Blue Toes

Abstract

A 65-year-old diabetic male on insulin injections for the past 15 years, hypertensive on amlodepine, dyslipidemic on statins and a nonsmoker was presented to the Emergency department with acute infero-posterior wall ST-elevation myocardial infarction along with complete heart block with heart rate of 40 beats per minute and blood pressure of 100/70 mmHg. A prophylactic transvenous temporary pacing wire was inserted from the right femoral vein after placing a femoral sheath. While attempting femoral venous cannulation, the right femoral artery was inadvertently punctured and a sheath was temporarily introduced and removed. Following the stabilization with a pacing wire, the patient was thrombolyzed with intravenous reteplase (10 units + 10 units, 30 minutes apart), followed by unfractionated heparin infusion (5000 units bolus + 1000 units/hour infusion). The patient responded well with a return of sinus rhythm at 70 beats per minute. The pacing wire along with the sheath was removed after 48 hours. His urea and creatinine were elevated at 15.5 mmol/L (n: 3.3-7) and 251 µmol/L (n: 45-100) from the baseline value of 9.7 mmol/L and 146 µmol/L, respectively. His white cell count was 9.1 × 10^9/L (n: 3.6-11.5) with an eosinophil count of 0.4 × 10^9/L (n: 0-0.5), and normal liver function tests. On the third day of admission, the patient developed bluish discoloration of the right toes with palpable proximal and distal pedal pulses.