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Neurovascular Impairment and Compartment Syndrome

Background and description of neurovascular impairment compartment syndrome

This nursing essay explores various aspects of neurovascular impairment compartment syndrome as an exemplar of the neurovascular condition of musculoskeletal (Wright, 2009). It covers pathophysiology, signs and symptoms, treatment modalities, and nurse role in the collaborative setting particularly in critical care clinical setting.

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Neurovascular impairment affects millions of Americans and is a potential condition for musculoskeletal trauma and surgery (Wright, 2009). Early diagnosis for the condition is imperative for treatment modalities because if left unattended, it could lead to loss of limbs, stroke, and death. Critical care nurses have critical routine roles to perform for patients with neurovascular impairment. Observation is a part of the essential care delivered to such patients in a clinical environment.

Neurovascular impairment includes any abnormalities that affect the blood vessels that supply or are within the brain and spine. The impairment may be identified in narrowed arteries, which restrict the flow of blood to the brain but increase the chances of stroke, specifically ischemic stroke. In addition, they also make arteries weak and set a condition for brain aneurysms, as well as increase the risk for intracranial bleeding, a condition referred to as a hemorrhagic stroke. Therefore, this condition associated with musculoskeletal trauma may result in severe injuries to blood vessels and nervous systems, which could cause temporary or permanent impairment in normal functions of the body.

An acute case of neurovascular impairment is a destructive condition that may occur undetected in critically ill people. The condition is of concern because of its ability to cause permanent impairment, loss of limbs, and death. For acute compartment syndrome (ACS), the clinical impairment results in escalated tissue pressure found in the muscle compartments, which are held by fascia, and they have the potential to trigger critical ischemia for the affected muscle and/or nerve tissue found within the compartment(Johnston-Walker & Hardcastle, 2011). In addition, insults that are close to the muscle compartment could also result in localized damage and edema of the tissue. As a result, the distal supply of the blood may be impaired, causing poor distal perfusion and the ejection of inflammatory chemicals in the affected parts of the muscle compartment as an attempt to enhance blood supply and oxygenation of the tissue (Johnston-Walker & Hardcastle, 2011).

Systemic conditions may also result because of the discharge of “intracellular muscle constituents into the circulation and extracellular fluid” (Johnston-Walker & Hardcastle, 2011, p. 171). Therefore, any conditions that result in a decrease in the size of the muscle compartment or an increase in the pressure in the muscle compartment may cause acute compartment syndrome.

It has been recognized that current guidelines have captured the variations in prognoses of the condition and therefore different therapeutic interventions are required (Kennedy & Buchan, 2004). The acute neurovascular syndrome may need a shift in clinical interventions to enhance outcomes. Studies have identified significant cases of early risk recurring ischemia, particularly in minor or recovered patients (Kennedy & Buchan, 2004).

Description of the pathophysiology of neurovascular impairment compartment syndrome

The notable changes associated with the neurovascular condition could be temporary or permanent impairment of the affected muscles or nervous system in the brain or the spine (Johnston-Walker & Hardcastle, 2011). An acute condition is degenerative and results in musculoskeletal trauma that may progress silently in critically ill individuals. The condition is important because of its ability to cause permanent damages to the limbs and dysfunction resulting in death.

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The identified condition is associated with escalating tissue pressure that impairs the affected muscle compartment. The condition could result in severe ischemia in the affected muscles and/or nerve tissue (Wright, 2009). Further, any insults that are adjacent to the muscle compartment could result in inflammation and tissue edema in the affected region. This situation may result in poor flow of distal blood, causing impaired distal perfusion and the discharge of anti-inflammatory chemicals within the affected muscles as an attempt to enhance the circulation of blood and oxygen to tissues. It may further cause vasodilatation of the capillary and leaching of fluid and colloid proteins that originate from vascular space into soft tissue (Johnston-Walker & Hardcastle, 2011). The fluid later flows into fascia muscles and causes edema, as well as enhanced pressure, which affects or inhibits the flow of blood into the muscle compartment.

Compartment syndrome normally results when the arterial perfusion pressure to “one or more of the fascial compartments of the affected limb falls below the tissue pressure” (Johnston-Walker & Hardcastle, 2011, p. 171). Too much tissue pressure that occurs because of edema, therefore, overwhelms arterial flow causing low perfusion and supply of oxygen. This condition causes ischemia of the muscles and nerves located within the affected muscle compartment (Johnston-Walker & Hardcastle, 2011). Nurses must detect and treat critical ischemia within a few hours because any delays could lead to the development of permanent muscle or nerve impairment, joint muscle tightening, or gangrene. In some instances, a patient may need an amputation.

Systemic conditions may also result from the impairment because of the discharge of intracellular elements of the muscle into the circulation system. Moreover, muscle insult and ischemia are also responsible for the breakdown and necrosis of muscle tissues because they discharge large volumes of “myoglobin, creatinine kinase (CK), potassium, phosphate and urate from the muscle into the circulation (rhabdomyolysis)” (Johnston-Walker & Hardcastle, 2011, p. 171). Renal failure could also result from myoglobin in the renal system. Myoglobinaemia may harden and block renal tubular. In addition, hyperkalemia is also most likely to develop because of the discharge of potassium, which is released because of muscle degeneration. This condition normally enhances the possibility of developing cardiac dysrhythmias. Another notable common condition is rhabdomyolysis, which can be extremely high specifically among patients with traumatic muscle insults.

Acute neurovascular impairment may result from any condition that either escalates the pressure in the muscle compartment or restrict the capacity of the compartment.

It is noted that many patients at risk of developing acute neurovascular impairment are mainly involved in severe injuries with fractures in which tibial shaft and distal radius and ulna fractures are common (Johnston-Walker & Hardcastle, 2011, p. 171). In addition, cases of burns, vascular insults, and surgical orthopedic patients who have undergone internal or external fixation of fractures are also at greater risks of developing acute compartment syndrome. Further, patients who may suffer long-term external pressure from casts or tight wraps are also most likely to develop the condition. The period for the risk is normally short, and it could range from two to 64 hours after surgery or a traumatic experience. This period is imperative for patients and nurses because critical care is normally needed within this short period. It is therefore important for critical care nurses to understand factors that could influence the development of acute neurovascular impairment and then take the right interventions after critical risk assessment (Judge, 2007).

Description of typical and actual signs and symptoms of neurovascular impairment compartment syndrome

It is imperative to note that the diagnosis of neurovascular impairment compartment syndrome relies upon slight changes in symptoms and some clinical examination results (Taylor, Sullivan, & Mehta, 2012). Therefore, nurses and physicians must be extremely careful because of the devastating consequences associated with delays.

The notable symptoms of the condition include weakness and numbness in affected parts of the body. Patients may lose their abilities to speak, see or feel, as well as lose body coordination and balance. In some instances, the symptoms could be mild or brief and may disappear within a few minutes or hours. For instance, a patient may lose vision or feel weak in the limb but these experiences may disappear within a few minutes completely. Disappearing signs could be warning signs for later stroke because they are transient ischemic attacks.

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Therefore, an initial assessment of the condition is imperative for patients. An injured extremity significantly depends on such assessment and subsequent immediate treatment. Studies have shown that delays in assessment and recognition of neurovascular conditions could result in amputation of the affected extremity or even death of the patient (Altizer, 2002). Nurses therefore must possess the right foundational knowledge concerning all neurovascular functional capabilities and be able to identify cases of impairment for accurate assessment of signs and symptoms and then recommended the required immediate interventions.

One major challenge has been the lack of literature on the assessment of pediatrics neurovascular conditions (Shields & Clarke, 2011). In fact, only a single tool had evaluation criteria for pediatric use (Shields & Clarke, 2011). Nevertheless, clinical experts have concurred that the assessment for neurovascular impairment should focus on the five Ps, including pain, pallor, pulses, paraesthesia, and paralysis (Dykes, 1993). Practitioners and researchers have determined that pain remains the most effective indicator, particularly in cases where assessment could be difficult (Shields & Clarke, 2011).

For children, nurses require effective neurovascular assessment tools to ensure that the outcomes are reliable. They should use a flow sheet or chart for neurovascular assessment to document outcomes. These findings must be classified appropriately for various multidisciplinary teams. Critical care nurses for children must also possess appropriate qualifications for such roles.

Pain has been consistently identified as the most relevant element of neurovascular assessment. However, it is also difficult to evaluate in some situations, especially when patients are unable to talk because of sedation or low levels of consciousness.

Pallor and perfusion are assessed to determine the color and warmth of the patient’s limbs because they reflect possible damages to tissues (Johnston-Walker & Hardcastle, 2011, p. 173). A pale or whitish skin could show poor “arterial perfusion, while cyanosis suggests venous stasis” (Johnston-Walker & Hardcastle, 2011, p. 173).

Nurses and physicians must also conduct an assessment on the peripheral pulse to determine the consistency of blood flow through arteries, affected area of the trauma, cast or surgery, and evaluate limb perfusion simultaneously (Johnston-Walker & Hardcastle, 2011).

Paraesthesia and paralysis are used to determine abnormal activities of the limb. For the sensory nerves, physicians must assess abnormal sensations because nerve systems are extremely sensitive to changes in body pressure. Numbness, pins and needles, and tingling have been associated with elevated fascial pressure.

For later stages of the condition, physicians and nurses may focus on the paralysis of the limb or extremity. Paralysis results from nerve compression or permanent damages to the muscle.

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Compartment pressure monitoring is also a significant component of diagnosis. In fact, acute compartment syndrome is normally regarded as a clinical diagnosis when the outcomes of the five Ps are considered. However, there are challenges with assessment specifically in critically ill patients. Thus, clinical assessment of neurovascular impairment could be challenging. Patients may be unconscious, uncooperative, or sedated and therefore the assessment could be subjective (Gonzalez, 2005). Acute compartment pressure can be measured through intramuscular compartment pressures (ICPs), which is believed to provide objective findings to assist in determining the onset of neurovascular impairment. ICPs perhaps could be the primary means of diagnosis for the impairment. Absolute pressure may be used to assess ICPs particularly for fasciotomy for the first six to eight hours before permanent changes take place on the limbs or extremity. Currently, differential pressure has been adopted because it tends to be more specific relative to absolute pressure because it can deliver measure that is more reflective in patients with “abnormal physiology, such as shock, compensatory hypertension and alteration in blood vessel resistance” (Johnston-Walker & Hardcastle, 2011, p. 175).

Description of common treatment modalities associated with the neurovascular impairment compartment syndrome

Treatment modalities for neurovascular impairment entail instant and thorough fasciotomy of every muscle compartment affected. The goal of these treatment options is to reduce tissue pressure, improve the flow of blood and control further damages to tissues and other related functional abilities (Johnston-Walker & Hardcastle, 2011).

In addition, management of pain and wound is vital for patient outcomes. Nurses may leave open wounds for a minimum of two days or until the condition is resolved.

It is imperative to note that neurovascular impairment is a highly complex condition involving delicate brain and spinal tissues with the interaction of several body mechanisms. Thus, treatments have often focused on effective comprehension and treatment of ischemic neural insult (Zhang, Zhang, & Chopp, 2012).

Description of common pharmacological treatment modalities associated with the neurovascular impairment compartment syndrome

Available pharmacological treatment modalities for neurovascular impairment are drug regimens consisting of opioids, nonopioids, and nonsteroidal anti-inflammatory drugs (NSAIDs), which are administered to manage pain in patients (Mar, Barrington, & McGuirk, 2009).

It is imperative to observe variations in dosage for adults and pediatrics. In addition, it is advisable to consider side effects and patient profiles when selecting medications for patients. For instance, acetaminophen may cause “liver damage, narcotics maybe lead to gastrointestinal distress, constipation, and sedation, in addition to possible addiction while NSAIDs could cause gastrointestinal upset, bleeding, renal damage and impaired coagulation” (Mar et al., 2009, p. 3).

With medications, pain and wound management strategies are the most important indicators of quality of care for patients. These drugs may ensure the comforts of patients while their sedating effects could provide beneficial results to patients with severe insults or trauma.

Analysis of collaborative interventions associated with the neurovascular impairment compartment syndrome

The trauma surgeon must lead and work with other professionals, especially orthopedic physicians to provide care for the patient. The patient may undergo resuscitation procedures, and nurses should observe vital functions about the five Ps, focus on life-threatening developing issues, and ensure care coordination with professionals (Lewis, Dirksen, Heitkemper, & Bucher, 2013).

In addition, nurses for neurovascular must possess important orthopedic knowledge to ensure that they can deliver the best care for enhanced patient outcomes (Altizer, 2002).

Inclusion of related concepts associated with the neurovascular impairment compartment syndrome and population-specific prevalence

Risk factors associated with neurovascular impairment include coagulation abnormalities associated with enhanced risk of intracompartmental hemorrhage, and a longer period of limb compression, which causes high chances for muscle ischemia, necrosis, and localized inflammatory changes (Johnston-Walker & Hardcastle, 2011). In addition, male and younger patients are at greater risks because of large muscle mass that may lower fascial compartment space and systemic hypotension that may cause muscle ischemia because of poor perfusion.

Nurses must possess exceptional abilities to detect compromised limbs, especially in children, and recommended effective treatment (Judge, 2007).

Neurovascular impairment has a relatively short period for risks and therefore immediate intervention is recommended after a thorough assessment.

Fasciotomy for limb intervention may be effective but has been associated with increased morbidity due to damages to nerves and muscle damage (Ferlic, Singer, Kraus, & Eberl, 2012). The incision may leave a large, horrid, and chronic wound that requires long-term care. Thus, wound and pain management in patients must be assessed effectively (Raza & Mahapatra, 2015).

There are medicolegal issues associated with neurovascular impairment and related outcomes (Raza & Mahapatra, 2015). Most of these issues are associated with physicians’ negligence and most rulings favor patients.

Tibial shaft fractures could be difficult to fix because of delayed union or nonunion in neurovascular impairment (Taylor, Sullivan, & Mehta, 2012). Thus, nurses have the responsibility to inform patients about their conditions, including high chances of fracture and wound management complications.

Conclusion

Neurovascular impairment is devastating for patients because of potential damages to the nerves and muscles. It causes loss of functional abilities, either temporary or permanent. It is imperative for nurses and physicians to detect the condition early to avoid potential permanent or long-term morbidity.

Patients who have experienced high impacts from insults and trauma face greater risks for developing neurovascular loss.

Five Ps have been agreed upon to be useful in assessment and nurses must rely on them for effective assessments by identifying possible changes in patients and recommending appropriate interventions. The case of children remains the most challenging because of the few guidelines available and medication restrictions.

There are risk factors for the condition but it remains a surgical emergency where effective diagnosis relies on subtle clinical outcomes and a thorough assessment and understanding of risk factors. Pressure monitoring is the most effective means of confirming the diagnosis. In all these processes, critical care nurses remain vital care providers.

References

Altizer, L. (2002). Neurovascular Assessment. Orthopaedic Nursing, 21(4), 48–50.

Dykes, P. (1993). Minding the Five P’s of Neurovascular Assessment. American Journal of Nursing, 93(6), 38-39.

Ferlic, W., Singer, G., Kraus, T., & Eberl, R. (2012). The acute compartment syndrome following fractures of the lower leg in children. Injury, 43(10), 1743-6.

Giddens, J. (2013). Concepts for nursing practice. St. Louis, MO: Mosby.

Gonzalez, D. (2005). Crush Syndrome. Critical Care Medicine, 31(1 Suppl), S34-41.

Johnston-Walker, E., & Hardcastle, J. (2011). Neurovascular assessment in the critically ill patient. British Association of Critical Care Nurses, 16(4), 170-177.

Judge, N. L. (2007). Neurovascular Assessment. Nursing Standard, 21(45), 39-44.

Kennedy, J., & Buchan, A. M. (2004). Acute Neurovascular Syndromes: Hurry Up, Please, It’s Time. Stroke, 35, 360-362.

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2013). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). St. Louis: Mosby.

Mar, G. J., Barrington, M. J., & McGuirk, B. R. (2009). Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. British Journal of Anaesthesia, 102(1), 3-11.

Raza, H., & Mahapatra, A. (2015). Acute Compartment Syndrome in Orthopedics: Causes, Diagnosis, and Management. Advances in Orthopedics, 2015, 543412.

Shields, C. J., & Clarke, S. (2011). Neurovascular observation and documentation for children within Accident and Emergency: A critical review. International Journal of Orthopaedic and Trauma Nursing, 15(1), 3–10.

Taylor, R. M., Sullivan, M. P., & Mehta, S. (2012). Acute compartment syndrome: obtaining diagnosis, providing treatment, and minimizing medicolegal risk. Current Reviews in Musculoskeletal Medicine, 5(3), 206–213.

Wright, E. (2009). Neurovascular impairment and compartment syndrome. Paediatric Nursing, 21(3), 26-9.

Zhang, L., Zhang, Z. G., & Chopp, M. (2012). The neurovascular unit and combination treatment strategies for stroke. Trends in Pharmacological Sciences, 33(8), 415– 422.

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