Acute Compartment Syndrome Pathway: Management at Johns Hopkins All Children’s Hospital, Slides of History

Download Acute Compartment Syndrome Pathway: Management at Johns Hopkins All Children’s Hospital and more Slides History in PDF only on Docsity! JOHNS HOPKINS ALL CHILDREN’S HOSPITAL Compartment Syndrome Clinical Pathway @) JOHNS HOPKINS All Children’s Hospital an | a 2 Johns Hopkins All Children’s Hospital Compartment Syndrome Clinical Pathway Table of Contents 1. Rationale 2. Background a. Table 1: Factors Associated With Compartment Syndrome b. Figure 1: Vicious Cycle of Acute Compartment Syndrome (ACS) 3. Diagnosis a. Clinical Suspicion b. Physical Exam c. Pain d. Parasthesias & Paralysis e. Pallor & Pulselessness f. Diagnostic Tests 4. Emergency Center Management a. Early Recognition b. Preventative Measures c. Confirmed ACS d. High Risk Patients e. Low Risk Patients f. Emergency Center Acute Compartment Syndrome Clinical Pathway 5. Inpatient Management a. Suspected ACS b. Confirmed ACS c. High Risk Patients d. Low Risk Patients e. Inpatient Acute Compartment Syndrome Clinical Pathway 6. Special Circumstances 7. Documentation Reminders 8. References 9. Outcomes 10. ACS Clinical Pathway Review Team Updated: April 2020 Owners: Dr. Gregory Hahn This pathway is intended as a guide for physicians, physician assistants, nurse practitioners and other healthcare providers. It should be adapted to the care of specific patient based on the patient’s individualized circumstances and the practitioner’s professional judgment. 5 Diagnosis The diagnosis of ACS is predominately a clinical one and requires consideration of the entire clinical picture including a thorough physical exam. Classically, the hallmark signs and symptoms of compartment syndrome are a swollen/tense compartment associated with the five Ps: pain, paresthesias, paralysis, pallor, and pulselessness. These are all present in late stages of ACS in adults but are not all seen early on and not nearly as reliable in children. The challenge is to diagnosis a developing compartment syndrome prior to the presence of all five Ps. In children, an additional set of findings designated the “Three As” has been proposed as more appropriate. The “Three As” are increasing anxiety, agitation, and analgesic requirements. Clinical Suspicion First and foremost, clinical suspicion for a compartment syndrome is critical as many of the signs and symptoms of ACS are routinely seen in the setting of pediatric trauma. It is easy to attribute swelling, pain, and paresthesias as routine findings following a significant trauma and this may lead to a missed or late diagnosis of ACS. Physical Exam The most consistent finding in ACS is a markedly swollen and tense muscle compartment. In some cases, this may be obvious but in many it is quite difficult for several reasons. Often, the involved compartment is covered either in dressings, a splint, or a cast making direct examination of the compartment impossible. Second, some of the compartments are anatomically deep and hidden from examination by the subcutaneous tissues. Therefore, the other signs and symptoms become even more critical to evaluate. Pain Pain is the first symptom of a compartment syndrome in most cases and there are specific characteristics that need to be evaluated. In general, pain out of proportion to the injury is worrisome. In children, this may be manifested by uncontrolled pain, pain requiring a significant increase in analgesics, marked anxiety or agitation. Specifically, pain with passive stretch of the muscles within the suspected muscle compartment is concerning for a compartment syndrome. These symptoms may be masked in children with a regional block, those that are obtunded, or in late presentations when nerve injury occurs resulting in paresthesias or complete numbness. While pain is typically seen in virtually all etiologies of ACS, the pain should not worse with treatment of the underlying condition. It is also important to point out that in vascular related ACS substantial pain was NOT present in the majority of cases. Neurovascular symptoms were the prevailing clinical findings. Parasthesias & Paralysis Similar to pain, paresthesias are a common finding in pediatric trauma irrespective of compartment syndrome. However, these are typically seen at presentation and should not worsen following treatment. Development of paresthesias or paralysis following treatment in a child who was neurologically intact upon presentation is worrisome for a developing compartment syndrome. This is complicated by the fact that young children often give an 6 unreliable neurologic exam secondary to fear or lack of understanding. Repeated examinations are sometimes helpful in this regard. Again, in the setting of a vascular related ACS paresthesias and paralysis is noted more frequently than excessive pain. Pallor & Pulselessness In trauma related ACS, pallor along with poor capillary refill and true pulselessness are fairly late findings in compartment syndrome. In these cases, permanent muscle and nerve necrosis has already likely begun. However, in vascular related ACS these may be the presenting findings. In either case, these findings are very worrisome for a compartment syndrome or vascular injury, both of which require prompt evaluation and intervention. Diagnostic Tests In most cases of ACS, the diagnosis is made strictly on the basis of the clinical exam findings combined with the index of suspicion given the clinical scenario. No further diagnostic testing is needed and the patient is treated with an emergent fasciotomy and any associated vascular procedures if indicated. In some cases, such as in neonatal cases, obtunded children, those with a regional anesthetic, or very young children with an unreliable exam, the clinical exam does not provide enough information and compartment pressures may be measured. Compartment pressures should be measured by a member of the orthopaedic team using the Stryker pressure monitor. There is no consensus as to which value of compartment pressure constitutes a compartment syndrome. Some studies advocate the use of a compartment pressure measurement greater than 30 mmHg while others suggest a P value of less than 20 mmHg from the patient’s diastolic pressure or less than 30 mmHg from the patient’s mean arterial pressure. These guidelines were all established in adults and have not yet been verified in children. In particular, there is no evidence-based studies in neonates who have far different resting pressures. Some studies also suggest that in a vascular associated ACS a P of less than 40 mmHg may be more appropriate. Compartment pressure measurements have also been shown to be highly variable even in experienced hands so serial measurements may play a role in some scenarios. Emergency Center Management Early Recognition As previously mentioned, the first priority in treating potential acute compartment syndromes is to recognize the injuries and clinical scenarios that predispose a child to the development of ACS. In children considered at risk the appropriate orthopaedic and trauma services should be notified and the child promptly evaluated. Preventative Measures Preventive measures include maintaining normal blood pressure and avoiding excessive pressure or tight circumferential dressings on the anatomic compartment of concern. Traction and elevation of the involved limb should be avoided whenever possible. For those children being evaluated in the emergency center both the orthopaedic and trauma services should be 7 consulted and the treatment algorithm that is recommended is provided below. For those with an obvious orthopaedic injury and no vascular concern, the orthopaedic service would be the admitting and treating service. In those scenarios where there is concern for a vascular etiology, the trauma service will be the admitting and treating service. Confirmed ACS For those children with a confirmed diagnosis of ACS, the treating service should notify the operating room that an emergent fasciotomy is indicated and this should be scheduled as a Level 1 case. Every effort should be made to minimize delay in operative treatment. While the surgical treatment for ACS is a complete fasciotomy of all compartments in the affected limb, it is important to remember that additional procedures may be required such as fracture stabilization or vascular repair. In most cases of ACS, the wound is left open to allow for further swelling. Wound vacs are often utilized to aid in delayed closure. Admission of “High Risk” Patients For those patients who are not felt to have an acute compartment syndrome but are deemed at high risk for future development of one, they should be admitted to a designated floor or ICU that is appropriately staffed to be able to provide hourly neurovascular checks. The admitting service should be physically present to give report to the admitting nurse/attending. There should be a review of the concerns for compartment syndrome and a baseline exam should be done together so there is complete agreement on the examination findings. Ideally, the subsequent neurologic exams should be done by the same individual on the admitting service as well as the same floor/icu nurse. In all changes of shift, the incoming and outgoing nurses should perform an examination together to confirm the exam findings and concerns in the presence of the admitting service if possible. All serial examinations should be fully documented by both the bedside nurse and the admitting service. The admitting service should be immediately notified of any change in the exam in between scheduled examinations. This includes any observed increased anxiety, agitation or analgesic requirements. The duration and interval of serial examinations will be determined by the admitting service and will be individualized for each clinical scenario. “Low Risk” Patients For those patients who are not felt to have an ACS and require admission for observation or ongoing treatment but are deemed at low risk for compartment syndrome, they may be admitted routinely to the admitting service. The clinical presentation of ACS should be reviewed with the admitting nurse/attending and the serial examinations should be performed by the bedside nurse as directed in the admitting orders. The duration and interval of the serial examinations will be determined by the admitting service and will be individualized for each clinical scenario. Any change in the exam should be documented by the bedside nurse and the admitting service should be notified. For low risk patients not requiring admission, they may be discharged home after the orthopaedic or trauma team has reviewed the signs and symptoms of ACS with the family. 10 “Low Risk” Patients For those patients who are not felt to have an ACS and are deemed at low risk for compartment syndrome, they may remain in their current location. The clinical presentation of ACS should be reviewed with the bedside nurse/attending and the serial examinations should be performed by the nurse as directed by the consulting service. The duration and interval of the serial examinations will be determined by the consulting service and will be individualized for each clinical scenario. Any change in the exam should be documented by the bedside nurse and the consulting service should be immediately notified. Special Circumstances As mentioned throughout the pathway, acute compartment syndrome is a clinical diagnosis and as such, relies heavily on a reliable physical exam. Unfortunately, there are many scenarios in pediatric patients that prohibit or significantly compromise the reliability of the physical exam. Some examples are evaluation of a neonate, an obtunded or developmentally delayed child, a child who has suffered a neurologic injury or one who has been given a regional anesthetic. In any scenario when a reliable examination cannot be performed, then compartment pressure measurements may be indicated. Compartment pressure measurements are often difficult to perform and interpret. The test is prone to technical errors and the even when done correctly the measurement may be difficult to interpret as there is no consensus of accepted norms for young children. Therefore, these should only be done by a member the orthopaedic or trauma service that has experience in performing the procedure. Again, it is important to remember that a single compartment pressure measurement may not be diagnostic and serial measurements may need to be performed to assess progression. In all cases, the measurements should be used as an additional tool for determining the likelihood of an ACS and when in doubt a fasciotomy should be performed. 11 Johns Hopkins All Children's Hospital Inpatient Acute Compartment Syndrome Clinical Pathway Monitor Closely With Serial Examinations Monitor Closely With Serial Examinations & Possible Repeat Measurements Transfer to appropriate monitoring floor if necessary No further workup needed and ready for discharge once cleared by primary team Emergent Fasciotomy Positive Pressure > 30mm Hg or P < 30 from MAP (Mean Arterial Pressure) Negative But High Risk Compartment pressure measurement Unequivocal Positive Unequivocal Negative Questionable Exam Findings Reliable Examination (awake and alert patient) Unreliable Examination (eg. Neonate, obtunded, neurologic injury, regional anesthesia, developmental delay) Suspected Compartment Syndrome: Swollen/tense compartment associated with the “Five Ps”: pain, paresthesias, paralysis, pallor, and pulselessness OR The “Three As”: Anxiety, agitation, increasing analgesic requirements OR Clinical Suspicion based off history, mechanism of injury or provider experience Notify Orthopedic or Trauma Teams High Risk Low Risk  Remove any dressings on extremity  Avoid traction and elevation of the involved limb whenever possible 12 Documentation Reminders Documentation Suggestions: • Timeline is important, document a clear clinical picture with timestamps • It is important to document the specific location and laterality, if applicable (i.e. abdomen, left hip, right thigh, etc.) • It is important to document if it is associated with a post-procedural complication • It is important to document if it is related to trauma • It is important to document any medical co-morbidities the patient has • It is important to document any complications the patient is experiencing, such as the specific electrolyte derangements (hypokalemia), ischemic muscle infarction, reperfusion syndrome, acute kidney injury/failure, etc. Patient Status Suggestion: • Low risk patients being observed for serial exams with anticipated length of stay less than 24 hours should be placed in OBSERVATION status • All patients that are high risk and/or are taken to the OR should be placed in INPATIENT status