Therapeutic Management of Accidental Epinephrine Injection

Objective: To review the literature regarding therapeutic options for accidental epinephrine exposure via EpiPen (Mylan Specialty Inc.) autoinjector devices and to suggest a treatment algorithm based on the most common approaches found therein. Data Sources: A literature search of MEDLINE (1950-March 2012) was conducted, using the search term accidental epinephrine injection in combination with the terms adrenaline, EpiPen, anaphylaxis, autoinjector, and treatment. Case reports, case series, and systematic reviews were evaluated for efficacy and safety data. In addition, the references of the reviewed articles were examined to identify additional reports or data. Study Selection and Data Extraction: All English-language articles describing accidental exposure to epinephrine were identified. Our search included both pediatric and adult patient populations. Articles were excluded if the exposure to epinephrine was purposeful and the EpiPen described in the report was being used as intended or the outcome was not clear. Individual case reports were described in detail whereas case series and systematic reviews were included but were not described in detail. To our knowledge, there have been no clinical trials that describe or compare therapeutic options for accidental exposure to epinephrine. Data Synthesis: Accidental exposure to epinephrine is an underreported phenomenon that could warrant medical attention. The importance of this issue has recently been emphasized with the legislative requirement of many schools to store epinephrine (EpiPen) autoinjector devices. The available therapeutic options can be divided into pharmacologic and nonpharmacologic categories. The most common pharmacologic options described in the literature include phentolamine, subcutaneous terbutaline, topical nitrates, and calcium channel blockers. Nonpharmacologic options include observation and/or warm water soaks. Treatment recommendations in our proposed algorithm were based solely on the available data that we describe in our review. Conclusions: The literature did not provide clear guidance on the most appropriate management of accidental epinephrine injection. However, if pharmacologic therapy is necessary, phentolamine appears to be considered the most effective. Guidelines may be helpful in improving the management of accidental epinephrine injection, as well as in preventing unnecessary therapy

Coltsfoot as a Potential Cause of Deep Vein Thrombosis and Pulmonary Embolism in a Patient Also Consuming Kava and Blue Vervain

Objective: To report a case of deep vein thrombosis (DVT) with symptomatic pulmonary embolism (PE) possibly associated with the use of coltsfoot, kava, or blue vervain. Case Summary: A 27-year-old white male presented with leg pain and swelling, tachycardia, and pleuritic chest pain. He had no significant medical history. A medication history revealed extensive herbal medication use including: coltsfoot, passionflower, red poppy flower petals, wild lettuce, blue lily flowers, wild dagga flowers, Diviners Three Burning Blend® (comprised of salvia divinorum, blue lily, and wild dagga), kavakava, St. John\u27s Wort, blue vervain, and Dreamer\u27s Blend® (comprised of Calea zacatechichi, vervain, Entada rheedii, wild lettuce, and Eschscholzia californica). Lower extremity Doppler ultrasound and computed topography (CT) of the chest revealed DVT and PE. A hypercoagulable work-up was negative. The patient was treated with enoxaparin and warfarin and was discharged home. Discussion: While no distinct agent can be identified as a sole cause of this venous thromboembolic event, coltsfoot could potentially affect coagulation through its effect on vascular endothelial cells as they regulate nitric oxide. Nitric oxide is a known mediator of platelet activity and coagulation, particularly in the pulmonary vasculature. Kava and vervain have estrogenic properties. Conclusions: Of the medications consumed by this self-proclaimed herbalist, coltsfoot is a potential cause of venous thromboembolic disease (VTE)

Prescribing of Low-Molecular-Weight Heparin and Warfarin in Patients with Acute Venous Thromboembolism and Active Cancer

Background: Malignancy is a significant risk factor for venous thromboembolism (VTE), conferring a 4- to 7-fold increased risk in patients with cancer. Because of its effect on certain tumors, low-molecular-weight heparin (LMWH) has been evaluated as a treatment option for cancer and as an alternative to traditional warfarin therapy in patients with active cancer. LMWH is associated with a reduced recurrence of VTE, fewer adverse bleeding events, and, in some instances, decreased mortality. The American College of Chest Physicians/American Society of Clinical Oncology has recommended LMWH for at least the initial 3 to 6 months when treating VTE in patients with cancer, based on the positive outcomes associated with LMWH. Objective: The purpose of this study was to evaluate physician prescribing patterns for LMWH or warfarin in patients with acute VTE and active cancer. Methods: We conducted a retrospective chart review of hospitalized patients at a community teaching hospital with an affiliated regional cancer center located in a rural area of the United States. Patients included in the analysis had an International Classification of Diseases, Ninth Revision code indicative of any cancer type and a concomitant code for any VTE. The primary outcome was the drug prescribed at discharge for the treatment of VTE. Secondary outcomes included specialty of the prescribing physician, adverse bleeding events, and the need for transfusion. VTE treatment regimen was evaluated using the binomial test, and logistic regression analysis was used to determine correlation of the prescriber’s specialty with the patient’s prescribed regimen. Results: Of 129 patients included in the analysis, 107 (82.9%) were prescribed warfarin compared with 9 (7%) who were prescribed LMWH. Hematologists and oncologists were more likely to prescribe LMWH than general practitioners (odds ratio, 7.8; 95% hazard ratio, 1.5-42). Seven patients had a documented adverse bleeding event and 2 patients required a transfusion. Four of the 7 adverse bleeding events and 1 of the 2 transfusions occurred in the group receiving vitamin K antagonist therapy. Conclusion: Physicians in our system were significantly more likely to prescribe warfarin for acute treatment of VTE in patients with active cancer—despite consistent evidence and multiple evidence­-based guidelines recommending treatment with LMWH in this patient population. This was lower than other observations in Canadian populations but may more accurately represent nonteaching centers in the United States, particularly those in rural areas. Specialists in oncology were significantly more likely to prescribe LMWH than generalists