Unintentional intra-arterial injection

Background

Accidental intra-arterial cannulation and administration of medications can result in severe pain, paresthesias, swelling. In severe case, direct vascular and tissue injury can progress to compartment syndrome, gangrene and even auto-amputation. This is significant and potentially severe complication of medication administration that every provider should be able to recognize. Must consider this scenario any time patient begins complaining of paresthesias or pain distal to IV site. Self-inflicted cases are also being described in patients with IVDA

Risk Factors include:

• Obesity
• Hypotension
• Procedurally difficult situations (ie. agitated patient, back of ambulance)
• Aberrant vascular anatomy

Pathophysiology: Is often multifactorial and dependent upon type of medication administered. Theories include NE induced vasospasm, crystal formation, venous constriction, lipid solubility, direct cytoxicity, endothelial damage and high osmolality. All pathways suggest the primary mediator of tissue injury is thrombosis

Medications known to cause severe injury if administered IA:

• Benzodiazepines
• Barbiturates
• Propofol
• Penicillins
• Amphetamines
• Phenothiazines
• Phenytoin
• Heroin
• Tubocurarine
• Atrcurium
• TPN
• NaHCO3
• Hypertonic Dextrose (D50)

Management:

1. Maintain catheter in place - to be used for arteriogram and administration of vasodilators
2. Thoroughly evaluate medications administered through this catheter
3. Evaluate severity of injury (soft compartments, neuro-vascular exam)
4. Consider anticoagulation with heparin initial loading dose 60IU/kg
5. Treat pain and symptoms

Treatment:

• Hypertonic dextrose - no antidote

1. Serial compartment exams
2. Pain control