A potentially lifesaving error: unintentional high-dose adrenaline administration in anaphylaxis-induced cardiac arrest; a case
report

A potentially lifesaving error: unintentional high-dose adrenaline administration in anaphylaxis-induced cardiac arrest; a case
report

Cardiopulmonary resuscitation, Advanced cardiac life support, Anaphylaxis, Neoplasms, Medical errors,
Emergency medicine, Crew resource management, Healthcare

Abstract

Background Cardiopulmonary resuscitation is a crucial skill for emergency medical services. As high-risk-low-
frequency events pose an immense mental load to providers, concepts of crew resource management, non-technical

skills and the science of human errors are intended to prepare healthcare providers for high-pressure situations.
However, medical errors occur, and organizations and institutions face the challenge of providing a blame-free
error culture to achieve continuous improvement by avoiding similar errors in the future. In this case, we report a
critical medical error during an anaphylaxis-associated cardiac arrest, its handling and the unexpected yet favourable
outcome for the patient.
Case presentation During an out-of-hospital cardiac arrest due to chemotherapy-induced anaphylaxis, a patient
received a 10-fold dose of epinephrine due to shortcomings in communication and standardization via a central
venous port catheter. The patient converted from a non-shockable rhythm into a pulseless ventricular tachycardia
and subsequently into ventricular fibrillation. The patient was cardioverted and defibrillated and had a return of
spontaneous circulation with profound hypotension only 6 min after the administration of 10 mg epinephrine. The
patient survived without any residues or neurological impairment.
Conclusions This case demonstrates the potential deleterious effects of shortcomings in communication and
deviation from standard protocols, especially in emergencies. Here, precise instructions, closed-loop communication
and unambiguous labelling of syringes would probably have avoided the epinephrine overdose central to this case.
Interestingly, this serious error may have saved the patient’s life, as it led to the development of a shockable rhythm.
Furthermore, as the patient was still in profound hypotension after administering 10 mg of epinephrine, this high
dose might have counteracted the severe vasoplegic state in anaphylaxis-associated cardiac arrest. Lastly, as the

patient was receiving care for advanced malignancy, the likelihood of termination of resuscitation in the initial non-
shockable cardiac arrest was significant and possibly averted by the medication error.

Felix Patricius Hans1*, Leo Benning1

, Jan-Steffen Pooth1

and Hans-Jörg Busch1

https://doi.org/10.1186/s12245-024-00663-9

2024

Peri Irawan

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