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High Pressure Injection Wound
Aka: High Pressure Injection Wound, Spray Gun Injection Injury- Background
- Associated with occupational paint or spray gun use
- Nozzle pressures are very high (up to 10,000 psi, much higher than rated psi)
- Injected materials typically spread broadly
- Spread along neurovascular bundles, tendon sheaths and hand compartments
- Results in direct injury, local ischemia, chemical inflammation and Granulomatous reaction
- Also sets the stage for secondary infection
- Risk Factors: Amputation
- High pressure >1000 psi (43% versus 19% with low pressure injections)
- Delay to operating room >6 hours (58% versus 38% with earlier surgery)
- Injected solvents are at highest risk of amputation
- Organic solvents (paint thinner, paint and oil-based products)
- Water or air injections are not associated with amputations
- References
- Symptoms
- Non-dominant index finger most commonly affected
- Patient develops numbness, burning or pain over time
- Signs
- Deceptively small entry wound despite severe subcutaneous damage
- Labs: Agent injected has risk of hepatotoxicity and nephrotoxicity
- Management
- Immediate surgical Consultation
- Emergent surgical intervention is per surgeon's discretion
- Most injection injuries require surgical management
- Injection injuries (water and air only) without Compartment Syndrome may not require surgery
- Poison control Consultation (if indicated by substance injected)
- High risk injury!
- General measures
- Tetanus Prophylaxis
- Elevate the affected extremity
- Broad-spectrum empiric antibiotics
- Parenteral antibiotics
- Leave wounds open
- Avoid measures that results in decreased perfusion (excessive swelling and vasospasm)
- Avoid Digital Blocks
- Avoid local ice
- Immediate surgical Consultation
- Complications
- Pyogenic Flexor Tensynovitis
- Staphylococcus aureus is most common
- Pyogenic Flexor Tensynovitis
- Course
- Precaution
- Most high pressure washers provide >2000 psi at the nozzle (which may be >10x higher than rated psi)
- Amputation Incidence
- Amputation rate: 50% if injection psi >2000
- Amputation rate: <40% if injection psi <2000
- Precaution
- References
- Hori (2015) Crit Dec Emerg Med 29(3): 2-7
- Vasilevski (2000) Am J Emerg Med 18:820-4 [PubMed]