A Case of Prehospital Magnesium Sulfate Extravasation

A 73-year-old female with chronic obstructive pulmonary disease presented via emergency medical services (EMS) for shortness of breath. She was found to be hypoxic, tachypneic, and in notable distress by EMS. She was treated with inhaled albuterol, oral dexamethasone, and intravenous (IV) magnesium sulfate. Upon arrival to the emergency department her left hand was noted to have significant bleeding, and on further investigation it was determined that the IV catheter had inadvertently become dislodged causing medication extravasation, causing the magnesium to enter the subcutaneous space. The bleeding was significant and noted to be pulsatile; a tourniquet was applied; vascular damage was noted and was ultimately ligated by the trauma surgery service.

Intravenous medication administration is ubiquitous with emergency care in both the hospital and prehospital environments. Medication use is paramount to treatment of a vast majority of emergent clinical conditions; furthermore, the route of administration is often via IV in the patient with emergent illness. The placement of IV catheters is a skill that nurses, paramedics, and advanced emergency medical technicians learn early in their training. The care team is tasked with starting IV lines but also in monitoring them and ensuring medication is delivered into the systemic circulation and not elsewhere. Certain medications, notably potassium preparations and vasoactive medications, are known vesicants. We present a case of vascular extravasation of magnesium sulfate, not known for causing tissue damage, which led to significant vascular injury. This case highlights the need for prehospital professionals as well as members of the emergency department care team to be ever vigilant for medication extravasation.