Abstract
BackgroundComplications arising from accidental intraarterial drug injections have been described in the past. However, given the multitude of injected substances and complex pathophysiology, guidelines regarding diagnosis and management of patients with intraarterial injections remain vague. As such it remains unclear, when to expect limb ischemia and whether and for how long to monitor patients after intraarterial injections.Case reportWe present the case of a "near miss event" in an i.v. drug abuser presenting to the emergency department 3 hours after injection of water dissolved zolpidem (Ambien™) tablets into the right ulnar artery. Chief complaint was forearm pain. Clinical examination at the time revealed no concern for limb ischemia and patient was discharged. The patient returned unplanned 18 hours after injection with an ischemic right hand. Angiography revealed no flow in the distal ulnar artery and minimal flow in the palmar arch. Emergent intraarterial thrombolysis with Urokinase was performed and restored hand perfusion. Clinical follow-up 3 months after injury showed full recovery with regular recapillarisation and normal Allen test.ConclusionThis case report highlights the need to rigorously monitor patients with suspected intraarterial injections for potential delayed onset of limb ischemia. This is to our knowledge the first described case report of a successful revascularization after prolonged ischemia with delayed onset after zolpidem injection. We recommend close monitoring of these patients for at least 24 hours in addition to starting prophylactic anticoagulation.
Highlights
Complications arising from accidental intraarterial drug injections have been described in the past
On the patient side, various different pathophysiological responses, ranging from vasospasm, thrombosis, acral embolism due to non dissolvable drug components or thromboembolism can be encountered. This reflects the difficulty in treating this group of patients and the fact that there are no current universal evidence-based guidelines regarding the management of inadvertent intraarterial drug injections [3,4]. This case report describes a "near miss" event in a patient presenting with forearm pain but no signs of apparent ischemia in the emergency room after intraarterial injection of tap water dissolved zolpidem (AmbienTM) tablets – an imidazopyridine drug commonly prescribed for shortterm treatment of insomnia
The Cochrane review for lower extremity ischemia showed successful limb salvage after more than 24 hours with thrombolytic therapy, we present to our knowledge the first case describing a successful revascularization in intraarterial injection of crushed zolpidem after more than 18 hours in the upper extremity
Summary
The rising popularity in injection of crushed water dissolved tablet formulations has resulted in increased incidence of acute upper extremity ischemia seen in emergency rooms. The onset of hand ischemia can be – as seen in our case report – delayed and the risk of pending limb loss may be missed upon initial presentation. We describe the successful thrombolytic management of an ischemic hand in a patient presenting 18 hours after accidental intraarterial zolpidem injection into the ulnar artery and an initial bland, innocuous appearance 3 hours after the injury. Physicians attending primarily to these patients must be aware to this pathology and authors recommend 24 hours of close observation even in patients appearing to have a well perfused extremity. Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
