Aspirin/lidocaine/epinephrine/nitroglycerin

Abstract

Digital necrosis and lack of efficacy: case report A 57-year-old woman developed digital necrosis following treatment with lidocaine/epinephrine. Additionally, she also exhibited lack of efficacy during treatment with aspirin and nitroglycerin for digital necrosis [routes and exact duration of treatment to reaction onset not stated; not all dosages stated]. The woman presented to hand surgery department for the swelling of her right small finger. The day before, she had received a 3mL digital block of 1% lidocaine with 1:100,000 epinephrine injection for the removal of four warts. She reported that the block was placed at the volar proximal phalanx. Shortly after, she noticed swelling and blistering that progressed throughout the day. Dressings were reportedly not tight. At home, she proceeded with warm water soaks. However, the next day she returned to her dermatologist due to worsening symptoms. A large blister on the finger was drained, and she was referred for orthopedic evaluation. On examination, there was superficial skin separation with serosanguinous fluid from the proximal interphalangeal joint distally, which presented as a large blister encompassing the entire finger distally. After it was unroofed, there was superficial epidermal loss, but the exposed area appeared viable, with oozing bleeding. The nail was loose and came off with the blister. The small fingertip was cooler to touch and there was decreased light touch sensation, with pressure sensation intact. There was no indication of purulence and the finger was soft throughout. She was diagnosed with distal superficial tip necrosis secondary to lidocaine/epinephrine. The woman was treated with local wound care and was closely monitored over the next several weeks. She continued with local wound care and was prescribed aspirin and nitroglycerin [nitropaste] early to try to maximize the blood flow to the finger. But, she stopped using nitroglycerin, as she felt that it worsened the swelling. She had diffuse dorsal proximal interphalangeal joint swelling with superficial watery drainage. The distal fingertip became darker and lost all sensation by day 12 after the injection. The distal superficial tip necrosis increased from 7mm to 17mm by day 19. Approximately one month after the initial evaluation, she developed necrosis distal to the midportion of the middle phalanx, with complete firm dry gangrene and with no supple soft tissue palpable beneath. At 8 weeks after the initial presentation, amputation of the right small finger was performed. She did well with hand therapy and was discharged 13 weeks after surgery.