Emergency Medicine: Open Access
Open Access

Abstract

A Case of Pulseless Ventricular Tachycardia Induced by Iatrogenic Adrenaline Overdose

Kota Hoshino, Yasumasa Kawano, Reiko Yamasaki, Daiki Ohta, Takeshi Nishida and Hiroyasu Ishikura

Case: The patient was a 19-year-old male. The patient presented anaphylaxis after the administration of

phosphomycin. Adrenaline (1 mg) was intravenously administered to treat his anaphylaxis. Immediately after the injection of adrenaline, the patient lost pulse and the monitor showed ventricular tachycardia (VT). Spontaneous circulation returned 21 minutes after the onset of VF.

Outcome: We did not observe arrhythmia on the patient’s monitor during the course of his hospitalization. The cause of this pulseless VT was determined to be an iatrogenic overdose of adrenaline. After 13 days, he was discharged without hypoxic encephalopathy.

Conclusion: Safety measures to prevent the incorrect administration of adrenaline are required as soon as possible. First, medical practitioners need to attend study meetings to address their lack of knowledge in relation to the usage of adrenaline. Second, most emergency carts have adrenaline products (1 mg/ml) for CPA, not for anaphylaxis. An epinephrine autoinjector (EpiPen®) for anaphylaxis should be put into emergency carts.