Focal, left arm edema


• Scene – vitals
• En route – IV; temp; CBG, 2x/50mcg fentanyl, 100mcg total; arm supported with pillows
• Hospital – 1mg dilaudid, X-ray, blood labs and cultures


• Response to treatment – no change in pain from fentanyl. Numbness worsened en route
• Disposition – likely admitted with surgical consult


• Elliot Williams, Paramedic Woodburn Ambulance
• Greg Juzeler, Paramedic Woodburn Ambulance Service


• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center
• Melisa McNeil, EMT WCU

• Cellulitis

Differential Diagnosis

• Lymphangitis
• Cellulitis
• Necrotizing fasciitis
• Blood clot
• Fracture
• Abscess

Patient Workup

• Pain onset was 6 days ago after mild trauma at work; co-worker dropped a metal beam they were both carrying and extreme vibration hurt his left hand and wrist.
• Patient was seen at two different emergency rooms 2 and 4 days ago, both took X-rays; one prescribed ibuprofen and the other gave hydrocodone, last taken yesterday.
• States that today pain and swelling are much worse, and he now feels like he has a fever. Patient states he last used heroin 1 week ago, last injected heroin into left arm 2 weeks ago; injection site was vein on top of L thumb.

Physical Exam

• Extreme edema in left arm, radial pulse intact.
• Left arm skin is very tight, edema is non-pitting.
• Swelling extends up to elbow, radiates up arm into shoulder; left arm is warm to touch.
• Patient reports hand going numb en route to hospital.
• GCS – 15
• EKG – SR
• CBG – 132

Key Points

• Below are discussion points for educators to consider:
• Discussion point: difference between the dispatch information (chest pain) and chief complaint on arrival (arm pain).
• Discussion point: differentiation between injury and infection (redness, swelling, and temperature).
• Discussion point: addiction, dependence, tolerance. Does the history of drug abuse effect the outcomes of Fentanyl administration?
• Discussion point: Cellulitis treatment; drainage, antibiotics, etc… This can lead into a discussion about prehospital administration of broad spectrum antibiotics.

Editor’s Notes

It’s not uncommon for health care providers to give IV drug users complaining about pain less diligence, especially when they look like this gentleman. Be aware of your own biases. According to patient, both previous visits focused on making sure the arm wasn’t broken and didn’t fully address infection possibilities. The skin tension on the patient’s arm is similar to patients who have had their arm submerged in hot fry oil. The skin was tight enough that it was about to split around his wrist. – Elliott Williams, Paramedic on scene; Woodburn Ambulance Service

Suggested References

Cutaneous Complications of Intravenous Drug Abuse


• Gender: Male
• Age: 40 years
• Height: Not Available


• Temperature: 100.2 F/37.9 C
• Blood Pressure: 150/95
• Heart Rate: 91
• Respiratory Rate: 18
• Pulse Oximetry: 100% RA
Signs and Symptoms
6 days worsening arm pain, edema; fever


• Treated for non-specific chronic pain with opiates prior to moving to Oregon; no long taking pain medication and no longer on pain contract. No primary care in Oregon.
• Allergies: None.
• Dispatch info: Chest pain, no nausea, feels feverish (did not mention arm or swelling).


• 27 pack year smoker
• IV heroin use average 2x/day; last used 1 week ago.

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