compartment syndrome-did I cause it?

[Lynn RN ER TX]

Adult female pt came to ER c/o severe abd pain. Was triaged for same in ER day before - left R/T long wait time. Hx CRF, currently doing PD @ home, after assessing her I asked another nurse to start her IV (I was pretty busy w/ other pt's) she put a 20g in L wrist. Before doc had seen her I sent blood (drawn by other RN when IV started) for lab/blood cx. Also sent PD drainage for cx.

After doc saw pt no other labs ordered. Pt given Demerol/Phenergan for pain, flushed w/ saline before & after and meds were diluted in 10cc to ease the burn.

Labs came back - pt has peritonitis. Holding her as admit - waiting on room. Throughout day several doses Demerol/Phenergan given in same fashion as above. @ 1600 when pushing Demerol/Phenregan pt stated it burned. I stopped, asked her if it burned @ insertion site. She said "no, it burns all the way up my arm, the same as before". I flushed w/ 10cc of saline before continuing w/ meds to make sure no infiltration, then again flushing after. Site was not swollen nor any change in color.

About 30 minutes later pt c/o pain at IV site. Swelling noted. Saline lock was removed, hand eleveted on two pillows and hot wet towels wrapped around hand. Re-check approx q 5 min each time re-apply new hot wet towel. Within 30 min hand started to swell, appeared like venous congestion. MD notified - charge nurse notified. I checked radial and ulnar pulses w/ vascular doppler and checked pulse oximetry on each finger (all was normal)also motor sensory was normal. Within approx 10 min MD in room and plastic surgeon consulted. Plastics doc shows up within about twenty minutes, by this time hand looks like crap - swollen blue/purple - loosing sensation, pulses still strong, motor still intact. Decision to take to OR for fasciotomy. I gave my manager full report within twenty minutes of pt going to OR.

Next day I was called to meeting w/ administrative legal people - risk management - me and my manager. It was deemed a "Centinel Event" and we had a "Root Cause Analysis Meeting". Although this meeting was supposedly to "figure out what went wrong and prevent it from ever happening again", they were asking me things like "what is your experience, how many hours did you work that day, how many shifts in a row was this for you, what other type of pt's did you have that day, how busy was the ER?". It was a little intimidating and they nor I could come up with anything I could've done to prevent this - however my charting was picked to pieces. I chart a significant amount more than most of our ER nurses, I even make some of them chart more before they report off to me. Am I at risk here because of too little charted? Everything in this posting IS CHARTED.

[teeituptom, BSN, RN]

Phenergan has been given IV,IM,PO,and PR for a long time now. Its accepted practice. I personally prefer Zofran as its more effective. But I have patients who much prefer Promethazine.We use it all the time, with only rare problems mostly associated with Dystonic reactions.

And yes I have given it to my wife, she didnt like the "Burn" but that only lasts a few minutes,

and as far as lawyers go

deep down they are basically good

six feet down that is

:rotfl: :rotfl: :rotfl:

[Repat]

We give Phenergan all the time IV, and I have never noticed a problem. Occasionally a patient will complain that it burns, but that it about it. As Tom says, I have noted a few (a very few) dystonic reactions, and occasionally it really "snows" a patient, but I admit I have never heard this controversy before (and I have worked in many states and settings).

[Tweety, BSN, RN]

So, what do you do if you do not have the proper antidote to treat an extravasation? You DON'T GIVE THE MEDICATION IV!!!QUOTE]

Yep. No brainer there. Thanks. :)

[teeituptom, BSN, RN]

so what hospital wouldnt carry antidotes for extravasation

[Tweety, BSN, RN]

so what hospital wouldnt carry antidotes for extravasation

Those that have lost the lawsuits that stevierae is talking about.

[stevierae]

Phenergan has been given IV for a long time now. Its accepted practice. :

Sigh. There is just no reasoning with you, Tom, so I will not try. I have seen some of your other posts regarding giving IV Propofol to non-intubated patients in the ER setting--a very, very dangerous practice, and one that has resulted in many unnecessary, tragic deaths nationwide. But, you cited the same rationale you did with Phenergan via peripheral IV: "We do it all the time. No biggie."

Phenergan via peripheral IV is NOT accepted practice.

Those institutions, and those nurses, who choose to ignore published, evidence based practice standards and do so does not MAKE it accepted practice.

Those nurses who choose to ignore published evidence based practice standards are at risk of sitting in a courtroom, because there will be a legal nurse consultant just like me behind the scenes showing the plaintiff attorney the evidence based practice standards. As I said, those ALWAYS overrule regional or institutional policy and procedure. To the fact finders,(judge and jury) they are all that matter. Anecdotal testimony from a nurse who "does it all the time; no biggie" will simply increase the amount of the award to the plaintiff.

As I said, juries do not like arrogant nurses who choose to ignore published evidence based practices.

Interestingly, the peripheral IV Phenergan extravasation case I am currently reviewing is a Texas one--from a small town near Austin. Happened in the ER. If this case costs this hospital big money, (and it will) you can bet that, in Texas, your practice of giving IV Phenergan "all the time" despite what published evidence based practices state will cease, once and for all.

Why take the risk, when it could possibly cost the patient a limb? Why risk your own license and professional reputation? Give it IM or, if a peds patient, via rectal suppository.

[mattsmom81]

What about the percentages of people who have recieved Phenergan WITHOUT problem over the decades?? Every drug has untoward effects listed in the PDR...and a small percentage of patients will react badly. Those numbers are small or the FDA would NOT release them.

Hopefully people (juries) are smart enough to understand that a few bad outcomes will always be found...also that there will always be a lawyer (and their 'expert witnesses') close by to point a finger. Life is certainly not risk free: not for patients nor nurses.

Texas leads the nation in lawsuits against nurses...the attorneys and their 'expert witnesses' seem to be doing well here, unfortunately. I've given Phenergan for 28 yrs without major problems but all of a sudden its a lawsuit inducing drug? Hmmm...whatever. I'll make sure to have a good attorney in MY corner too if I get taken to court about Phenergan.

Since we're in Texas Tom...you and I better be careful.

[teeituptom, BSN, RN]

I like attacks

1. as long as the PDR says it can be given IV

2. as long as my hospitals formulary says it can be given IV

3. as long as the doctor orders it IV

4. as long as the patient has no allergy to phenergan

Then, no, I dont have a leg to stand on to refuse an order.

If you want, change the system and I will change also.

But I cant tell a doctor or my supervisor that I refuse to give phenergan IV because I read it on All Nurses .com message board. Somehow or another I dont think that will fly in the face as numbers 1 , 2 , 3.

Now we know attorneys are really nice people, :rotfl:

however if paid they will sue anyone with whatever complaint they can come up with. Weve all seen that before and they even advertise that on TV. " hello; Im so and so" did you have a fender bender let me get the big bucks for you.

[teeituptom, BSN, RN]

and particularly since there are more shysters in Texas than anywhere else in the country

:rotfl: :rotfl: :rotfl:

[Repat]

I think he moved to Washington....

[teeituptom, BSN, RN]

No Im still in Texas

[Repat]

Oh, Tom, I think you know who I meant!!!