Adrenaline in a (lawyer’s) finger…

Author: Ciaran Eugene McKenna / Editor: John P Sloan / Reviewer: Joe Schrieber, Mohamed Gresha / Codes: NeuP8, OptP4, PC1, PhP1, SLO4 / Published: 01/03/2021 / Reviewed: 31/01/2025

While working in the minors area of a busy teaching hospital’s Emergency Department (ED), a somewhat flustered junior doctor approaches you to confess her actions.

She explains that she has seen a 32-year-old, left hand dominant lawyer with a fish-hook embedded in the pulp of his left middle finger. After discussing with a senior, she had felt happy to administer a digital nerve block and remove the hook.

As she was tidying up, she realised that she had used 2% lidocaine with 1:200,000 adrenaline (epinephrine). She is very concerned, as she initially thought she had used plain 2% lidocaine. She fears that the lawyer will lose his finger, and initiate negligence proceedings against her.

On reviewing the patient (who is very grateful and keen to return to his fishing competition) you observe the hand as shown in the image. There is no colour or temperature difference between the anaesthetised finger and the others. His finger is completely numb.

The ring block was administered approximately 10 minutes ago. Your colleague tells you she injected 1.5-2mls of anaesthetic solution to each of the ulnar and radial apsects of the digit using a two injection, dorsal approach to the web spaces.

You quickly ascertain that the patient is a smoker (10/day for 15 years) and hypertensive. His only medications are Ramipril 5mg OD. He has no allergies.