STRICTLY CLINICAL

Rapid Response

Early detection of acute

compartment syndrome
Quick action prevents serious harm.
By Aaron M. Sebach, PhD, DNP, AGACNP-BC, FNP-BC, CEN, CPEN, CNE, CNEcl, SFHM

BRIAN WICK*, age 33, is admitted to the or- rival, you administer the I.V. morphine sulfate
thopedic medical-surgical unit for observation and ask the charge nurse to bring a Doppler
and pain management after an ATV accident. ultrasound to the bedside. The orthopedic
His right forearm was pinned under the vehi- surgeon confirms your assessment and hears
cle, and he required assistance from a a faint, weak radial pulse via Doppler ultra-
passerby to free it. An X-ray of the forearm in sound. She calls the operating room and plans
the emergency department shows a distal ra- for an emergency fasciotomy.
dius fracture, which is splinted by an ortho-
pedic surgical resident. Outpatient open re- Outcome
duction and internal fixation of the fracture is The fasciotomy restores arterial flow. The
recommended, but Mr. Wick is admitted due wounds are left open for 4 days to allow the
to uncontrolled pain. swelling to resolve. Mr. Wick is then taken
back to the operating room for wound irriga-
History and assessment tion and closure, as well as open reduction
Throughout the day, Mr. Wick receives oxy- and internal fixation of the radius fracture.
codone 5 mg and acetaminophen 325 mg He’s discharged the next day and will require
every 4 hours as needed for pain as well as outpatient physical and occupational therapy
I.V. morphine sulfate 1 mg every 2 hours as with close orthopedic surgery follow-up.
needed for breakthrough pain. Neurovascular
assessments of Mr. Wick’s right upper extrem- Education and follow up
ity every 4 hours remain unchanged with a ra- ACS develops as a result of increased pressure
dial pulse rated 3/4, capillary refill time of 3 within an anatomic compartment, which can
seconds, full sensation and finger range of lead to decreased or absent blood flow to mus-
motion, and warm, pink skin. cle and nerve cells. It’s most common after trau-
At shift change, you hear Mr. Wick calling matic injury to an extremity, although it also can
out for pain medication. You determine that occur after surgery. Chronic compartment syn-
he’s due for I.V. morphine sulfate 1 mg. Mr. drome, which occurs with exercise and resolves
Wick reports 10/10 burning pain and pressure with rest, is not a surgical emergency.
in the right forearm. He also reports a pins-and- ACS is a clinical diagnosis. When assessing
needles sensation and difficulty moving his fin- for it, use the 5 Ps: disproportionate pain,
gers. You’re unable to palpate a radial pulse paresthesia, paralysis, pallor, and pulseless-
and note that his skin is pale. His vital signs are ness. Paralysis frequently is a late finding. Ear-
temperature 98.4° F (36.9° C), heart rate 124 ly identification, rapid response team activa-
beats per minute, respiratory rate 22 breaths per tion, and surgical intervention are critical to
minute, blood pressure 154/86 mmHg, and prevent permanent disability of the affected
oxygen saturation 95% on room air. extremity. AN

Taking action *Name is fictitious.

You immediately identify that Mr. Wick is like-
Access references at myamericannurse.com/?p=75950.
ly experiencing acute compartment syndrome
(ACS), an orthopedic emergency. You remove Aaron M. Sebach is associate professor and chair of the doctor of
the circumferential wrap holding the splint nursing practice program at Wilmington University in New Castle,
and page the orthopedic surgeon. You do not Delaware, and a hospitalist nurse practitioner at TidalHealth Penin-
elevate the extremity. While waiting for her ar- sula Regional in Salisbury, Maryland.

12 American Nurse Journal Volume 16, Number 6 MyAmericanNurse.com

 About myxedema coma
Myxedema coma is the most severe, potentially life-threatening form
of hypothyroidism. It can result in the slowing of multiple organs. Hall-
marks of myxedema coma include altered level of consciousness (rang-
ing from lethargy to psychosis) and hypothermia. It also can cause hy-
potension, hypoventilation, bradycardia, hyponatremia, and
hypoglycemia.
Myxedema coma can occur in acutely ill patients with pre-existing
primary or central hypothyroidism that is untreated or undertreated.
Predisposing factors include infection, cold exposure, myocardial in-
farction, surgery, and certain drugs. Patients with undiagnosed or
poorly managed hypothyroidism and older adult women are at highest
risk.
Myxedema coma diagnosis is based on history, physical exam, and
exclusion of other diagnoses; it’s confirmed with thyroid function stud-
ies. TSH levels are highly elevated in patients with primary hypothyroid-
ism but may be closer to normal or only slightly elevated in those with
central dysfunction. Free T4 levels usually are very low.
Myxedema coma treatment should be initiated quickly if the condi-
tion is suspected and may include both T3 and T4 I.V., although opti-
mal treatment is still being investigated. Patients with central hypothy-
roidism are at risk of hypopituitarism and adrenal insufficiency, so they
may be treated with stress doses of glucocorticoids until those condi-
tions are ruled out. Hypotension and bradycardia are corrected by thy-
roid hormone replacement therapy, although vasopressors may be re-
quired in the short-term. Passive warming helps correct hypothermia.
Treatment advances have reduced mortality rates to between 20% and
25%; however, emergent and aggressive treatment are key.

MyAmericanNurse.com June 2021 American Nurse 13

 STRICTLY CLINICAL
Rapid Response

Bradykinin-induced
angioedema
Quick treatment results in a good outcome.
By Veronica Y. Amos, PhD, CRNA, PHCNS-BC

MARCUS GREEN* is a 45-year-old Black man given propofol 200 mg I.V. as a general anes-
with a 5-year history of hypertension who takes thetic, and the respiratory therapist places him
his blood pressure medication on the way to on a ventilator. Mr. Green is taken to the ICU
work. About 20 minutes after taking it this where his angioedema subsides in 4 hours and
morning, his tongue begins to feel heavy and he’s extubated 24 hours later. He’s discharged
his lips and tongue begin to swell. He drives home 3 days later, and his provider prescribes
himself to the emergency department (ED). losartan, an angiotensin-receptor blocker.

History and assessment Education

Jane Jackson, Mr. Green’s nurse, conducts a Angiotensin-converting enzyme (ACE) in-
quick assessment, noticing the swelling. When hibitors such as lisinopril can cause bradykinin-
she learns that Mr. Green is taking lisinopril for induced angioedema (increased release of the
his hypertension, she realizes he’s likely experi- enzyme bradykinin, which can cause increased
encing angioedema. She obtains vital signs and, tissue permeability with dilatation of the ves-
per protocol, starts oxygen at 2 liters/minute via sels and swelling). In the United States, 30% to
nasal cannula. Mr. Green’s vital signs are BP 40% of angioedema diagnoses in the ED are re-
98/60 mmHg, heart rate 128 bpm, respiration lated to ACE inhibitors, with 0.1% to 2.2% be-
rate 24 breaths/minute, oxygen saturation 98%, ing life-threatening.
and axillary temperature 98.1°F (36.7°C). Typical signs of angioedema related to ACE
Mr. Green is alert and oriented, but he’s be- inhibitors include lip, face, and tongue swelling
coming increasingly anxious and his lips and without rash or itching. However, the larynx
tongue continue to swell. Jane starts ECG mon- and pharynx also can be involved. In most cas-
itoring; inserts an 18-gauge peripheral I.V. in his es, angioedema resolves without complications
right arm; and administers epinephrine, methyl- in a few days, but Mr. Green’s respiratory man-
prednisolone, and diphenhydramine, as or- ifestations made prompt treatment essential.
dered, but without effect. No standardized treatment for bradykinin-
induced angioedema exists, but the off-label
Clinical management use of FFP has been shown to be an effective
Concerned that Mr. Green may rapidly deterio- treatment for severe episodes. Bradykinin re-
rate, the ED provider asks an anesthesia sponds to the kininase II in FFP, which is iden-
provider to perform a fiberoptic nasal intuba- tical to ACE.
tion to protect the patient’s airway. The anes- Unfortunately, in one reported case, despite
thesia provider doesn’t give Mr. Green a benzo- a patient receiving epinephrine, methylpred-
diazepine or medication for pain because it may nisolone, and diphenhydramine, followed by
cause sedation and impede spontaneous breath- I.V. FFP, their symptoms progressed and 2
ing. However, the anesthesia provider does or- hours later intubation was required, as was the
der 2 units of fresh frozen plasma (FFP) I.V. case with Mr. Green. Therefore, nurses should
After two unsuccessful intubation attempts, follow the research in this area. AN
the anesthesia provider administers glyco-
*Name is fictitious. To view a list of references, visit
pyrrolate 0.2 mg I.V. to decrease Mr. Green’s myamericannurse.com/?p=71927.
excessive bronchial secretions and prevent
bronchospasm. Mr. Green remains alert and Veronica Y. Amos is an assistant director of the nurse anesthesia
cooperative and the airway is secured nasally program and assistant professor at the University of Maryland
with an endotracheal tube. He’s immediately School of Nursing in Baltimore.

MyAmericanNurse.com June 2021 American Nurse Journal 11