• No definitive clinical trial evidence
  • Small and sporadic number of cases

• Tissue Ischaemia Score
  • Cyanosis
  • Capillary refill > 3 sec
  • Sensory deficit
  • Cool temperature

• Hospital settings
  • Unrecognised arterial cannulation
    • Basilic / brachial
    • Femoral A / V
  • Accidental injection into known arterial cannula
  • Drugs with most severe complications, eg. gangrene
    • BDZ = diazepam
      • midazolam ok
    • Penicillin-based drugs = penicillin, clindamycin
    • Thiopentone
  • Less dangerous
    • Fentanyl
    • SCh
    • Pancuronium
    • Atropine
    • Rocuronium
    • Propofol = severe pain, but no necrosis
• Recreational drugs
  • Mistaken for IV injection
  • May be ground up tablets with binding agents that were not intended for injection
  • Most common
    • Crushed BDZ, esp flunitrazepam
    • Upper extremity

• Mechanisms of injury
  • Endothelial injury
  • Vasospasm
  • Drug crystallisation
  • Thrombosis
  • Lipid soluble worse than hydrophilic drugs

• Chronic pain
• Tissue necrosis
  • May require amputation

• Analgesia
• Some benefit
  • Anticoagulation
    • IV heparin 5000 + infusion
    • APTT 2.0-2.5x normal
  • Thrombolysis
    • Intra-arterial recombinant tissue plasminogen activator
    • 8 mg IA then 1 mg/hr for 4 hours
  • Prostaglandins
    • Alternate with rTPA
    • Intra-arterial PGE1 or PGI2
    • 1.25 mcg/hr for 4 hours
• Minimal benefit
  • Vasodilators
  • Steroids
• Consult interventional radiologist and vascular surgeon
• Repeat angiography at 24 hours and Q12 h until angiographic improvement or 48 hours

• Pre-op
• Intra-op
• Post-op

The incidence, significance, and management of accidental intraarterial injection: a narrative review, CJA 2019