lntra-Arterial Injection of Barbiturate--Peter Nathan
INTRA-ARTERIAL
INJECTION OF BARBITURATE
PETER NATHAN, Portland, Oregon There have been numerous instances of accidental intra-arterial injection cited in the medical literature. Early reports stemmed from the administration of anaesthetics or sedatives and more recently, drug addition has brought self-inflicted vascular injuries to the fore. Excruciating pain, ischaemic changes and eventual necrosis commonly follow the injection regardless of its source. The reader is referred to reviews by Cohen, (1948) and Stone and Donnelly (1961) for complete listings of case reports and experimental investigations of the problem. The following case report exemplifies the clinical symptoms manifested in the hand after mistaken injection of a barbituate into a peripheral artery. It is believed to be unusual in the extent to which the dry, gangrenous changes occurred and in the social purpose to which the patient applied his disabled hand prior to amputation. CASE REPORT
A thirty-eight year old male was seen nine months after injecting an aqueous suspension of four Seconal capsules (estimated 4.5 grains) into his right radial artery. His background included a long history of the use of narcotics before attempted venous injection on February 1, 1971. The patient reported that immediately after the injection he experienced excruciating pain and that his hand turned cold and purplish. Examination one hour and ten minutes after the injection revealed the affected wrist and hand to be cyanotic and cold. Radial and ulnar pulses were strong. Diffuse, extreme pain continued. Axillary blocks were performed at regular intervals following admission to relieve the pain and to control vasospasm. One hundred milligrams Papaverine were also administered intramuscularly. Relief from the pain occurred within ten minutes of each block and the colour of the dorsal skin showed gradual, though limited, improvement. On February 2, treatment was extended from nerve blocks to include antibiotics and topical application of 70% dimethyl sulfoxide (DMSO) solution. This was continued until February 5, when marked erythema proximal to the elbow was noted accompanied by a low-grade fever. The concentration of DMSO was reduced to 50°/° on February 6. A black line of demarcation was apparent at the proximal interphalangeal joint level on all digits by February 13. Although DMSO treatment continued until the author's contact with the patient in October, there was no evidence of reversal of the necrosis which followed the initial extensive vascular damage. EXAMINATION
The author examined the patient on October 28, 1971, an alert, thin man of thirty-nine. He was noted to have slight slurring of speech and some awkwardness in his gait. Specific findings in the right upper extremity included dry, gangrenous changes of all five digits extending proximally to the thenar creases and metacarpal heads. The skin was black and rigid and flexion contractures were noted at the proximal interphalangeal joint level. The metacarpophalangel joints of all five digits, as well as the interphalangeal joint of the thumb, were held in extension. A bridge of metacarpal bone appeared between the proximal viable tissue and the mummified hand (Figures 1 and 2). The H a n d - - V o l . 7
No. 2
1975
175
lntra-Arterial Injection of Barbiturate--Peter Nathan
Fig. 1. Eight months after radial artery injectionof barbituate. Fig. 2. Dorsal view. Excellent hypothenar eminence function was observed with some preservation of intrinsic function within the thenar eminence. Sensation in these areas appeared normal, with the exception of an hyperaesthetic area on the radial border of the thenar eminence. On tapping the hand proximal to the demarcation zone, pain was felt within the digits radiating to their tips. The patient reported a similar sensation after applications of DMSO. X-rays: Review of numerous X-rays taken from April 16, 1971 to October 1971 revealed the contractures at the proximal interphalangeal joints and a progressive, generalised demineralisation of the entire hand and carpus. An angiogram performed on February 14, 1972 through a right femoral approach revealed complete occlusion of the right radial artery beyond the distal forearm. No perfusion into the right hand was present beyond the deep palmar arch. TREATMENT
The patient continued in the Methadone programme while being employed in the Police Community Relations Department. In this capacity he visited various schools, churches and community groups where he had an opportunity to relate his experiences to school children and young adults in an active programme against the use of narcotics. In July 1972, the patient requested amputation of the hand. This was performed at the demarcation zone. In October 1972, a phalangisation of the metacarpus was attempted to permit active motion between the thenar and hypothenar eminences by disarticulation of the second, third and fourth metacarpals at their carpal junction (Figures 3 and 4). Active use following this procedure was not obtained. The patient requested and received a cosmetic hand. 176
The Hand--Vol. 7
No. 2
1975
Intra-Arterial Injection of Barbiturate--Peter Nathan
Fig. 3. Dorsal view after attempted phalangisation of metacarpus. Fig. 4. Palmar view--maximum abduction. The patient has continued his association with the police department. He has been released from the Methadone programme and currently denies use of any drugs. DISCUSSION
The present case illustrates the results of intra-arterial injection, a phenomenon known to trigger chemical endarteritis (Stone & Donnelly, 1961), mechanical blockage of vessels by crystal formation (Brown et al., 1968), possible vascular spasm (Burn, 1960), stasis and thrombosis (Burn, 1960; Jaccob, 1971). The patient was treated for vasospasm and for pain. Anticoagulants were not employed. Application of DMSO appears to have had value as a topical analgesic and may have acted as a surface decontaminant. After review of its experimental and clinical applications, other beneficial effects attributable to the drug do not appear to apply to this case (Jacob, 1971). ACKNOWLEDGEMENTS
The author wishes to express his gratitude to Professor Stanley Jacob, Department of Surgery, University of Oregon Medical School, for his kind referral of the patient. REFERENCES
COHEN, S. M. (1948). Accidental Intra-arterial Injection of Drugs. Lancet, 2: 361-371. STONE, H. H. and DONNELLY, C. C. (1967). The Accidental Intra-arterial Injection of Thiopental. Anaesthesia, 22: 995. The H a n d - - V o l . 7
No. 2
1975
177
Intra-Arterial Injection o[ Barbiturate--Peter Nathan
BROWN, S. S., LYONS, S. M. and DUNDEE, J. W. (1968). Intra-arterial Barbituates. A Study of some factors leading to Intravascular Thrombosis. British Journal of Anaesthesia, 40: 13-19. BURN, J. H. (1960). Why Thiopentone Injected Into An Artery May Cause Gangrene. British Medical Journal, 2: 414-416. KINMONTH, J. B. and SHEPERD, R. C. (1959). Accidental Injection Of Thiopentone Into Arteries. British Medical Journal, 2: 914-918. JACOB, S. W., ROSENBAUM, Edward E., WOOD, Don C., eds. (1971). Dimethyl Sulphoxide (in 2 vols.). Vol. I Basic Concepts in Dimethyl Sulphoxide. Dekker, New York.
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The H a n d - - V o l . 7
No. 2
1975
INTRA-ARTERIAL
INJECTION OF BARBITURATE
PETER NATHAN, Portland, Oregon There have been numerous instances of accidental intra-arterial injection cited in the medical literature. Early reports stemmed from the administration of anaesthetics or sedatives and more recently, drug addition has brought self-inflicted vascular injuries to the fore. Excruciating pain, ischaemic changes and eventual necrosis commonly follow the injection regardless of its source. The reader is referred to reviews by Cohen, (1948) and Stone and Donnelly (1961) for complete listings of case reports and experimental investigations of the problem. The following case report exemplifies the clinical symptoms manifested in the hand after mistaken injection of a barbituate into a peripheral artery. It is believed to be unusual in the extent to which the dry, gangrenous changes occurred and in the social purpose to which the patient applied his disabled hand prior to amputation. CASE REPORT
A thirty-eight year old male was seen nine months after injecting an aqueous suspension of four Seconal capsules (estimated 4.5 grains) into his right radial artery. His background included a long history of the use of narcotics before attempted venous injection on February 1, 1971. The patient reported that immediately after the injection he experienced excruciating pain and that his hand turned cold and purplish. Examination one hour and ten minutes after the injection revealed the affected wrist and hand to be cyanotic and cold. Radial and ulnar pulses were strong. Diffuse, extreme pain continued. Axillary blocks were performed at regular intervals following admission to relieve the pain and to control vasospasm. One hundred milligrams Papaverine were also administered intramuscularly. Relief from the pain occurred within ten minutes of each block and the colour of the dorsal skin showed gradual, though limited, improvement. On February 2, treatment was extended from nerve blocks to include antibiotics and topical application of 70% dimethyl sulfoxide (DMSO) solution. This was continued until February 5, when marked erythema proximal to the elbow was noted accompanied by a low-grade fever. The concentration of DMSO was reduced to 50°/° on February 6. A black line of demarcation was apparent at the proximal interphalangeal joint level on all digits by February 13. Although DMSO treatment continued until the author's contact with the patient in October, there was no evidence of reversal of the necrosis which followed the initial extensive vascular damage. EXAMINATION
The author examined the patient on October 28, 1971, an alert, thin man of thirty-nine. He was noted to have slight slurring of speech and some awkwardness in his gait. Specific findings in the right upper extremity included dry, gangrenous changes of all five digits extending proximally to the thenar creases and metacarpal heads. The skin was black and rigid and flexion contractures were noted at the proximal interphalangeal joint level. The metacarpophalangel joints of all five digits, as well as the interphalangeal joint of the thumb, were held in extension. A bridge of metacarpal bone appeared between the proximal viable tissue and the mummified hand (Figures 1 and 2). The H a n d - - V o l . 7
No. 2
1975
175
lntra-Arterial Injection of Barbiturate--Peter Nathan
Fig. 1. Eight months after radial artery injectionof barbituate. Fig. 2. Dorsal view. Excellent hypothenar eminence function was observed with some preservation of intrinsic function within the thenar eminence. Sensation in these areas appeared normal, with the exception of an hyperaesthetic area on the radial border of the thenar eminence. On tapping the hand proximal to the demarcation zone, pain was felt within the digits radiating to their tips. The patient reported a similar sensation after applications of DMSO. X-rays: Review of numerous X-rays taken from April 16, 1971 to October 1971 revealed the contractures at the proximal interphalangeal joints and a progressive, generalised demineralisation of the entire hand and carpus. An angiogram performed on February 14, 1972 through a right femoral approach revealed complete occlusion of the right radial artery beyond the distal forearm. No perfusion into the right hand was present beyond the deep palmar arch. TREATMENT
The patient continued in the Methadone programme while being employed in the Police Community Relations Department. In this capacity he visited various schools, churches and community groups where he had an opportunity to relate his experiences to school children and young adults in an active programme against the use of narcotics. In July 1972, the patient requested amputation of the hand. This was performed at the demarcation zone. In October 1972, a phalangisation of the metacarpus was attempted to permit active motion between the thenar and hypothenar eminences by disarticulation of the second, third and fourth metacarpals at their carpal junction (Figures 3 and 4). Active use following this procedure was not obtained. The patient requested and received a cosmetic hand. 176
The Hand--Vol. 7
No. 2
1975
Intra-Arterial Injection of Barbiturate--Peter Nathan
Fig. 3. Dorsal view after attempted phalangisation of metacarpus. Fig. 4. Palmar view--maximum abduction. The patient has continued his association with the police department. He has been released from the Methadone programme and currently denies use of any drugs. DISCUSSION
The present case illustrates the results of intra-arterial injection, a phenomenon known to trigger chemical endarteritis (Stone & Donnelly, 1961), mechanical blockage of vessels by crystal formation (Brown et al., 1968), possible vascular spasm (Burn, 1960), stasis and thrombosis (Burn, 1960; Jaccob, 1971). The patient was treated for vasospasm and for pain. Anticoagulants were not employed. Application of DMSO appears to have had value as a topical analgesic and may have acted as a surface decontaminant. After review of its experimental and clinical applications, other beneficial effects attributable to the drug do not appear to apply to this case (Jacob, 1971). ACKNOWLEDGEMENTS
The author wishes to express his gratitude to Professor Stanley Jacob, Department of Surgery, University of Oregon Medical School, for his kind referral of the patient. REFERENCES
COHEN, S. M. (1948). Accidental Intra-arterial Injection of Drugs. Lancet, 2: 361-371. STONE, H. H. and DONNELLY, C. C. (1967). The Accidental Intra-arterial Injection of Thiopental. Anaesthesia, 22: 995. The H a n d - - V o l . 7
No. 2
1975
177
Intra-Arterial Injection o[ Barbiturate--Peter Nathan
BROWN, S. S., LYONS, S. M. and DUNDEE, J. W. (1968). Intra-arterial Barbituates. A Study of some factors leading to Intravascular Thrombosis. British Journal of Anaesthesia, 40: 13-19. BURN, J. H. (1960). Why Thiopentone Injected Into An Artery May Cause Gangrene. British Medical Journal, 2: 414-416. KINMONTH, J. B. and SHEPERD, R. C. (1959). Accidental Injection Of Thiopentone Into Arteries. British Medical Journal, 2: 914-918. JACOB, S. W., ROSENBAUM, Edward E., WOOD, Don C., eds. (1971). Dimethyl Sulphoxide (in 2 vols.). Vol. I Basic Concepts in Dimethyl Sulphoxide. Dekker, New York.
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The H a n d - - V o l . 7
No. 2
1975
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