Download Dugan, Nicholas Abstract

Title: Presentation and management of upper extremity ischemia following self-injection of crushed
oral medication: a case series and review of the literature
Nicholas Dugan MD, Hoyune Cho MD, Christopher Scola MD, Zendee Elaba MD, Alan Babigian MD
Institution: University of Connecticut School of Medicine, Hartford Hospital
Introduction: Extremity ischemia following accidental injection of crushed oral medications is a rare
event. However, morbidity is significant with amputation rates approaching 40%. Treatment regimens
contain a wide variety of modalities all of which include anticoagulation. Successful treatment has been
observed to be dependent on rapid diagnosis and initiation of treatment, usually within 14-24 hours after
injection. Diagnosis cane sometimes be difficult because of how rare it occurs and symptoms may mimic
other disease processes such as soft tissue infections or vasculitis. We present a case series of accidental
intra-arterial injection of crushed oral drugs causing upper extremity ischemia.
Methods: Cases at Hartford Hospital involving upper extremity ischemia following injection of crushed
oral medications, were reviewed from 2006-2016. Three cases were Identified. Presentation, management
and outcomes were compared to previously reported cases and case series in the literature.
Results: Case 1: A 35 year old male with no history of drug abuse who presented with right hand pain,
erythema, and cyanosis. Pulses were intact, CT angiography demonstrated normal vasculature, and the
patient denies drug abuse. After consults to hand surgery, vascular surgery, rheumatology, and infectious
disease, a diagnosis of vasculitis vs soft tissue infection was made. He was treated with antibiotics and
steroids with some improvement. However he would return soon after discharge with worsening of his
symptoms and ulcerations on his fingertips. Pathology from a punch biopsy revealed crystals within a
arterial thrombus within the dermis. He eventually admitted to injecting crushed oral Zofran when taking
it by mouth did not relive chronic nausea he was being treated for. He was treated with pain control and
was told to follow up for debridement vs amputation once demarcation occurred. He was lost to follow
up.
Case 2: A 51year old female who presented with pain in right upper extremity immediately following
self-injection of crushed Dexedrine pills into the antecubital fossa. She presented with severe pain,
swelling, mottling, and dusky discoloration of the right forearm and hand. She had decreased sensation to
the hand and no motor ability. Hand was cool to touch. The patient was taken to the operating room
urgently for an attempt at limb salvage. Angiography demonstrated vascular spasm throughout the
forearm and thrombus with severely limited flow within the deep and superficial arch. She was treated
with a heparin drip, catheter directed TPA, and papaverine. Therapy has limited results and she would
require a fasciotomy of the forearm and hand. The extent of soft tissue damage would progress despite
therapy and amputation of the distal forearm was required.
Case 3: A 54 year old female presented approximately 12 hours after admitting to injecting crushed
Percocet into her left antecubital fossa. She complained of pain in her left forearm, on exam it was
swollen and tense, fingers had decreased sensation, and pain was elicited on passive motion. Ct
angiogram demonstrated patent vasculature. An emergent volar forearm fasciotomy was performed for
compartment syndrome. On discharge the patient had sensation and improved motor function, she was
discharged with wound care but was lost to follow up.
Conclusion: Extremity ischemia caused by accidental arterial injection of crushed oral medications is a
rare event. Diagnosis can be difficult without an admission of injection. Because early treatment is
important, clinicians should include accidental arterial injection in their differential diagnosis despite a
normal angiogram and lack of drug use history. Multiple treatment regimens have been used however
permanent injury remains prevalent. Steroid therapy has shown some promise of improving outcomes
however no significant studies have been performed.