title: Unrecognized hand ischemia after intraarterial drug injection: successful management of a "near miss" event.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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 (Ambientrade mark) 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Orthopedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado, USA. kyros.ipaktchi@dhha.org.
authors.forename: Kyros
authors.initials: K
authors.lastname: Ipaktchi
authors.forename: Ramin
authors.initials: R
authors.lastname: Ipaktchi
authors.forename: Andreas D
authors.initials: AD
authors.lastname: Niederbichler
authors.forename: Peter M
authors.initials: PM
authors.lastname: Vogt
authors.forename: Karsten
authors.initials: K
authors.lastname: Knobloch