Promethazine, a common
antiemetic, can cause severe tissue injury with intravenous (IV) injection.
Dihydroergotamine (DHE), commonly used for the acute treatment of
migraine, can cause arterial vasoconstriction. We report a rare complication of brachial artery vasospasm in a patient receiving IV
promethazine and DHE sequentially through the same midline IV
catheter. A 40-year-old woman with history of
migraine headaches and
Raynaud phenomenon was admitted for treatment of
status migrainosus with scheduled IV DHE infusions. While receiving the DHE infusions, IV
promethazine was added to the patient's regimen to treat
nausea. During an infusion of DHE, the patient developed
acute pain near the
catheter insertion site due to active extravasation of IV DHE. An arterial Doppler ultrasound demonstrated
stenosis in the right brachial artery near the region of infusion. The patient ultimately required balloon angioplasty and
intra-arterial injection of
nitroglycerin to restore adequate blood flow. We hypothesize that
caustic injury to the right brachial vein from IV
promethazine predisposed the patient to the extravasation of DHE, which, in turn, caused adjacent brachial artery vasospasm. This case suggests the need for careful consideration, if not strict avoidance, of the use of concurrent IV
promethazine and DHE.