compartment syndrome-did I cause it?

Nurses General Nursing

Published

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.

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Phenegan SUCKS IV. When I had my daughter,they gave it to me IVP, diluted in 10cc of saline, and it hurt all the way up to my armpit. Not too long after my IV infiltrated and the whole area became so red and raw, I was convinced way back then, IV phenergan was no goood. I can attest, giving phenergan, even diluted IVP hurts like a bear.

Now I need to correct myself from an earlier post, if I may.

I should NOT BE saying necessarily this OP "caused" compartment syndrome with phenergan IV. I agree with "prmenurse", the OP needs to get involved in the follow up of this case and all of us need to learn more. It could have been a combination of factors that led to this problem, and I bet it was. I am very, very sorry I mis-stepped in my first post saying it was the phenergan that caused this. I don't know for sure what did, and I believe strongly we need get out of the "fingerpointing" habit nursing and medicine are into, (myself included here), and get past it----And LEARN from these things.

I hope the OP will check back in and let us know what the findings are so we all can learn here. I am sorry for any assignment of blame on my part. The blame and ego's are not important, learning and doing better in the future for patients surely IS.

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Phenegan SUCKS IV. When I had my daughter,they gave it to me IVP, diluted in 10cc of saline, and it hurt all the way up to my armpit. Not too long after my IV infiltrated and the whole area became so red and raw, I was convinced way back then, IV phenergan was no goood. I can attest, giving phenergan, even diluted IVP hurts like a bear.

Now I need to correct myself from an earlier post, if I may.

I should NOT BE saying necessarily this OP "caused" compartment syndrome with phenergan IV. I agree with "prmenurse", the OP needs to get involved in the follow up of this case and all of us need to learn more. It could have been a combination of factors that led to this problem, and I bet it was. I am very, very sorry I mis-stepped in my first post saying it was the phenergan that caused this. I don't know for sure what did, and I believe strongly we need get out of the "fingerpointing" habit nursing and medicine are into, (myself included here), and get past it----And LEARN from these things.

I hope the OP will check back in and let us know what the findings are so we all can learn here. I am sorry for any assignment of blame on my part. The blame and ego's are not important, learning and doing better in the future for patients surely IS.

Sorry this happened to you. As you said the pt. had no visible veins but, man, I hate those wrist IV's.

Sorry this happened to you. As you said the pt. had no visible veins but, man, I hate those wrist IV's.

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

From Rxlist.com:

Inadvertent Intra-Arterial Injection: Due to the close proximity of arteries and veins in the areas most commonly used for intravenous injection, extreme care should be exercised to avoid perivascular extravasation or inadvertent intra-arterial injection. Reports compatible with inadvertent intra-arterial injection of promethazine, usually in conjunction with other drugs intended for intravenous use, suggest that pain, severe chemical irritation, severe spasm of distal vessels, and resultant gangrene requiring amputation are likely under such circumstances. Intravenous injection was intended in all cases reported, but perivascular extravasation or arterial placement of the needle is now suspect. There is no proven successful management of this condition after it occurs, although sympathetic block and heparinization are commonly employed during the acute management because of the results of animal experiments with other known arteriolar irritants. Aspiration of dark blood does not preclude intra-arterial needle placement, because blood is discolored upon contact with promethazine. Use of syringes with rigid plungers or of small bore needles might obscure typical arterial backflow if this is relied upon alone.

When used intravenously, promethazine hydrochloride should be given in a concentration no greater than 25 mg per ml and at a rate not to exceed 25 mg per minute. When administering any irritant drug intravenously, it is usually preferable to inject it through the tubing of an intravenous infusion set that is known to be functioning satisfactorily. In the event that a patient complains of pain during intended intravenous injection of promethazine, the injection should immediately be stopped to provide for evaluation of possible arterial placement or perivascular extravasation.

Demerol can also burn like hades when given IV. The 50mg glass amps of phenergan are marked in tall letters NOT FOR IV USE.

I wonder if being a smaller (20) int it was beginning to infiltrate as mentioned above. The sentinel event investigation looks to be fairly standard. Did you feel that there were accusatory statements? It seems to me you did everything properly. Let us know if you get an outcome report.

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

From Rxlist.com:

Inadvertent Intra-Arterial Injection: Due to the close proximity of arteries and veins in the areas most commonly used for intravenous injection, extreme care should be exercised to avoid perivascular extravasation or inadvertent intra-arterial injection. Reports compatible with inadvertent intra-arterial injection of promethazine, usually in conjunction with other drugs intended for intravenous use, suggest that pain, severe chemical irritation, severe spasm of distal vessels, and resultant gangrene requiring amputation are likely under such circumstances. Intravenous injection was intended in all cases reported, but perivascular extravasation or arterial placement of the needle is now suspect. There is no proven successful management of this condition after it occurs, although sympathetic block and heparinization are commonly employed during the acute management because of the results of animal experiments with other known arteriolar irritants. Aspiration of dark blood does not preclude intra-arterial needle placement, because blood is discolored upon contact with promethazine. Use of syringes with rigid plungers or of small bore needles might obscure typical arterial backflow if this is relied upon alone.

When used intravenously, promethazine hydrochloride should be given in a concentration no greater than 25 mg per ml and at a rate not to exceed 25 mg per minute. When administering any irritant drug intravenously, it is usually preferable to inject it through the tubing of an intravenous infusion set that is known to be functioning satisfactorily. In the event that a patient complains of pain during intended intravenous injection of promethazine, the injection should immediately be stopped to provide for evaluation of possible arterial placement or perivascular extravasation.

Demerol can also burn like hades when given IV. The 50mg glass amps of phenergan are marked in tall letters NOT FOR IV USE.

I wonder if being a smaller (20) int it was beginning to infiltrate as mentioned above. The sentinel event investigation looks to be fairly standard. Did you feel that there were accusatory statements? It seems to me you did everything properly. Let us know if you get an outcome report.

Yes very information indeed. Thanks stevierae. Our computerized med sheets give instructions for giving it IV. I kind of disagree about "what a prudent nurse would do", so if I ever get in trouble, then I'm taking down the pharmacy, the docs, and the hospital with me. :)

But I'm going to contact the nursing/pharmacy committee on this one. Sounds like we definately need to change our policy and quit giving it. Thank goodness with demerol going out of favor, we don't give it all that often anymore.

Vesicants are going to extravasate, that's a fact. People are then going to sue and blame the nurse. That's another sad fact. Sigh...the joys of having a license. :)

3rd shift guy, you won't have to take them down with you--believe me, they will all go down, because of the deep pockets theory, and the fact that the hospital is held liable for the actions of its employees. The plaintiff attorneys will be right on top of taking everybody down.

The other thing about extravasations, especially of vesicants--one is expected to treat the extravasation RIGHT AWAY with the agent that can neutralize it, and in most cases that agent is Wydase. Now, I know that for a long time Wydase was unavailable; I don't know if there was a shortage of it nationwide or if the manufactureers quit making it.

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

If the pharmacy/nursing committees disagree with you and give you all kinds of half-a**ed rationales why your hospital has found the practice of giving Phenergan through a peripheral IV acceptable, simply show them the published INS standards. They cannot argue with those in a court of law.

Yes very information indeed. Thanks stevierae. Our computerized med sheets give instructions for giving it IV. I kind of disagree about "what a prudent nurse would do", so if I ever get in trouble, then I'm taking down the pharmacy, the docs, and the hospital with me. :)

But I'm going to contact the nursing/pharmacy committee on this one. Sounds like we definately need to change our policy and quit giving it. Thank goodness with demerol going out of favor, we don't give it all that often anymore.

Vesicants are going to extravasate, that's a fact. People are then going to sue and blame the nurse. That's another sad fact. Sigh...the joys of having a license. :)

3rd shift guy, you won't have to take them down with you--believe me, they will all go down, because of the deep pockets theory, and the fact that the hospital is held liable for the actions of its employees. The plaintiff attorneys will be right on top of taking everybody down.

The other thing about extravasations, especially of vesicants--one is expected to treat the extravasation RIGHT AWAY with the agent that can neutralize it, and in most cases that agent is Wydase. Now, I know that for a long time Wydase was unavailable; I don't know if there was a shortage of it nationwide or if the manufactureers quit making it.

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

If the pharmacy/nursing committees disagree with you and give you all kinds of half-a**ed rationales why your hospital has found the practice of giving Phenergan through a peripheral IV acceptable, simply show them the published INS standards. They cannot argue with those in a court of law.

Specializes in ER, ICU, L&D, OR.

Except for the fact it burns like hades, we give it all the time in ER. the only problems we ever encounter outside of pain is an occasional flaring of some Superficial Thrombophlebitis

Specializes in ER, ICU, L&D, OR.

Except for the fact it burns like hades, we give it all the time in ER. the only problems we ever encounter outside of pain is an occasional flaring of some Superficial Thrombophlebitis

Except for the fact it burns like hades, we give it all the time in ER. the only problems we ever encounter outside of pain is an occasional flaring of some Superficial Thrombophlebitis

The only problems you have encountered TO DATE have been pain and superficial thrombophlebitis. You have been exceptionally lucky.

I repeat: The fact that you give it "all the time" in your institution will not make a difference in a court of law when a more serious IV Phenergan complication occurs in your institution--and the INS standards are blown up to about 100 times their textbook size, and set side by side with the package insert stating the pH of Phenergan, also blown up, for a jury to view.

Juries don't like nurses who choose to ignore evidence-based standards in favor of what "they do all the time" or "what their institution does all the time."

All a savvy plaintiff attorney has to ask the nurse on the witness stand who gave it, "Would you have felt comfortable ignoring the published INS standards and giving Phenergan through a peripheral IV if the patient were YOUR MOTHER?" (or wife, or sister, etc.) and then looking in disgust at the jury while that nurse hemmed and hawed through his/her answer.

Another no-brainer.

Except for the fact it burns like hades, we give it all the time in ER. the only problems we ever encounter outside of pain is an occasional flaring of some Superficial Thrombophlebitis

The only problems you have encountered TO DATE have been pain and superficial thrombophlebitis. You have been exceptionally lucky.

I repeat: The fact that you give it "all the time" in your institution will not make a difference in a court of law when a more serious IV Phenergan complication occurs in your institution--and the INS standards are blown up to about 100 times their textbook size, and set side by side with the package insert stating the pH of Phenergan, also blown up, for a jury to view.

Juries don't like nurses who choose to ignore evidence-based standards in favor of what "they do all the time" or "what their institution does all the time."

All a savvy plaintiff attorney has to ask the nurse on the witness stand who gave it, "Would you have felt comfortable ignoring the published INS standards and giving Phenergan through a peripheral IV if the patient were YOUR MOTHER?" (or wife, or sister, etc.) and then looking in disgust at the jury while that nurse hemmed and hawed through his/her answer.

Another no-brainer.

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