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Further treatments for cytotoxic extravasations.

⁰⁰¹ Give hydrocortisone via the venflon and s/c hydrocortisone as 0.2ml multiple injections around the circumference of the affected area

^1. For the next 7-14 days apply DSMO every 6 hours, alternating with topical hydrocortisone cream every 6 hours (a preparation applied every 3 hours on an alternate basis)

^2. Manage the situation symptomatically.

3. At 8-12 hours post incidence apply DSMO 2-hourly for the next 24 hours, and then 4 times a day for a further 10-14 days.

^4. Apply warm compressions g alternated with the application of topical antihistamine cream for the following three days.

^5. On following days apply a topical non-steroidal anti-inflammatory cream to the affected area, four times a day for the subsequent seven days.

⁶ DMSO is normally applied topically, by painting on with a ‘cotton bud’ to the affected area four times a day for 5-7 days, it could be alternated with topical hydrocortisone. Do not use an occlusive cover. If required cover once the area is dry.

Common managements for cytotoxic extravasations

a Hyaluronidase : Dilute 1500 units of hyaluronidase in 2 ml of water for injection, or 0.9% sodium chloride. Gently massage the area to facilitate dispersal.

b Thiosulphate : Infiltrate 1-3 ml of 3% isotonic sodium thiosulphate into the affected area using multiple ‘pin cushion’ injections. To achieve 3% sodium thiosulphate from the 50% vial in the extravasation kit, dilute 1.2ml of 50% to 20ml wiwth water for injection

^c Sodium Bicarbonate : Infiltrate with 1-3 ml of 2.1% sodium bicarbonate. To achieve 2.1% sodium bicarbonate from the 8.4% vial in the extravasation kit, take 5ml of 8.4% sodium bicarbonate, add 5ml of water for injection, discard 5ml of this new solution and add a further 5ml of water for injection. Caution and expert advice should be exercised, before using this antidote.

d Mixture : Infiltrate the area with 1-3 ml of a100mg hydrocortisone and 10 mg chlorpheniramine upto 10 ml with water for injection. Depending upon the size it may not be necessary to use the whole 3 mls. Large-volume extravasation may need as much as 10 ml.

e Surgical excision : Moderate to severe pain persisting for 1-2 weeks after extravasation . Wide excision with use of grafts may be indicated. Inadequate excision is associated with continuing necrosis at the margins, poor granulation and failure of engraftment.

^f hypodermoclysis : The process of giving fluids under the skin as opposed to IV

g Warm Compression W.C.C. Warm Continuous Compression. This involves applying firmly but without undue pressure a heat source (hot water bottle or small electrically heated blanket ) to the area continuously for 24 hours. The heat source should not be in direct contact with the skin and a piece of dry gauze should be laid in between. This assists the natural dispersal of the drug.

^h Cold Compression : P.C.C. Pulsed Cold Compress . This involves applying, firmly but without pressure a cold source (crushed ice, flexible cold pack or cold bandage) intermittently (for 30 minutes in every 2 hours) over the area for the first 24 hours, unless advised otherwise . The cold source should however not be placed directly on the skin and a piece of dry gauze should be laid in direct contact.

i Platinum Treatment Regime: Treatment administered within 24 hours should be ‘spread’and dilute. Injuries not treated immediately should be localise and neutral.

^j Acidic Extravasations : If the extravasation has been misdiagnosed or the volume extravasated wrongly assessed, the treatment could lead to an alkali extravasation. If this secondary extravasation occurs, it is far more serious and the consequence far more devastating than those associated with venous extravasation. Caution and expert advice should be exercised before proceeding with this specific management.