Epinephrine
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Myocardial ischaemia following inadvertent overdose: case report A 16-year-old boy developed myocardial ischaemia following an accidental IV epinephrine overdose. The boy who had a history of attention deficit hyperactivity disorder, got stung by an insect (possibly a bee) behind his right ear. Initial reported symptoms included "weird feeling" and swelling at the site without any chest pain or shortness of breath. EMS was called, and the paramedics placed an IV. He was then administered diphenhydramine [benadryl] and was inadvertently administered the IM dose of epinephrine (1:1000; 0.3mg) as an IV rapid push. He then presented to the emergency department. Initial examinations (in the emergency department) showed a BP of 103/69mm Hg and HR of 105. After that, his BP rapidly decreased to 88/54mm Hg, so fluid administration was started along with unspecified H2-blockers and unspecified steroids. In the emergency department, he started to complain about chest pain. Therefore, an ECG was performed, which showed T-wave inversion in inferior leads indicative of acute ischemia. Hence, administration of aspirin was started. His troponin was 0.169 ng/mL and brain natriuretic peptide was 13 pg/mL. During his ED stay, he became progressively hypotensive (lowest BP was 78/58mm Hg). Therefore, an additional 20 mL/Kg crystalloid was administered. Peripheral examination showed cold extremities with poor perfusion. An echo showed qualitatively normal systolic function. Additionally, he developed hypoxaemia, requiring highflow nasal cannula to maintain oxygen level at ≥90%. A chest x-ray showed pulmonary oedema. Due to persistent cold extremities, pulmonary oedema and hypotension, epinephrine drip was initiated and titrated up to 0.1 mcg/kg/min. Later, echocardiography showed a dilated left atrium with an overall normal left ventricle systolic function and relatively hyperdynamic apical segments with normal contractility of basal segments in the presence of tachycardia, moderate mitral valve regurgitation, and abnormal inflow Doppler to the mitral valves with fused E and A waves. The echo findings were suggestive for diastolic dysfunction. Due to the significant hypoxemia, he was placed on non-invasive BiPAP ventilatory support. His troponin was 1.708 ng/mL (12h after the bee sting) and serum lactate level was 5.0 mmol/L (6h after bee sting). His clinical shock fluctuated between cold and warm in the initial hours of therapy. Overnight his BP gradually returned to baseline values. Epinephrine was then weaned off. Repeat ECG (performed 1 day after admission) showed resolution of the T-wave inversion. The pulmonary oedema gradually resolved over 2 days. Repeat echo performed on the following day and ECG done 3 days after admission, showed normalisation of the systolic and diastolic left ventricle function while off inotropic support with improved mitral regurgitation. On day 4, he was discharged with a prescription of epinephrine [EpiPen]. Tripathi S, et al. Acute myocardial ischemia following bee sting in an adolescent male:
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