Fluid injection injuries – medical guidelines
Published: 05 June, 2014
Following on from surveying appropriate treatment for fluid injection injuries last month, the British Fluid Power Association (BFPA) outlines three main categories of this type of injury, and suggests a list of optimal guidelines for medical professionals to follow in the event of such an occurrence.
Although relatively rare, when a fluid injection injury does take place, swift and effective action must be the number one priority. Following on from last month’s look at how to treat such injuries, this article suggests a series of optimal procedures for medical professionals to follow in the treatment of such injuries.
First, with reference to Mason, M. L. & Queen, F. B. (1941), we would like to highlight three phases that define the natural history of high-pressure injection injuries: Acute, intermediate and late.
Acute
The immediate symptoms resulting from the injection of the foreign the material are swelling, numbness and vascular insufficiency.
This distension of the tissues may cause the pressure build-up that exceeds hydrostatic pressure, limiting tissue perfusion similar to that in compartment syndrome.
The chemical injury caused by the substance itself may result in tissue destruction and an inflammatory reaction (which leads to more swelling, which may further compromise the tissue perfusion).
Infection may occur in the necrotic tissue or from contamination from the substance injected.
Initially, the patient may complain only of mild pain and may even continue working, leading to a delay of care. The injured area may at first seem inconspicuous, presenting a small pinprick, and caregivers who may not be familiar with this injury may regard it as insignificant. The finger eventually becomes painful, numb, bloated, oedematous, tense, pale and cold.
Radiographs may help assess the extent of the spread of the injected material, which may present as air in the soft tissue, or as radiopaque material in other cases.
Intermediate
Oleomas often develop following the acute phase. These are nodular ‘tumours’ that develop as a result of a foreign body reaction to the injected material.
Oleomas may remain unchanged for years, but fibrosis often occurs with them, leading to a loss of function. Because of this, oleomas should be excised completely along with any fibrosis associated with them.
Late
Skin overlying the untreated oleoma may break down. This may lead to also and training sinus formation.
The skin becomes thick and pitted.
The ulcers and training sinuses may become infected.
Development of squamous epithelioma in the sinuses have been reported.
Optimal treatment
Now let’s look at what the BFPA recommends at optimal treatment to be carried out by medical professionals in the event of such an injury taking place:
• Early medical evaluation, including radiographic studies.
• Prompt surgical consultation. Patients treated properly within 10 hours of injury had much better outcomes than those treated in a delayed fashion.
• Administration of tetanus prophylaxis and intravenous antibiotics.
• Elevation and splinting before and after surgical exploration. Do not use cooling packs to control edema because their use may further compromise tissue perfusion.
• Surgical exploration using general anaesthesia or axillary block. Digital and local blocks may contribute to tissue oedema and are associated with worse outcomes.
• Use of an extremity tourniquet to establish a bloodless operative field after exsanguinating the arm by elevation. Esmarch bandage exsanguination may cause further spread of the injected toxins into tissue planes or compartments.
• Wide surgical exploration, including decompression of tissue compartments, debridement of non-viable tissue, and high-volume saline irrigation. Particular attention should be directed towards fluid tracking around neurovascular bundles. Flexor tendon sheaths are less likely to be involved.
• Wound cultures when appropriate to direct antibiotic therapy.
• Consider leaving the wound open, with a planned second look operative irrigation and debridement.
• Consider early amputation of a cool or poorly perfused digit.
• If oedema is significant, consider administering 100 mg of hydrocortisone intravenously every six hours until improvement is observed. Change to 25 mg of oral prednisone daily and taper over 3 to 5 days. Restart hydrocortisone if oedema, erythema or pain worsens.
• Frequent post-operative reassessment and return to the operating room if indicated.
• Early post-operative hand therapy to maximise functional outcome.
Training and guidance
The subject of hydraulic fluid injection injury is covered in existing BFPA training courses offered by the British Fluid Power Association (BFPA), incorporating the British Fluid Power Distributors Association (BFPDA):‘Hose Integrity, Inspection and Management Training Programme’ or other related BFPA courses – ‘the BFPA Foundation Course in Working Safely with Hydraulic Hose and Connectors’ and ‘the BFPA Hose Assembly Skills Training Programme’. The BFPA has also published a booklet titled ‘Fluid Injection Injury Emergency – The Facts’, priced at £3.10 for BFPA/BFPDA members and £6.25 for non-members. To order your copy of the booklet, or to enquire about the BFPA’s training courses, please email: enquiries@bfpa.co.uk or phone the BFPA on (+44)1608 647900.
