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High-pressure injection injury with river water
EMERGENCY CASE REPORT
High-Pressure Injection Injury with River Water Michael I. Greenberg, MD Philadelphia, Pennsylvania
A case of high pressure injection and laceration of the calf with river water is reported, the first such case appearing in the literature. As with high pressure injection of grease, paint, paint thinner, mineral spirits, diesel oil, gasoline, and turpentine, this injury is a surgical emergency. All patients must be admitted for surgical debridement, irrigation, parenteral antibiotics, and observation. River water, contaminated by sewage and industrial wastes, has great irritative and infective potential. Greenberg MI: High-pressure injection injury with river water. JACEP 7:241-242, June, 1978. injection injury, river water.
INTRODUCTION High pressure spray technique is a common mode of delivery for m a n y ind u s t r i a l substances. 1 Soft tissue injury r e s u l t i n g from the i n a d v e r t e n t injection of grease,2, a pairlt, 4,5 p a i n t t h i n n e r , m i n e r a l spirits, diesel oil, gasoline, and turpentine s under pressures of 3,000 to 7,000 lb/sq in have all been reported. Extensive destruction of tissue r e s u l t s from this injury secondary to the chemical n a t u r e of the m a t e r i a l introduced, the time i n t e r v a l from injury to t r e a t m e n t , and the a m o u n t of pressure under which the m a t e r i a l is injected. 6-s We r e p o r t the accidential injection of an u n r e p o r t e d substance, river water, to emphasize the need for p r o m p t e m e r g e n c y d e p a r t m e n t r e c o g n i t i o n and t r e a t m e n t of t h i s dangerous injury.
CASE REPORT A 22-year-old m a n presented to t h e emergency d e p a r t m e n t 30 m i n u t e s after the i n a d v e r t e n t laceration of his r i g h t calf by a high-pressure w a t e r hose which he was using to cut cinder blocks. The hose delivered w a t e r pumped into the p a t i e n t ' s job site from the n e a r b y Delaware River, an end site for much local i n d u s t r i a l waste and sewage. This polluted w a t e r was delivered at approxim a t e l y 8,000 lb/sq in. On e x a m i n a t i o n , the p a t i e n t h a d a laceration of the posterior-lateral aspect of the r i g h t calf a p p r o x i m a t e l y 4.0 cm in l e n g t h and 3.0 cm wide, e x t e n d i n g into the deep fascia. There was no active b l e e d i n g p r e s e n t and no swelling of the calf. All motor, sensory, and v a s c u l a r aspects of the limb were intact. An x - r a y film (Figures 1 and 2) r e v e a l e d air e x t e n d i n g into the soft tissue about the knee and into the s u p r a p a t e l l a r b u r s a as well. The p a t i e n t was a d m i t t e d to the surgical service for operative debridement, irrigation, p a r e n t e r a l antibiotics, and observation. However, the a t t e n d i n g surgeon opted to t r e a t the p a t i e n t and discharge him i m m e d i a t e l y . The wound was cleaned, debrided, and oral antibiotics were begun. The p a t i e n t was i n s t r u c t e d in local wound care and a follow-up clinic visit was arranged. From the Section of Emergency Medicine, The Medical College of Pennsylvania, Philadelphia, Pennsylvania. Address for reprints: Michael I. Greenberg, MD, Section of Emergency Medicine, The Medical College of Pennsylvania, 3300 Henry Avenue, Philadelphia, Pennsylvania 19129. 7:6 (June) 1978
JACEP
241/35
Seven days later, the patient a g a i n p r e s e n t e d to t h e e m e r g e n c y d e p a r t m e n t . His leg showed evidence of diffuse cellulitis w i t h o u t abscess formation. At this time, the p a t i e n t was a d m i t t e d to the hospital a n d recovered u n e v e n t f u l l y w i t h i n t r a v e n ous antibiotics, w a r m soaks, and elevation.
DISCUSSION The p a t h o p h y s i o l o g y of h i g h pressure injection injuries has been discussed in detail elsewhere.6, s-l° Several aspects of our case are unique. All previously reported cases involve h i g h - p r e s s u r e i n j e c t i o n inj u r i e s to the fingers or hands. These a r e e x t r e m e l y s e r i o u s i n j u r i e s because of the m a n y delicate s t r u c t u r e s in p o t e n t i a l l y c l o s e d s p a c e s . A n y closed space infection is serious bec a u s e v a s c u l a r a n d n e u r o l o g i c aspects of l i m b s c a n be j e o p a r d i z e d . Our case d e m o n s t r a t e s t h a t injectiont y p e i n j u r i e s can occur e l s e w h e r e . B e a r i n g in m i n d the pressures, highpressure fluid injections could be at l e a s t as d e v a s t a t i n g as a g u n s h o t wound if s u s t a i n e d in the t h o r a x or abdomen. The injury reported here is s i g nificant in a n o t h e r respect as well. T h e s u b s t a n c e in q u e s t i o n , r i v e r water, is a significant biological and chemical toxin. Its i r r i t a t i v e a n d infective potential is great. This injury r e p r e s e n t s a surgical emergency. Efficient, accurate e m e r g e n c y d e p a r t m e n t e v a l u a t i o n , and t r e a t m e n t , is essential to save the limb. The first aspect of the e m e r g e n c y d e p a r t m e n t e v a l u a t i o n is the recognition of high-pressure injection inj u r y as a surgical emergency. There is no place for o u t p a t i e n t m a n a g e m e n t of t h i s p r o b l e m . A l l h i g h p r e s s u r e i n j e c t i o n s m u s t be hospitalized. Specific n o t a t i o n of the nat u r e of t h e injected s u b s t a n c e , the force of injection, the t i m e i n t e r v a l before p a t i e n t presentation, and the s t a t u s of motor, sensory and v a s c u l a r a s p e c t s of t h e i n v o l v e d p a r t u p o n p r e s e n t a t i o n , m u s t be m a d e . Deb r i d e m e n t , cleaning, i r r i g a t i o n and wound culture should be i n i t i a t e d in t h e e m e r g e n c y d e p a r t m e n t . Appro-
36/242
F i g s . 1 a n d 2. X-ray films showing air in soft tissue planes. p r i a t e p a r e n t e r a l antibiotic t h e r a p y should be s t a r t e d in the e m e r g e n c y d e p a r t m e n t in c o n s u l t a t i o n w i t h the surgeon who will s u b s e q u e n t l y care for the patient. Splinting, elevation, and t e t a n u s i m m u n i z a t i o n a n d app r o p r i a t e p a i n m e d i c a t i o n administ r a t i o n should also be accomplished in the e m e r g e n c y d e p a r t m e n t . Furt h e r m o r e , x - r a y e v a l u a t i o n i n the emergency d e p a r t m e n t of the injured a r e a is e s s e n t i a l . 11 T h i s is accomplished to a s c e r t a i n the e x t e n t of soft tissue injury and to rule out the possibility of a fracture. Finally, several i n v e s t i g a t o r s m a k e cautious recomm e n d a t i o n s for t h e use of systemic steroids in h i g h - p r e s s u r e injection injury. 4,s However, the w i d e s p r e a d use of s t e r o i d s , in t h i s s e t t i n g , s h o u l d a w a i t controlled study.
REFERENCES 1. Gelberman RH, Posch JL: Highpressure injection injuries of the hand. J Bone Joint Surg 57-A:935-937, 1975. 2. Stark HH, Wilson JN, Boyes JH: Grease-gun injuries of the hand. J Bone Joint Surg 43-A:485-491, 1961.
JACEP
3. Tanzier RC: Grease-gun type injuries of the hand. Surg Clin North Am 43:1277-1282, 1963. 4. Gillespie CA, Rodeheaver GT, Smith S, et al: Airless paint gun injuries: Definition and management. Am J Surg 126:383-391, 1974. 5. Stark HH, Ashworth CR, Boyes JH: Paint-gun injuries of the hand. J Bone Joint Surg 43-A:637-647, 1967. 6. Kaufman HD: The clinicopathological correlation of high-pressure injection injuries, Br J Surg 55:214-218, 1968. 7. Parks BJ, Horner RL, Trimble C: Emergency treatment of high-pressure injection injurie:s of the hand. JACEP 4:216-217, 1975. 8. Ramos H, Posch JL, Lie KK: Highpressure injection injuries of the hand. Plast Reconstr Surg 45"-221-226, 1970. 9. Phelps DB, Hastings H, Boswick JA: Systemic corticosteroid therapy for highpressure injection injuries of the hand. J Trauma 17:206-210, 1976. 10. Silsby JJ: Pressure gun injection injuries of the hand. West J Med 125:271276, 1976. 11. O'Reilly RJ, Blatt G: Accidental high-pressure injection gun injuries of the hand. J Trauma 15:24-31, 1975.
7:6 (June) 1978
High-Pressure Injection Injury with River Water Michael I. Greenberg, MD Philadelphia, Pennsylvania
A case of high pressure injection and laceration of the calf with river water is reported, the first such case appearing in the literature. As with high pressure injection of grease, paint, paint thinner, mineral spirits, diesel oil, gasoline, and turpentine, this injury is a surgical emergency. All patients must be admitted for surgical debridement, irrigation, parenteral antibiotics, and observation. River water, contaminated by sewage and industrial wastes, has great irritative and infective potential. Greenberg MI: High-pressure injection injury with river water. JACEP 7:241-242, June, 1978. injection injury, river water.
INTRODUCTION High pressure spray technique is a common mode of delivery for m a n y ind u s t r i a l substances. 1 Soft tissue injury r e s u l t i n g from the i n a d v e r t e n t injection of grease,2, a pairlt, 4,5 p a i n t t h i n n e r , m i n e r a l spirits, diesel oil, gasoline, and turpentine s under pressures of 3,000 to 7,000 lb/sq in have all been reported. Extensive destruction of tissue r e s u l t s from this injury secondary to the chemical n a t u r e of the m a t e r i a l introduced, the time i n t e r v a l from injury to t r e a t m e n t , and the a m o u n t of pressure under which the m a t e r i a l is injected. 6-s We r e p o r t the accidential injection of an u n r e p o r t e d substance, river water, to emphasize the need for p r o m p t e m e r g e n c y d e p a r t m e n t r e c o g n i t i o n and t r e a t m e n t of t h i s dangerous injury.
CASE REPORT A 22-year-old m a n presented to t h e emergency d e p a r t m e n t 30 m i n u t e s after the i n a d v e r t e n t laceration of his r i g h t calf by a high-pressure w a t e r hose which he was using to cut cinder blocks. The hose delivered w a t e r pumped into the p a t i e n t ' s job site from the n e a r b y Delaware River, an end site for much local i n d u s t r i a l waste and sewage. This polluted w a t e r was delivered at approxim a t e l y 8,000 lb/sq in. On e x a m i n a t i o n , the p a t i e n t h a d a laceration of the posterior-lateral aspect of the r i g h t calf a p p r o x i m a t e l y 4.0 cm in l e n g t h and 3.0 cm wide, e x t e n d i n g into the deep fascia. There was no active b l e e d i n g p r e s e n t and no swelling of the calf. All motor, sensory, and v a s c u l a r aspects of the limb were intact. An x - r a y film (Figures 1 and 2) r e v e a l e d air e x t e n d i n g into the soft tissue about the knee and into the s u p r a p a t e l l a r b u r s a as well. The p a t i e n t was a d m i t t e d to the surgical service for operative debridement, irrigation, p a r e n t e r a l antibiotics, and observation. However, the a t t e n d i n g surgeon opted to t r e a t the p a t i e n t and discharge him i m m e d i a t e l y . The wound was cleaned, debrided, and oral antibiotics were begun. The p a t i e n t was i n s t r u c t e d in local wound care and a follow-up clinic visit was arranged. From the Section of Emergency Medicine, The Medical College of Pennsylvania, Philadelphia, Pennsylvania. Address for reprints: Michael I. Greenberg, MD, Section of Emergency Medicine, The Medical College of Pennsylvania, 3300 Henry Avenue, Philadelphia, Pennsylvania 19129. 7:6 (June) 1978
JACEP
241/35
Seven days later, the patient a g a i n p r e s e n t e d to t h e e m e r g e n c y d e p a r t m e n t . His leg showed evidence of diffuse cellulitis w i t h o u t abscess formation. At this time, the p a t i e n t was a d m i t t e d to the hospital a n d recovered u n e v e n t f u l l y w i t h i n t r a v e n ous antibiotics, w a r m soaks, and elevation.
DISCUSSION The p a t h o p h y s i o l o g y of h i g h pressure injection injuries has been discussed in detail elsewhere.6, s-l° Several aspects of our case are unique. All previously reported cases involve h i g h - p r e s s u r e i n j e c t i o n inj u r i e s to the fingers or hands. These a r e e x t r e m e l y s e r i o u s i n j u r i e s because of the m a n y delicate s t r u c t u r e s in p o t e n t i a l l y c l o s e d s p a c e s . A n y closed space infection is serious bec a u s e v a s c u l a r a n d n e u r o l o g i c aspects of l i m b s c a n be j e o p a r d i z e d . Our case d e m o n s t r a t e s t h a t injectiont y p e i n j u r i e s can occur e l s e w h e r e . B e a r i n g in m i n d the pressures, highpressure fluid injections could be at l e a s t as d e v a s t a t i n g as a g u n s h o t wound if s u s t a i n e d in the t h o r a x or abdomen. The injury reported here is s i g nificant in a n o t h e r respect as well. T h e s u b s t a n c e in q u e s t i o n , r i v e r water, is a significant biological and chemical toxin. Its i r r i t a t i v e a n d infective potential is great. This injury r e p r e s e n t s a surgical emergency. Efficient, accurate e m e r g e n c y d e p a r t m e n t e v a l u a t i o n , and t r e a t m e n t , is essential to save the limb. The first aspect of the e m e r g e n c y d e p a r t m e n t e v a l u a t i o n is the recognition of high-pressure injection inj u r y as a surgical emergency. There is no place for o u t p a t i e n t m a n a g e m e n t of t h i s p r o b l e m . A l l h i g h p r e s s u r e i n j e c t i o n s m u s t be hospitalized. Specific n o t a t i o n of the nat u r e of t h e injected s u b s t a n c e , the force of injection, the t i m e i n t e r v a l before p a t i e n t presentation, and the s t a t u s of motor, sensory and v a s c u l a r a s p e c t s of t h e i n v o l v e d p a r t u p o n p r e s e n t a t i o n , m u s t be m a d e . Deb r i d e m e n t , cleaning, i r r i g a t i o n and wound culture should be i n i t i a t e d in t h e e m e r g e n c y d e p a r t m e n t . Appro-
36/242
F i g s . 1 a n d 2. X-ray films showing air in soft tissue planes. p r i a t e p a r e n t e r a l antibiotic t h e r a p y should be s t a r t e d in the e m e r g e n c y d e p a r t m e n t in c o n s u l t a t i o n w i t h the surgeon who will s u b s e q u e n t l y care for the patient. Splinting, elevation, and t e t a n u s i m m u n i z a t i o n a n d app r o p r i a t e p a i n m e d i c a t i o n administ r a t i o n should also be accomplished in the e m e r g e n c y d e p a r t m e n t . Furt h e r m o r e , x - r a y e v a l u a t i o n i n the emergency d e p a r t m e n t of the injured a r e a is e s s e n t i a l . 11 T h i s is accomplished to a s c e r t a i n the e x t e n t of soft tissue injury and to rule out the possibility of a fracture. Finally, several i n v e s t i g a t o r s m a k e cautious recomm e n d a t i o n s for t h e use of systemic steroids in h i g h - p r e s s u r e injection injury. 4,s However, the w i d e s p r e a d use of s t e r o i d s , in t h i s s e t t i n g , s h o u l d a w a i t controlled study.
REFERENCES 1. Gelberman RH, Posch JL: Highpressure injection injuries of the hand. J Bone Joint Surg 57-A:935-937, 1975. 2. Stark HH, Wilson JN, Boyes JH: Grease-gun injuries of the hand. J Bone Joint Surg 43-A:485-491, 1961.
JACEP
3. Tanzier RC: Grease-gun type injuries of the hand. Surg Clin North Am 43:1277-1282, 1963. 4. Gillespie CA, Rodeheaver GT, Smith S, et al: Airless paint gun injuries: Definition and management. Am J Surg 126:383-391, 1974. 5. Stark HH, Ashworth CR, Boyes JH: Paint-gun injuries of the hand. J Bone Joint Surg 43-A:637-647, 1967. 6. Kaufman HD: The clinicopathological correlation of high-pressure injection injuries, Br J Surg 55:214-218, 1968. 7. Parks BJ, Horner RL, Trimble C: Emergency treatment of high-pressure injection injurie:s of the hand. JACEP 4:216-217, 1975. 8. Ramos H, Posch JL, Lie KK: Highpressure injection injuries of the hand. Plast Reconstr Surg 45"-221-226, 1970. 9. Phelps DB, Hastings H, Boswick JA: Systemic corticosteroid therapy for highpressure injection injuries of the hand. J Trauma 17:206-210, 1976. 10. Silsby JJ: Pressure gun injection injuries of the hand. West J Med 125:271276, 1976. 11. O'Reilly RJ, Blatt G: Accidental high-pressure injection gun injuries of the hand. J Trauma 15:24-31, 1975.
7:6 (June) 1978