What are the treatment options for burning pain in the arm at the site of an intravenous (IV) medication administration during a stress test?

Treatment of Burning Pain at IV Site After Stress Test

Immediate cooling with cold tap water (15-25°C) until pain relief, followed by topical petrolatum-based ointment and oral analgesics (acetaminophen or NSAIDs), represents the most appropriate initial management for burning pain at an IV medication site.

Immediate Management

Cooling Therapy

• Apply cold tap water (15-25°C) to the affected area immediately and continue until pain is relieved 1
• If running water is unavailable and skin is intact, ice wrapped in cloth may be used as an alternative 1
• Monitor for hypothermia during cooling, particularly if prolonged application is needed 1
• Cooling reduces pain by affecting the inflammatory cascade at the injury site 1

Important caveat: Do not apply ice directly to the skin, as this can cause tissue ischemia and further injury 1

Initial Wound Care

• Remove any jewelry from the affected arm before swelling develops to prevent constriction injury 1
• After cooling, thoroughly irrigate the area with warm or room temperature potable water to clean any residual medication 1

Topical Treatment

First-Line Topical Agents

• Apply a thin layer of petrolatum (Vaseline) or petrolatum-based antibiotic ointment (polymyxin B or bacitracin, avoiding sulfonamides) to the affected area 1
• Aloe vera gel or medical-grade honey may be applied as alternatives to promote healing and reduce pain 1
• Cover loosely with a clean, non-adherent dressing to promote healing and reduce infection risk 1

Alternative Topical Options for Persistent Pain

• High-strength topical corticosteroids may be considered if inflammatory response is significant 2
• Topical emollients and petrolatum-based products can provide barrier protection 2
• Dimethicone may be offered as an alternative to petrolatum 2

Pain Management

Oral Analgesics

• Administer acetaminophen or NSAIDs as first-line oral analgesics for pain relief 1
• Consider multimodal analgesia combining both acetaminophen and NSAIDs if pain is significant 1
• For severe or refractory burning pain, gabapentin has demonstrated significant efficacy in reducing neuropathic-type pain symptoms 3

Clinical pearl: Burning sensations specifically may indicate developing neuropathic pain characteristics, which respond better to gabapentin than traditional analgesics 3

Escalation for Severe Pain

• If pain is severe and unresponsive to oral medications, small intravenous opioid boluses titrated against effect may be appropriate 4
• Oral antihistamines can be added for associated pruritus or inflammatory symptoms 2

Monitoring and Follow-Up

Red Flags Requiring Immediate Medical Attention

• Seek immediate evaluation if burning pain involves significant skin changes (blistering, skin sloughing, or erythema spreading beyond the IV site) 2
• Progressive pain despite initial treatment measures 1
• Signs of infection (increasing warmth, purulence, fever, or red streaking) 1
• Development of numbness, tingling, or other neuropathic symptoms suggesting nerve injury 3
• Severe pain unresponsive to first-line treatments 1

Risk Factors for Chronic Pain Development

• History of substance abuse or tobacco use increases risk of progression to chronic neuropathic pain 3
• Burning sensation as the primary pain descriptor is associated with refractory pain outcomes 3
• Patients with these risk factors warrant closer follow-up and earlier consideration of neuropathic pain medications 3, 5

Common Pitfalls to Avoid

• Do not apply ice directly to the burn site as it produces tissue ischemia 1
• Avoid prolonged cold exposure, which can cause further tissue injury 1
• Do not leave blisters intact if they develop—this recommendation applies to thermal burns, not chemical/medication injuries 1
• NSAIDs should be used cautiously if there are concerns about vascular complications, though they remain appropriate for localized pain management 2

Special Considerations

If Extravasation is Suspected

If the burning pain suggests medication extravasation (vesicant stress test medication leaked into tissues), the management approach remains similar but requires more aggressive monitoring for tissue necrosis 2. Elevation of the extremity may provide additional symptomatic relief 2.

Duration of Treatment

• Most localized IV site reactions resolve within days with conservative management 1
• If pain persists beyond 6 months, this constitutes chronic neuropathic pain requiring specialized pain management 3, 5
• Early initiation of gabapentin (within the first few weeks) may prevent progression to chronic pain in high-risk patients 3