Derm
High Pressure Injection Wound
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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
Granuloma
tous 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
Hogan (2006) J Orthop Trauma 20(7): 503-11 [PubMed]
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
Liver Function Test
s
Blood Urea Nitrogen
(BUN)
Serum Creatinine
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!
Gene
ral 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 Block
s
Avoid local ice
Complications
Pyogenic Flexor Tensynovitis
Staphylococcus aureus
is most common
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
References
Hori (2015) Crit Dec Emerg Med 29(3): 2-7
Vasilevski (2000) Am J Emerg Med 18:820-4 [PubMed]
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