector use for anaphylaxis is increasing. There are reports of digit injections because of incorrect autoinjector use, but no previous reports of lacerations, to our knowledge. We report complications of epinephrine autoinjector use in children and discuss features of these devices, and their instructions for use, and how these may contribute to injuries.

Methods

We queried emergency medicine e-mail discussion lists and social media allergy groups to identify epinephrine autoinjector injuries involving children.

Results

Twenty-two cases of epinephrine autoinjector–related injuries are described. Twenty-one occurred during intentional use for the child’s allergic reaction. Seventeen children experienced lacerations. In 4 cases, the needle stuck in the child’s limb. In 1 case, the device lacerated a nurse’s finger. The device associated with the injury was operated by health care providers (6 cases), the patient’s parent (12 cases, including 2 nurses), educators (3 cases), and the patient (1 case). Of the 3 epinephrine autoinjectors currently available in North America, none include instructions to immobilize the child’s leg. Only 1 has a needle that self-retracts; the others have needles that remain in the thigh during the 10 seconds that the user is instructed to hold the device against the leg. Instructions do not caution against reinjection if the needle is dislodged during these 10 seconds.

Conclusion

Epinephrine autoinjectors are lifesaving devices in the management of anaphylaxis. However, some have caused lacerations and other injuries in children. Minimizing needle injection time, improving device design, and providing instructions to immobilize the leg before use may decrease the risk of these injuries.

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Plan

Introduction

Materials and Methods

Study Design and Setting

Selection of Participants

Methods of Measurement

Primary Data Analysis

Results

Characteristics of Study Subjects

Main Results

Limitations

Discussion

	Please see page 308 for the Editor’s Capsule Summary of this article.
	Supervising editor: Steven M. Green, MD
	Author contributions: JCB conceived and designed the study, supervised the conduct of the study and data collection, undertook recruitment of participating centers and patients and managed the data, including quality control. All authors contributed patient information and event details. JCB and GP reviewed the literature and made videos of devices firing and drafted the manuscript. All authors contributed substantially to manuscript revision. JCB takes responsibility for the paper as a whole.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist.
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