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CASE REPORT

The Management Of Hydrocarbon Toxicity Following Subcutaneous Injection: Case Report And Literature Review

J R Kennedy,  Y Nishihara, K Chettiar, J Buchanan

Address for Correspondence:
James Richard Kennedy
NHS UK
United Kingdom
E-mail :
drjrkennedy@gmail.com

Abstract:

A forty four year old gentleman presents to the Emergency Department following an injection of paint thinner bilaterally into his antecubital fossa in an attempted suicide. The injections resulted in erythematous, tense, and painful swellings over the volar aspects of his forearms. The patient underwent extensive surgical debridement and washout for toxic fat necrosis.

He consequently developed a local abscess in his left antecubital fossa requiring incision and drainage. Subsequently, the patient was transferred to a regional specialist plastics centre for secondary closure of the wounds with split skin grafting.

Reports of subcutaneous injection of hydrocarbons in the medical literature are few and far between. There are no clear guidelines for management with some articles describing an initial conservative approach, while others advocating immediate surgical exploration of the affected area. We believe that early surgical intervention was critical in preventing limb-threatening complications and that individual case reporting should be encouraged to provide evidence-based guidelines.

J.Orthopaedics 2010;7(3)e4

Keywords:

hydrocarbon toxicity; subcutaneous injection;surgical debridement

Introduction:

Hydrocarbons are a heterogeneous group of organic substances that are primarily composed of carbon and hydrogen molecules. It is abundant in modern society such as in paint, gasoline, lighter fluid, and cleaning products.

Hydrocarbon intoxication has been commonly seen in domestic accidents and attempted suicide (1). Inhalation and ingestion of hydrocarbons have been well documented and can affect many different organs causing pulmonary, cardiovascular and central nervous system toxicity. However there have been very few documented reports on subcutaneous injection of hydrocarbons. Subcutaneous injection of petroleum distillate was originally documented in World War I when soldiers injected themselves with naphtha to escape military training (3).

The affects of hydrocarbon injection locally can range from mild cutaneous irritation to myonecrosis and compartment syndrome. Systemic effects can be profound causing severe pneumonitis, neurological impairment coma and even death.

Case Report

A forty four year old gentleman presented to the Emergency Department after injecting paint thinner into both his the antecubital fossa in an attempted suicide. He used a subcutaneous insulin injection pen to inject 3ml of paint thinner into his arms. He attempted to inject the substance into his veins, but was unable to penetrate the vein. He consequently gave himself multiple subcutaneous injuries localised to his arms.

On presentation to the Emergency Department 11 hours after injecting, the patient had erythematous, tense swellings, with the left arm much more extensive than the than right (Figure a,b). He displayed no signs of systemic toxicity with normal blood haematology, biochemistry and liver function tests.

The patient was taken direct to theatre where we found extensive fat necrosis, which was debrided. His wounds were washed out, packed with gauze and left open. A prophylactic regimen of intravenous benzylpenicillin and flucloxacillin were initiated. The wounds were monitored on the ward for signs of local complications, such compartment syndrome.

Postoperatively the patient developed pyrexia and two days later he was taken back to theatre for further washout and debridement of necrotic tissue. A small amount of pus was noted at the operation and swabs were sent for microscopy and culture. Again the wounds were left open and packed with gauze with a plan to return to theatre for further inspection and debridement.

On return to theatre three days later the lesion on his left arm was debrided back to bleeding tissue with a vacuum dressing applied over a large defect. Liquefied fat necrosis was removed from a smaller defect from his right arm, and a vacuum dressing applied.

Following his third operation he improved clinically with reduced pain and improved range of movement. However five days later he developed tense collection in the left antecubital fossa accompanied with a spike in his temperature and raised inflammatory markers. He was subsequently taken to theatre for a fourth time where 50-75ml of frank pus was drained from a large abscess. Microbiology swabs taken during the procedure showed no growth confirming a sterile abscess.

The plastic surgical team were consulted from the initial presentation and he was later transferred to a tertiary centre for split skin grafting. From early on in his admission the psychiatric team were involved in the care of the patient, and he will receive ongoing care in the community.

Discussion :

Hydrocarbons are an abundant substance in modern society and are accessible in products such as gasoline, turpentine, furniture polish and household cleansers. The physical property of hydrocarbons causes toxicity by solubilizing membrane lipids and disrupting their integrity (1,5). It is postulated that the hydrogen and carbon molecules dissolve in the lipid rich membranes of the microvasculature causing a defatting process and tissue necrosis (7). They distribute along tissue planes causing release of tissue mediators and inflammation through the soft tissues (1,5).

We reviewed the documented cases in the literature of subcutaneous injection of hydrocarbons, and there is some debate in the management of these patients, in particular relating to operative or conservative management, and also in the use of antibiotics.

The timing of surgical intervention is controversial (1-5). Shusterman et al have described their management to be similar as for a chemical cellulitis. They adopt and initial conservative approach with elevation and immobilisation, monitoring closely for limb threatening complications. They do not feel immediate wide surgical exploration of the affected area is necessary but that surgical debridement may well eventually be required. (1,2).

On the contrary, Kjossev and Losanoff from Sofia Bulgaria report seeing patients with soft tissue petroleum distillate injection once or twice a year in their emergency department. They comment that subcutaneous injection of less than 2cc of petroleum distillate results in fever, leukocytosis, and local abscess or extensive cellulitis. Their policy in the management of these patients is immediate, wide surgical exploration of the affected area followed by daily dressings for monitoring of the spread of necrosis (3).

Another report by Farahvash et al from Iran published a case series of twenty-one patients presenting with hydrocarbon injection between 2001-2005 (5). They believe that from their experience early surgical intervention is important, and that a delay in surgical intervention would allow the noxious agent to cause irreversible necrosis and possible suppuration (5,6). However, having argued the above, they conclude by stating that they feel surgical intervention is necessary when conservative management fails and/or local complications occur.

The use of antibiotic therapy is another area of controversy. There are no clear controlled studies available to determine if prophylactic antibiotics are beneficial in the management of these cases (1). Shusterman et al argue that antibiotic treatment should be considered on an individual basis, but is probably not helpful in the absence of sepsis or suprainfection of the wound (1). Kjossev and Losanoff agree that abscess content is usually sterile and even argue that early surgical debridement renders systemic antibiotic therapy unnecessary (3). However since the injection of hydrocarbons invariably occurs with non-sterile injection technique, they stress that Tetanus toxoid is mandatory (3). Farahvash et al recommends that intravenous antibiotics along with elevation of affected limbs are the main part of the treatment in these patients (5).

Conclusions:

What remains clear is that the initial management of these patients, following the initial resuscitation, stabilisation and adequate analgesia, should be the prevention or supportive treatments of systemic complications (5,6). The patient should have affected extremities elevated and immobilised. Injection sites need close monitoring for local complications such as compartment syndrome.

We believe that early aggressive surgical intervention was critical in preventing further limb-threatening complications. The initial clinical findings may not be consistent with the amount of potential damage to the skin and underlying structures, and therefore early surgical exploration and debridement is essential. We believe prophylactic antibiotics do have an important role in the prevention of secondary bacterial infection and that early discussion with a microbiologist can help guide treatment. Finally, a multidisciplinary team approach with early involvement of plastic surgeons, microbiologists, psychiatric team, and other allied professionals are important in the overall care of these patients.

a:

My Disc:X249135dsc_5327.jpg

b:

My Disc:X249135dsc_5325.jpg

c:

My Disc:X249135dsc_5332.jpg

d:

My Disc:X249135dsc_5331.jpg

(a,b) Dolor rubor and tumor of antecubital fossa around the injection sites. (c,d) Pictures taken at the initial operation- Fat necrosis seen extensively on the left side.

Reference:

  1. Shusterman EM, Williams SR, Childers BJ. Soft tissue injection of hydrocarbons: a case report and review of the literature. J Emerg Med 1999;17:63-5

  2. Rush MD, Schoenfield CN, Watson WA. Skin necrosis and venous thrombosis from subcutaneous injection of charcoal lighter fluid (naptha). Am J Emerg Med 1998;16: 508-11

  3. Krastanov P et al J Emerg Med. 1999 Nov-Dec;17(6):1073-4

  4. Krastanov P, Kjossev K, Losanoff, Iliev I, Mitev P, Mutafehijski V. Subcutaneous naptha injection: a review of 48 cases. Br J Surg 1996;83(S2):65

  5. Mohammad Reza Farahvash, Rooh-Allah Yegane, Mohammad Bashashati, Mina Ahmadi, Nasim Tabrizi. Surgical approach to hydrocarbon injection in upper extremities: Case series. International Journal of Surgery 2009;7:382-386

  6. Terzi C, Bacakoglu A, Unek T, Ozkan MH. Chemical necrotizing fascitis due to household insecticide injection: is immediate radical surgical debridement necessary? Hum Exp Toxicol 2002 Dec;21(12):687-90

  7. Machle W. Gasoline intoxication JAMA 1941;117:1965-71

This is a peer reviewed paper 

Please cite as: J R Kennedy: The Management Of Hydrocarbon Toxicity Following Subcutaneous Injection: Case Report And Literature Review

J.Orthopaedics 2010;7(3)e4

URL: http://www.jortho.org/2010/7/3/e4

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