Stellate ganglion block (SGB) is very effective in management of chronic regional pain syndrome (CRPS-1). However, serious complication may occur due to accidental intravascular (intra-arterial) injection of local anaesthetic agents. Abdi and others, has suggested a modified technique in which fluoroscopy-guided block is given at the junction of uncinate process and body of vertebra at C7 level. In this approach vascular structures remain away from the trajectory of needle and thus avoid accidental vascular injection. We have used this technique of SGB in nine patients who were treated for CRPS-I. The blocks were effective in all the patients all the time without any vascular or other serious complication.
CRPS-I; modified technique; stellate ganglion block
Accidental intra-arterial injection of intramuscular antibiotic preparations is described in 3 cases in infants. In 2 benzathine penicillin was injected, and in 1 rolitetracycline. The clinical features are dominated by arteriolar obstruction which produces gangrene of the most severely affected limb. In addition, neuroloigcal involvement occurs when vessels to nerves or spinal cord are involved. The arteriolateral aspect of the thigh is preferable to the buttock as a site for intramuscular injection, and a short (2.5 cm) needle should be used to minimise the risk of intra-arterial injection.
The intravenous (tail vein) and intra-arterial (internal carotid artery) toxicities of 2% lidocaine, 1:100,000 epinephrine, and the combination of drugs were tested in unanesthetized rats. At least 3 doses (normally 10 animals/dose) were used per drug and route of administration; the drugs were given by bolus injection. Probit analysis of lethal dose-response curve data revealed that lidocaine, with or without epinephrine, was significantly more toxic intravenously than by internal carotid artery injection and that epinephrine potentiated the intravascular toxicity of lidocaine. These results modify proposals suggesting that local anesthetics injected accidentally into a branch of the external carotid artery may cause serious adverse reactions by flowing in retrograde fashion down to the internal carotid artery and then directly to the brain.
Accidental intra-arterial injection as a consequence of drug misuse has been described in both the upper and lower limbs. We present a case in which a drug abuser injected heroin into his femoral artery. This resulted in necrosis of the femoral artery requiring an autologous graft. A life threatening haemorrhage necessitated ligation of the common femoral artery. His limb survived.
Femoral artery necrosis; Intravenous drug abuse; Intra-arterial injection
Complications 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.
We 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.
This 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.
Clinically apparent carbon dioxide (CO2) gas embolism is uncommon, but it may be a potentially lethal complication if it occurs. We describe a 40-year-old woman who suffered a CO2 gas embolism with cardiac arrest during laparoscopic surgery for colorectal cancer and liver metastasis. Intra-abdominal pressure was controlled to less than 15 mmHg during CO2 gas pneumoperitoneum. The right hepatic vein was accidentally disrupted during liver dissection, and an emergent laparotomy was performed. A few minutes later, the end-tidal CO2 decreased, followed by bradycardia and pulseless electrical activity. External cardiac massage, epinephrine, and atropine were given promptly. Ventilation with 100% oxygen was started and the patient was moved to the Trendelenburg position. Two minutes after resuscitation was begun, a cardiac rhythm reappeared and a pulsatile arterial waveform was displayed. A transesophageal echocardiogram showed air bubbles in the right pulmonary artery. The patient recovered completely, with no cardiopulmonary or neurological sequelae.
Carbon dioxide gas embolism; Laparoscopic surgery; Transesophageal echocardiography
Some factors have been identified as contributing to medical errors, such as labels, appearance and location of ampoules. We present a case of accidental injection of tranexamic acid instead of Bupivacaine during spinal anaesthesia. One minute after the injection of 3 mL of the solution, the patient developed myoclonus of her lower extremities. Accidental intrathecal injection of the wrong drug was suspected and a used ampoule of tranexamic acid was discovered in the trash can. The ampoules of Bupivacaine (5 mg/mL, trade name “Sensovac Heavy”) and tranexamic acid (500 mg/mL, Trade name “Nexamin”) were similar in appearance. Her myoclonus was successfully treated with phenytoin, sodium valproate, thiopental sodium infusion, midazolam infusion and supportive care of haemodynamic and respiratory systems. The surgery was temporarily deferred. The patient's condition progressively improved to full recovery.
Myoclonic jerks; spinal anaesthesia; tranexamic acid
Accidental injection into the digit from an epinephrine autoinjection device can cause discoloration, pain, and paresthesias. Although loss of digit is rare, treatment in the emergency department is commonly aimed at vasodilation of the affected tissue. We report two cases of accidental injection of epinephrine into the digits that were successfully treated with subcutaneous phentolamine injection with no adverse events.
The superficial brachial artery (SBA), a branch of the axillary artery, is one of the most common arterial variations in this area. While it is more vulnerable to accidental arterial injection or injury, it could be useful for the nourishment of a medial arm skin free flap. To analyze the relationship between the SBA of axillary origin and segmental variation of the axillary artery, we dissected 304 arms of Korean cadavers. We found an SBA of axillary origin in 12.2% of cadaveric arms. Unilateral occurrence was detected in 16 cadavers and bilateral in 10. SBAs gave rise to radial and ulnar arteries in the cubital fossa (8.9%), continued in the forearm as the radial artery (2.3%), or ended in the upper arm (1.0%). The SBA ended as ulnar artery was not found in any of the cadavers. The bifurcation of the SBA into the radial and ulnar arteries, presence of an SBA that ends in the upper arm, and the lack of continuation as the ulnar artery are characteristics of SBAs in Korean cadavers.
Superficial Brachial Artery; Axillary Artery; Superficial Radial Artery; Anatomical Variation
Emergency planning for a major accidental release of chlorine gas from industrial installations into the community is outlined for emergency services and hospitals. Realistic planning has been made possible with the advent of computer models for gas dispersion which may be used to estimate the numbers of deaths and casualties, according to their severity. For most purposes sufficient accuracy may be obtained by using a small number of computer analyses for the most serious reasonably foreseeable events under typical day and night weather conditions, and allowing for the emergency response to be scaled up or down according to the size of an actual release. In highly populated areas triage should be preplanned to deal with a large number of victims; field stations will be needed for the treatment and observation of minor casualties. The management and treatment of casualties is summarised. The best protection against a gas cloud is afforded by buildings whose windows, doors, and ventilation systems have been closed. Hospitals in the vicinity of an installation should draw up plans to protect patients and staff. Coordination in a disaster will require toxicological and epidemiological expertise and hospital plans should allow for this.
A 79-year man, admitted to our emergency department after accidental falling with syncope, had pelvic fractures and complete atrioventricular (AV) block.
He received transvenous pacer placement for complete AV block and required hemodynamic stability. His heart rate was successfully controlled. However, secondary deterioration of his hemodynamics concerning of pelvic fractures was occurred and immediate trancatheter arterial embolization was performed. Final angiography showed no findings of bleeding and he was discharged intensive care unit in good condition.
Combined transarterial and transvenous interventional radiology is an effective and safety resuscitation technique for an elderly with secondary life-threatening injury after accidental falling due to life-threatening cardiac arrhythmia.
This report describes a case of accidental needlestick injury involving a live equine vaccination, Equilis StrepE. A vet presented herself to the Emergency Department having accidentally injected herself with an equine vaccination. Her left thumb (injury site) was inflamed and had lymphangitis progressing proximally along her left arm. Her inflammatory markers were not raised. The swelling, erythma and lymphangitis had improved markedly with intravenous antibiotics. She had no sequelae at follow-up. Equilis StrepE is a vaccine for submucosal administration containing a modified live avirulent strain of Streptococcus equi subspecies equi (Strain TW). Group C streptococci infections are pathogenic in horses and uncommon in humans. A search of the literature revealed no prior case report of similar adverse reaction to this vaccine. The vaccine may have harmful effect on human health, if injected accidentally but more evidence needs to be collected.
Accidental hypothermia complicated by cardiac arrest carries a high mortality rate in urban areas. For moderate hypothermia cases conventional rewarming methods are usually adequate, however in severe cases extracorporeal membrane oxygenation (ECMO) is known to provide the most efficient rewarming with complete cardiopulmonary support. We report a case of severe hypothermia complicated by prolonged cardiac arrest successfully resuscitated using ECMO.
A 45 year old female was brought to our emergency department with a core body temperature <25°C. Shortly after arrival she had witnessed cardiac arrest in the department. Resuscitative efforts were started immediately including conventional rewarming techniques, followed by ECMO support. ECMO was used successfully in this case to resuscitate this patient from prolonged arrest (3.5 hours) when conventional techniques likely would have failed. After a prolonged hospital course this patient was discharged with her baseline mental and physical capacities intact.
This case demonstrates the advantages of advanced internal rewarming techniques, such as ECMO, for quick and efficient rewarming of severely hypothermic patients. This case supports the use of ECMO in severely hypothermic patients as the standard of care.
hypothermia; cardiac arrest; extracorporeal membrane oxygenation; rewarming
In a prospective study the number of children attending the Royal Liverpool Children's Hospital (RLCH) for examination after allegations of child abuse, and the type of abuse involved, was recorded from July to December 1990. The cost to the hospital of these examinations and initial investigations was assessed. The study was carried out in the major and minor accident and emergency departments and the Rainbow Centre of the RLCH. In six months 181 children were examined. Cases of sexual abuse and non-accidental injury were seen in equal numbers. Girls outnumbered boys and 60% were referred by social services. The costs over the six month period were 31,739 pounds. The minimum projected annual cost is 63,500 pounds. We conclude that the cost of running an effective service for the initial assessment of children who are possible victims of child abuse is considerable in practical terms and in medical time.
Anaphylaxis is traditionally diagnosed and treated as an acute emergency but should be always followed by a search for specific triggers, resulting in avoidance strategies. This case report highlights the relevance of a detailed evaluation after anaphylaxis for diagnosis of a rare but potentially life‐threatening allergy. Considering the high frequency of clobutinol application, IgE‐mediated allergic hypersensitivity seems extremely rare and has to be distinguished from infection‐associated urticaria and angioedema as well as non‐specific summation effects. Accidental re‐exposure has to be strictly avoided and therefore after identification of clobutinol as the anaphylaxis trigger, the patient received detailed allergy documents including international non‐proprietary and trade names of the culprit drug.
The aim of this study is to describe the appearance of intra-arterial administration of 18F-fluorodeoxyglucose (18F-FDG). The effect of this finding on the standard uptake values (SUVs) is also briefly discussed. Three cases of 18F-FDG positron emission tomography (PET) scans, detected over 2 years (2004–2006), with different presentations producing hot forearm and hot hand signs are described. It was shown that intra-arterial injections of 18F-FDG producing “the hot forearm sign” and the hot hand sign” are similar to the glove pattern of uptake noted following intra-arterial administration of technetium-99m methylene diphosphonate. Following intra-arterial injection, uptake of 18F-FDG is accentuated by hypoxia and exercise. A comparison is also made with the pattern of soft-tissue uptake seen following true intravenous injections with similar pre-injection vein enhancement techniques to the intra-arterial injections. Evaluation of the maximum intensity projection (MIP) and transaxial PET/CT fusion images of the arm, forearm and hand helps to confirm the diagnosis. Hands are often not included in PET/CT imaging and therefore cases might be missed. In conclusion, intra-arterial injection of 18F-FDG produces a “hot forearm sign” and “hot hand sign”. Hands are often not included in PET/CT imaging, and therefore the presence of hot forearm sign should suggest further investigation. It should be mentioned in the radiology report, as it may alter the sensitivity and specificity of the SUV value.
Previous studies show that intravascular injection of human bone marrow stromal cells (hBMSCs) significantly improves neurological functional recovery in a rat model of intracerebral hemorrhage (ICH). In the present study, we tested the hypothesis that mannitol improves the efficiency of intra-arterial MSC delivery (i.e., fewer injected cells required for therapeutic efficacy) after ICH. There were four post-ICH groups (N=9): group 1, negative control with only intra-arterial injection of 1 million human fibroblasts in phosphate-buffered saline (PBS); group 2, intravenous injection of mannitol alone in PBS (1.5 g/kg); group 3, intra-arterial injection of 1 million hBMSCs alone in PBS; and group 4, intravenous injection of mannitol (1.5 g/kg) in PBS followed by intra-arterial injection of 1 million hBMSCs in PBS. Group 4 exhibited significantly improved neurological functional outcome as assessed by neurological severity score (NSS) and corner test scores. Immunohistochemical staining of group 4 suggested increased synaptogenesis, proliferating immature neurons, and neuronal migration. The number of hBMSCs recruited to the injured region increased strikingly in group 4. Tissue loss was notably reduced in group 4. In summary, the beneficial effects of intra-arterial infusion of MSCs are amplified with intravenous injection of mannitol. Preadministration of mannitol significantly increases the number of hBMSCs located in the ICH region, improves histochemical parameters of neural regeneration, and reduces the anatomical and pathological consequences of ICH.
bone marrow stromal cell; neural regeneration; intracerebral hemorrhage; stroke
Human angiostrongyliasis results from accidental infection with Angiostrongylus, an intra-arterial nematode. Angiostrongylus cantonensis infections result in eosinophilic meningitis, and A. costaricensis infections cause eosinophilic enteritis. Immunological methodologies are critical to the diagnosis of both infections, since these parasites cannot be isolated from fecal matter and are rarely found in cerebrospinal fluid samples. A. costaricensis and A. cantonensis share common antigenic epitopes which elicit antibodies that recognize proteins present in either species. Detection of antibodies to a 31-kDa A. cantonensis protein present in crude adult worm extracts is a sensitive and specific method for immunodiagnosis of cerebral angiostrongyliasis. The objective of the present work was to isolate and characterize the 31-kDa proteins using soluble protein extracts derived from adult female worms using both one- (1DE) and two-dimensional (2DE) gel electrophoresis. Separated proteins were blotted onto nitrocellulose and probed using sera from infected and non-infected controls. The 31-kDa band present in 1DE gels and the 4 spots identified in 2DE gels were excised and analyzed by electrospray ionization mass spectrometry. Using the highest scores obtained following Mascot analysis, amino acid sequences were obtained that matched four unique proteins: tropomyosin, the 14-3-3 phosphoserine-binding protein, a protein containing a nascent polypeptide-associated complex domain, and the putative epsilon subunit of coatomer protein complex isoform 2. Oxidative cleavage of diols using sodium m-periodate demonstrated that carbohydrate moieties are essential for the antigenicity of all four spots of the 31-kDa antigen. In this article we describe the identification of the 31-kDa antigen, and provide DNA sequencing of the targets. In conclusion, these data suggest that reactivity to the 31-kDa proteins may represent antibody recognition of more than one protein, and recombinant protein-based assays for cerebral angiostrongyliasis diagnosis may require eukaryotic expression systems to maintain antigenicity.
Abdominal angiostrongyliasis; Angiostrongylus; Eosinophilic meningitis; Immunodiagnosis; 31-kDa antigen
This case report examined the natural course of reaction after accidental intramuscular administration of high dose Bacille Calmette-Guιrin (BCG) vaccine into the anterolateral aspect of thigh of a pre-term infant as a part of routine vaccination instead of intra-dermal injection into the arm. There is no consensus on the best management of this complication, although in this case healing was prolonged but was spontaneous without anti-tubercular chemotherapy.
Bacille Calmette-Guérin; tuberculosis; vaccination
Accidental injury to the common bile duct is a rare but serious complication of laparoscopic cholecystectomy. Accurate visualization of the biliary ducts may prevent or detect injuries early. Conventional X-Ray cholangiography is often used and can reduce the severity of injury when correctly interpreted. However, it may be useful to have an imaging method that could provide real-time extra-hepatic bile duct visualization without changing the field of view from the laparoscope. The purpose of this study was to use a new NIR fluorescent agent that is rapidly excreted via the biliary route in pre-clinical models to evaluate intra-operative real time near infrared fluorescent cholangiography (NIRFC).
To investigate probe function and excretion, a lipophilic near infrared fluorescent agent with hepatobiliary excretion was injected intravenously into one group of C57/BL6 control mice and four groups of C57/BL6 mice with the following experimentally-induced conditions: a) chronic biliary obstruction, b) acute biliary obstruction c) bile duct perforation and e) choledocholithiasis, respectively. The biliary system was imaged intravitally for one hour using near-infrared fluorescence (NIRF) with an intra-operative small animal imaging system (excitation 649 nm, emission 675 nm).
The extra hepatic ducts and extra-luminal bile were clearly visible due to the robust fluorescence of the excreted fluorochrome. Twenty-five minutes after intravenous injection, the target-to-background ratio peaked at 6.40 ± 0.83 but was clearly visible for ~ sixty minutes. The agent facilitated rapid identification of biliary obstruction and bile duct perforation. Implanted beads simulating choledocholithiasis were promptly identifiable within the common bile duct lumen.
NIRF agents with hepatobiliary excretion may be used intra-operatively to visualize extra hepatic biliary anatomy and physiology. Used in conjunction with laparoscopic imaging technologies this should enhance hepatobiliary surgery.
cholangiography; fluorescence; laparoscopic cholecystectomy; complications; surgical injuries; bile duct injuries
A 75-year-old woman presented with progressing pain, cyanosis, and hypaesthesia in her left hand after an intra-articular injection with diazepam into the wrist for osteoarthritis-related pain. Due to an iatrogenic intra-arterial injection, malperfusion of the ulnar digits developed. Angiography revealed blockage of perfusion of the 4th and 5th digits. Despite intra-arterial lysis, heparinisation, and vasodilatation, perfusion could not be reinstalled. Necrosis of the distal phalanges of the 4th and 5th digits developed, which had to be treated with amputation.
The pathomechanism of tissue damage and the treatment options after intra-arterial injections are reviewed and discussed.
This investigation aimed to demonstrate the potential of intraprocedural angiographic CT in monitoring complex endovascular coil embolization of direct carotid cavernous fistulas.
Angiographic CT was performed as a dual rotational 5 s run with intraarterial contrast medium injection in two patients during endovascular coil embolization of direct carotid cavernous fistulas. Intraprocedural angiographic CT was considered helpful if conventional 2D series were not conclusive concerning coil position or if a precise delineation of the parent artery was impossible due to a complex anatomy or overlying coil material. During postprocessing multiplanar reformatted and dual volume images of angiographic CT were reconstructed.
Angiographic CT turned out to be superior in the intraprocedural visualization of accidental coil migration into the parent artery where conventional 2D-DSA series failed to reliably detect coil protrusion. The delineation of coil protrusion by angiographic CT allowed immediate correct coil repositioning to prevent parent artery compromising.
Angiographic CT can function as a valuable intraprocedurally feasible tool during complex coil embolizations of direct carotid cavernous fistulas. It allows the precise visualization of the cerebral vasculature and any accidental coil protrusion can be determined accurately in cases where conventional 2D-DSA series are unclear or compromised. Thus angiographic CT might contribute substantially to reduce procedural complications and to increase safety in the management of endovascular treatment of direct carotid cavernous fistulas.
carotid cavernous fistula, endovascular approach, transarterial coil embolization, intraprocedural angiographic CT
Transcatheter arterial chemoembolization (TACE) currently is being used as an effective palliative therapy for unresectable cancers especially hepatocelluar carcinoma (HCC). Accidental lipiodol embolism to the lungs is a rare but potentially fatal complication of TACE. This procedure involves injection of drug-eluting microspheres (LC Bead) loaded with doxorubicin, followed by embolization with embozene microspheres until stasis is evident, being used in advanced HCC. We report a patient with inoperable HCC with underlying Hepatitis C and liver cirrhosis, who developed acute lung injury following targeted chemoembolization of selective feeding hepatic artery with LC beads loaded with doxorubicin. Acute lung injury as a complication of unintended lung chemoembolization with doxorubicin has not been previously reported in the literature. Interventional radiologists screen patients for potential hepatic A-V shunt and take appropriate precautions to prevent unintended pulmonary embolization. These include appropriate selection of LC bead particle size especially in patients who are embolized with radiation pellets. This report highlights the need for a screening total body scintigraphy after injection of radionuclide Tc-99 MAA in the feeding hepatic artery to identify patients with hepatic A-V shunt. In such patients, appropriate size selection of LC bead particles is critical to prevent unintended pulmonary chemoembolization and acute lung injury. Other measures include careful patient selection, low dose of chemotherapy, and transient selective hepatic vein balloon occlusion.
Chest imaging; drug; lung injury
Haemobilia usually occurs secondary to accidental or iatrogenic hepatobiliary trauma. It can occasionally present with cataclysmal upper gastrointestinal haemorrhage posing as a life threatening emergency. Haemobilia can very rarely be a complication of acute cholecystitis. Here we report a case of haemobilia manifesting as massive gastrointestinal haemorrhage in a patient without any prior history of biliary surgery or intervention and present a brief review of literature.
A 22 year old male admitted with history suggestive of acute cholecystitis subsequently developed waxing waning jaundice and recurrent episodes of upper gastrointestinal bleed. Endoscopy showed an ulcer in the first part of duodenum with a clot, no active bleed was visible. Angiography was suggestive of a ruptured pseudoaneurysm in the vicinity of the right hepatic artery probably originating from the cystic artery. Coil embolization was tried but the coil dislodged into the right branch of hepatic artery distal to the site of pseudoaneurysm. Review of angiographic video in light of operative findings demonstrated a fistulous communication between cystic artery and gallbladder as the cause, a simultaneous cholecystoduodenal fistula was also noted. Retrograde cholecystectomy, closure of cholecystoduodenal fistula and right hepatic arteriotomy with retrieval of the endo-coil and hepatic arterial repair was performed.
Fistula between the cystic artery and gallbladder has been commonly reported to occur after laparoscopic cholecystectomy. Spontaneous fistulous communication, i.e. in the absence of any prior trauma or intervention, between cystic artery and gallbladder is rare with very few reports in literature. Aetiopathogenesis of the disease, in the context of current literature is reviewed. The diagnostic dilemma posed by the confounding finding of an ulcer in the duodenum, the iconic video angiographic depiction as also the therapeutic challenge of a failed embolization with consequent microcoil migration and primary hepatic arterial repair in the emergency situation is discussed.
Cystic artery; Pseudoaneurysm; Haemobilia; Cholecystitis; Gastrointestinal; Haemorrhage
This study examined the risk of accidental events in older adults prescribed a sedating antidepressant, long-acting benzodiazepine, short-acting benzodiazepine, and nonbenzodiazepine, relative to a reference group (selective melatonin receptor agonist).
This was a retrospective cohort analysis of older adults (≥65 years) with newly initiated pharmacological treatment of insomnia. Data were collected from the Thomson MarketScan® Medicare Supplemental and Coordination of Benefits databases (January 1, 2000, through June 30, 2006). Probit models were used to evaluate the probability of an accidental event.
Data were analyzed for 445,329 patients. Patients taking a long-acting benzodiazepine (1.21 odds ratio [OR]), short-acting benzodiazepine (1.16 OR), or nonbenzodiazepine (1.12 OR) had a significantly higher probability of experiencing an accidental event during the first month following treatment initiation compared with patients taking the reference medication (P < 0.05 for all). A significantly higher probability of experiencing an accidental event was also observed during the 3-month period following the initiation of treatment (1.62 long-acting benzodiazepine, 1.60 short-acting benzodiazepine, 1.48 nonbenzodiazepine, and 1.56 sedating antidepressant; P < 0.05).
Older adults taking an SAD or any of the benzodiazepine receptor agonists appear to have a greater risk of an accidental event compared with a reference group taking an MR.
insomnia; accidental events; benzodiazepine receptor agonist; melatonin receptor agonist; older adults