High risk and low incidence diseases: High-pressure injection injury

High-pressure injection injury is a serious condition that carries with it a high rate of morbidity and mortality.

This review highlights the pearls and pitfalls of high-pressure injection injury, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

High-pressure injection injuries are uncommon entities caused by powerful jet streams, typically from high-pressure liquid spraying machines capable of generating forces exceeding thousands of pounds per square inch (psi). These injuries usually result from accidents or equipment malfunctions and most often involve the nondominant hand. The severity of these injuries can be easily overlooked due to the initially innocuous appearance of the small entry wound. Commonly injected substances in high-pressure injuries include paint, paint thinner, automotive grease, and diesel oil. Among these, diesel oil, paint, and paint thinner are associated with higher rates of morbidity and complications. Imaging is recommended to assess the affected area, which can reveal subcutaneous emphysema with the extent observed indicating the spread of the substance. Treatment of high-pressure injection injuries requires consideration of the injury to avoid treatment delays, emergent surgical consultation, analgesic and antibiotic administration, tetanus prophylaxis if necessary, irrigation to remove any large debris, and elevation of the affected extremity. Operative intervention typically includes decompression and debridement, and early intervention is associated with improved outcomes. The use of steroids is controversial. Patients should be admitted to optimize management and for further monitoring.

An understanding of high-pressure injection injury can assist emergency clinicians in diagnosing and managing this potentially devastating injury.