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Title: Presentation and management of upper extremity ischemia following self-injection of crushed oral medication: a case series and review of the literatureNicholas Dugan MD, Hoyune Cho MD, Christopher Scola MD, Zendee Elaba MD, Alan Babigian MDInstitution: 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. ................
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