https://doi.org/10.4081/ecj.2026.14763
Acute hand ischemia after inadvertent intra-arterial injection of crushed zolpidem tablets. A case report and literature review
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Published: 24 February 2026
We report the case of a 26-year-old man with a history of drug addiction who presented to our emergency department with forearm pain and signs of acute ischemia following an inadvertent intra-arterial injection of zolpidem tablets dissolved in tap water. Although relatively rare, this occurrence carries a high risk of inducing acute limb ischemia, which can lead to severe complications such as amputation or even death. The pathophysiology of limb ischemia is multifactorial, influenced by factors including the site of injection, the physicochemical properties of the drug, and the volume injected. Symptoms can range from severe pain without visible lesions to acral ischemia. In all suspected cases of intra-arterial injection, it is crucial to gather information regarding the time of injection, the type of drug used, and whether microcrystalline cellulose is present in the formulation. Current literature underscores the importance of timely diagnosis and a multidisciplinary approach in reducing the risk of amputation. In this case, the immediate combination therapy, including ketamine, iloprost, anticoagulation, and antibiotics was effective in treating the patient.
Downloads
1. Sen S, Chini EN, Brown MJ. Complications after unintentional intra-arterial injection of drugs: risks, outcomes, and management strategies. Mayo Clin Proc 2005;80:783-95. DOI: https://doi.org/10.4065/80.6.783
2. Charney MA, Stern PJ. Digital ischemia in clandestine intravenous drug users. J Hand Surg Am 1991;16:308-10. DOI: https://doi.org/10.1016/S0363-5023(10)80116-9
3. Righini M, Angellillo-Scherrer A, Gueddi S, et al. Management of severe ischemia of the hand following intra-arterial injection. Thromb Haemost 2005;94:219-21. DOI: https://doi.org/10.1055/s-0037-1614310
4. Ipaktchi K, Ipaktchi R, Niederbichler AD, et al. Unrecognized hand ischemia after intraarterial drug injection: successful management of a "near miss" event. Patient Saf Surg 2008;2:32. DOI: https://doi.org/10.1186/1754-9493-2-32
5. Devulapalli C, Han KD, Bello RJ, et al. Inadvertent Intra-Arterial Drug Injections in the Upper Extremity: Systematic Review. J Hand Surg Am 2015;40:2262-2268.e5. DOI: https://doi.org/10.1016/j.jhsa.2015.08.002
6. Chang MY, Lin JL. Irreversible ischemic hand following intraarterial injection of zolpidem powder. J Toxicol Clin Toxicol 2003;41:1025-8. DOI: https://doi.org/10.1081/CLT-120026529
7. Boucher A, Assaad S, Pariset C, Descotes J. Ischémie digitale après injection d'un comprimé pilé de zolpidem, amélioration tardive par l'iloprost [Digital ischemia following injection of a crushed tablet of zolpidem: tardive improvement with iloprost]. Therapie 2008;63:463-7. French. DOI: https://doi.org/10.2515/therapie/2008063
8. Détriché G, Goudot G, Khider L, et al. Acute digital ischemia after arterial injection of crushed zolpidem tablets: role of microcrystalline cellulose? A case report. Front Pharmacol 2020;11:560382. DOI: https://doi.org/10.3389/fphar.2020.560382
9. Pratikto TH, Strubel G, Biro F, Kröger K. Intra-arterial injection of dissolved flunitrazepam tablets. Vasa 2004;33:52-4. DOI: https://doi.org/10.1024/0301-1526.33.1.52
10. Shukla PC. Acute ischemia of the hand following intra-arterial oxymetazoline injection. J Emerg Med 1995;13:65-70. DOI: https://doi.org/10.1016/0736-4679(94)00124-3
11. Thalhammer C, Aschwanden M, Kliem M, et al. Akute Ischämie nach intraarterieller Drogeninjektion [Acute ischemia after intraarterial drug injection]. Dtsch Med Wochenschr 2004;129:2405-8. German. DOI: https://doi.org/10.1055/s-2004-835277
12. Kai Y, Hamada J, Morioka M, et al. The utility of the microcrystalline cellulose sphere as a particulate embolic agent: an experimental study. AJNR Am J Neuroradiol 2000;21:1160-3
13. Goldberg I, Bahar A, Yosipovitch Z. Gangrene of the upper extremity following intra-arterial injection of drugs. A case report and review of the literature. Clin Orthop Relat Res 1984;188:223-9 DOI: https://doi.org/10.1097/00003086-198409000-00032
14. Gay GR. Intra-arterial injection of secobarbital sodium into the brachial artery: sequelae of a "hand trip". Anesth Analg 1971;50:979-81. DOI: https://doi.org/10.1213/00000539-197150060-00015
15. Treiman GS, Yellin AE, Weaver FA, et al. An effective treatment protocol for intraarterial drug injection. J Vasc Surg 1990;12:456-65; discussion 465-6. DOI: https://doi.org/10.1067/mva.1990.22784
16. Gould JD, Lingam S. Hazards of intra-arterial diazepam. Br Med J 1977;2:298-9. DOI: https://doi.org/10.1136/bmj.2.6082.298
17. Ghouri AF, Mading W, Prabaker K. Accidental intraarterial drug injections via intravascular catheters placed on the dorsum of the hand. Anesth Analg 2002;95:487-91, table of contents. DOI: https://doi.org/10.1213/00000539-200208000-00048
18. Kinmonth JB, Shepherd RC. Accidental injection of thiopentone into arteries: studies of pathology and treatment. BMJ 1959;2:914-8 DOI: https://doi.org/10.1136/bmj.2.5157.914
19. Sadat-Ali M, Chowdhary UM, Mohanna M, Brismar J. Drug-induced arterial spasm relieved by lidocaine: case report. Acta Chir Scand 1986;152:697-9.
20. Ali AT, Montgomery WD, Santamore WP, Spence PA. Preventing gastroepiploic artery spasm: papaverine vs calcium channel blockade. J Surg Res 1997;71:41-8. DOI: https://doi.org/10.1006/jsre.1997.5138
21. Boudaoud S, Jacob L, Lagneau F, et al. Successful treatment of vasospastic acute ischaemia with intra-arterial nicardipine. Eur J Anaesthesiol 1993;10:133-4.
22. Samuel I, Bishop CC, Jamieson CW. Accidental intra-arterial drug injection successfully treated with iloprost. Eur J Vasc Surg 1993;7:93-4. DOI: https://doi.org/10.1016/S0950-821X(05)80553-5
23. Andreev A, Kavrakov T, Petkov D, Penkov P. Severe acute hand ischemia following an accidental intraarterial drug injection, successfully treated with thrombolysis and intraarterial iloprost infusion: case report. Angiology 1995;46:963-7. DOI: https://doi.org/10.1177/000331979504601013
24. Adir Y, Halpern P, Nachum Z, Bitterman H. Hyperbaric oxygen therapy for ischaemia of the hand due to intra-arterial injection of methadone and flunitrazepam. Eur J Vasc Surg 1991;5:677-9. DOI: https://doi.org/10.1016/S0950-821X(05)80905-3
25. European Society of Cardiology. 2019 Guidelines on Acute Pulmonary Embolism (Diagnosis and Management of). Available from: https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Pulmonary-Embolism-Diagnosis-and-Management-of#
26. Vangerven M, Delrue G, Brugman E, Cosaert P. A new therapeutic approach to accidental intra-arterial injection of thiopentone. Br J Anaesth 1989;62:98-100. DOI: https://doi.org/10.1093/bja/62.1.98
27. Geschwind JF, Dagli MS, Lambert DL, Kobeiter H. Thrombolytic therapy in the setting of arterial line-induced ischemia. J Endovasc Ther 2003;10:590-4. DOI: https://doi.org/10.1177/152660280301000327
28. Bittner Ch, Zuber M, Eisner L. Akute Ischämie der Hand bei einem Drogenabhängigen nach akzidenteller intraarterieller Injektion [Acute ischemia of the hand in a drug addict after accidental intra-arterial injection]. Swiss Surg 2002;8:281-4. German. DOI: https://doi.org/10.1024/1023-9332.8.6.281
29. Rautio R, Keski-Nisula L. Inadvertent intra-arterial drug injections: the role of angiographic and clinical findings. Acta Radiol 2006;47:554-8. DOI: https://doi.org/10.1080/02841850600702184
30. Darwood R, Berridge DC, Kessel DO, Robertson I, Forster R. Surgery versus thrombolysis for initial management of acute limb ischaemia. Cochrane Database Syst Rev 2018;8:CD002784. DOI: https://doi.org/10.1002/14651858.CD002784.pub3
31. Kretz JG, Weiss E, Limuris A, et al. Arterial emboli of the upper extremity: a persisting problem. J Cardiovasc Surg (Torino) 1984;25:233-5.
32. Zeller T, Frank U, Bürgelin K, et al. Treatment of acute embolic occlusions of the subclavian and axillary arteries using a rotational thrombectomy device. Vasa 2003;32:111-6. DOI: https://doi.org/10.1024/0301-1526.32.2.111
33. Hudson DA, Duminy F. Microembolectomy in the treatment of arterial occlusion of the hand: report of two cases. J Hand Surg Am 1996;21:884-7. DOI: https://doi.org/10.1016/S0363-5023(96)80209-7
CRediT authorship contribution
Erika Poggiali is a member of the editorial board of Emergency Care Journal. There are no funding, grants, or equipment provided for the project from any source. There are not any financial benefits to the authors. This abstract and manuscript have not been presented anywhere before.
How to Cite
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
