Adding epinephrine to a local anesthetic agent increases both the amount of drug that can be administered and the duration of action.4,14 It also decreases bleeding into the surgical field. There are, however, significant drawbacks to the use of epinephrine. This includes increased pain of infiltration, increased wound inflammation, increased wound infection rates, uncomfortable side effects in susceptible patients (e.g., palpitations, tremors, syncope), and the potential for severe tissue ischemia if used in regions of end arterial circulation such as the digits, the tip of the nose, the pinna, or the penis.12 Emergency Medicine dogma cautions against the use of an epinephrine containing local anesthetic agent in these regions in order to avoid potential distal tissue infarction and necrosis. However, the clinical evidence supporting this concern is questionable, and the little that does exist is over 50 years old. A study of elective hand procedures demonstrated no adverse consequences following over 3000 digital injections of epinephrine containing local anesthetic solutions.51,52 Literature focused on the inadvertent infiltration of epinephrine into fingers via improperly used autoinjectors has failed to demonstrate a single significant case of tissue necrosis. The majority of these cases demonstrate a spontaneous return of perfusion with only conservative treatments (i.e., warm soaks and digital massage). Prolonged vasospasm and ischemia in these areas can be reversed with the subcutaneous infiltration of 1.0 mL of 1:1000 phentolamine (i.e., 1 mg) diluted with saline in a 1:1 mixture at the local anesthetic injection site.53–57 A less invasive alternative is to apply topical nitroglycerine paste to the affected area. Caution must be used when administering epinephrine to patients who are elderly, taking beta-blockers, or with a history of coronary artery disease, hypertension, hyperthyroidism, or pheochromocytoma.6,12 Inadvertent intravascular injection of epinephrine can have fatal consequences.58,59