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Epinephrine/lidocaine/nitroglycerin Digital ischaemia following accidental injection (occupational exposure) and lack of efficacy: case report

A 26-year-old woman developed digital ischaemia following accidentally injecting (occupational exposure) epinephrine in her right index finger while handling auto-injector pen epinephrine pen [EpiPen]. Additionally, she exhibited lack of efficacy with nitroglycerin and lidocaine for digital ischaemia. The woman, who was a pharmacist, was brought to an emergency department (ED). She was a new pharmacist and received only general training and orientation without specific training to injectors. She presented to the ED with pain in her right index finger following accidentally injecting (occupational exposure) epinephrine while handling auto-injector epinephrine pen [EpiPen]. She injected whole epinephrine pen containing 0.3mg of 1:1000 epinephrine into the bulb of her index finger (distal digit) at 09:15AM. At 09:30AM, she presented to the ED, and then she left. She was called back at 10:30AM. She was moved to the procedure room. She appeared well. She reported no pain or other symptoms, but she had a small needle puncture wound on the tip of her index finger. All other examinations were normal. The right index finger was pale, with an obvious needle entry point at the index bulb, which was black. The capillary refill time was 4 sec in the right index finger only, while