Abstract
To the Editor:
We sincerely thank Dr Van Tilburg for calling attention to the adverse effect of accidental digital injection of epinephrine. As Muck et al (from Dr Van Tilburg's excellent list of references) described, the majority of such accidental injections resolved spontaneously or with warm compresses, but 23% of such cases received pharmacologic treatment. 1 The incidence of accidental injections is estimated to be 1 per 50,000 injections of epinephrine, but the true incidence is likely higher as a consequence of under-reporting. 2
As for the extent of anaphylaxis in the wilderness, the epinephrine roundtable report cited the National Outdoor Leadership School's database, that described 2 cases of anaphylaxis in 2.5 million participant-days or 20 years of operations. 3 On the other hand, Fortenberry et al (again from Dr Van Tilburg's references) described 8 cases of epinephrine administration in over 2 million visitors to a national park system. 4 So, taking both references into account, our best estimate of the extent of anaphylaxis in the wilderness may be expressed as a handful of cases per million travelers.
We appreciate Dr Van Tilburg's mountain rescue experience involving the misdiagnosis of anaphylaxis. Indeed, the epinephrine roundtable remarked that anaphylaxis may be either under-diagnosed or over-diagnosed—thereby emphasizing the importance of a good training program for providers who may be called upon to administer epinephrine. Moreover, the fundamental importance of a good training program would speak against reclassifying epinephrine autoinjectors as over-the-counter medication.
As for which providers or organizations should carry epinephrine into the field, or how to best obtain the legal support for such providers or organizations—the full answer to these questions lay beyond the scope of the roundtable discussion. Depending on its field of operations, as well as the ages and medical conditions of the people it serves, each organization must make its own risk-benefit analysis regarding the decision to carry epinephrine. The roundtable sought to provide general guidelines and academic support for those organizations whose risk-benefit analysis would weigh in favor of the decision to carry epinephrine. Future political or legal work in this area may be undertaken more properly by political-action arms of the WMS or like-minded groups.