What are the next steps for a patient with a newly placed intravenous (IV) line in their left arm, who now experiences severe, shocking pain radiating from their upper arm to their thumb, index finger, and middle finger, with tenderness to palpation in the wrist, hand, and arm?

Immediate Nerve Injury from IV Placement: Urgent Management Protocol

This patient has sustained an iatrogenic peripheral nerve injury during IV placement, most likely involving the median nerve or lateral antebrachial cutaneous nerve, and requires immediate IV removal, clinical documentation, and urgent hand surgery consultation within 24-48 hours to prevent permanent disability. 1, 2

Immediate Actions (Within Minutes)

Remove the IV catheter immediately – any paresthesia or shocking pain during or after IV placement indicates direct nerve contact or injury, and continued presence of the catheter risks progressive nerve damage. 2

• Document the exact location of IV placement, depth of insertion, number of insertion attempts, and precise distribution of pain/paresthesia (thumb, index, middle finger distribution suggests median nerve or lateral antebrachial cutaneous nerve injury). 2
• Perform focused neurological examination documenting motor function (wrist extension, finger extension, thumb opposition, grip strength) and sensory deficits in the affected nerve distribution. 2, 3
• Do not attempt to reinsert an IV in the same extremity – use the contralateral arm or alternative access site. 2

Clinical Assessment for Nerve Injury Type

Median nerve injury is most likely given the thumb/index/middle finger distribution of shocking pain:

• Test thumb opposition strength (0-5 scale) and sensation over the palmar aspect of thumb, index, and middle fingers. 2, 4
• Assess for Tinel's sign at the wrist (tapping over median nerve at carpal tunnel reproduces symptoms). 4
• Document any weakness of wrist flexion or finger flexion. 4

Lateral antebrachial cutaneous nerve may be involved if pain radiates from upper arm:

• This nerve is purely sensory and runs along the lateral forearm after emerging near the antecubital fossa. 4
• Injury presents with burning pain and numbness along the radial forearm without motor deficits. 4

Urgent Referral Protocol

Consult hand surgery or peripheral nerve surgery within 24-48 hours – early surgical evaluation is critical as nerve injuries may require exploration, decompression, or repair, and delays beyond 72 hours can compromise outcomes. 1, 2

• Provide the consultant with documentation of: exact IV site, time of injury, immediate symptoms, current neurological deficits, and photographic documentation if available. 2
• If the patient develops progressive weakness, increasing pain, or signs of compartment syndrome (tense swelling, severe pain with passive stretch), obtain emergency surgical consultation immediately. 1

Diagnostic Imaging

High-resolution ultrasound of the affected nerve from the upper arm through the forearm should be obtained within 48-72 hours to identify the exact site and nature of injury (direct trauma, hematoma compression, or intraneural injection). 5

• MRI with dedicated neurography sequences provides superior soft-tissue detail if ultrasound is equivocal or if surgical planning requires more anatomical information. 5
• Plain radiographs are not indicated unless there is concern for associated fracture or foreign body. 1

Symptomatic Management

Immobilize the wrist in neutral position (20-30 degrees extension) with a volar splint to prevent contractures and avoid overstretching of potentially denervated muscles. 5

• Apply ice to the IV site for 15-20 minutes every 2-3 hours for the first 48 hours to reduce inflammation and hematoma formation. 2
• Topical NSAIDs (diclofenac gel) applied to the injection site three times daily are first-line for localized pain and inflammation, with superior safety profile compared to systemic agents. 6, 5
• Avoid systemic NSAIDs initially unless pain is severe and uncontrolled, as they may mask evolving compartment syndrome. 6

Physical Therapy Initiation

Begin aggressive physical therapy within 48-72 hours focusing on:

• Passive range of motion exercises for wrist and fingers to prevent contractures. 5
• Active-assisted exercises for any preserved motor function. 5
• Nerve gliding exercises (median nerve glides) once acute pain subsides, typically after 3-5 days. 5, 7

Prognosis and Follow-Up

Recovery from peripheral nerve injury may take weeks to over 12 months depending on severity – neuropraxia (temporary conduction block) recovers in weeks to months, while axonotmesis (axonal disruption with intact nerve sheath) requires nerve regeneration at approximately 1mm per day. 2

• Schedule follow-up at 2 weeks, 6 weeks, 3 months, and 6 months to document recovery trajectory. 6, 2
• If no improvement occurs within 3 months, or if motor function deteriorates, urgent repeat surgical consultation is mandatory as delayed nerve exploration or grafting may be required. 8, 2
• Electromyography (EMG) and nerve conduction studies at 3-4 weeks post-injury can help differentiate neuropraxia from axonotmesis and guide prognosis. 3, 4

Critical Pitfalls to Avoid

Do not dismiss shocking pain during IV placement as "normal" – this is pathognomonic for nerve contact and mandates immediate catheter removal. 2

Do not delay hand surgery consultation beyond 48 hours – early intervention for nerve decompression (if hematoma or compartment develops) or exploration (if complete motor loss) significantly improves outcomes. 1, 2

Do not confuse this presentation with carpal tunnel syndrome or venous thrombosis – the acute onset immediately following IV placement, shocking quality of pain, and specific nerve distribution distinguish traumatic nerve injury from chronic compression or vascular complications. 1, 6, 4