Respond to peers for discussion post

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Below is the case study that my peers responded to. Below that in bold you will find two responses. Please respond to both with references.

Case scenario 1: A 60-year-old female with PMH of HTN, HLD, DM, and Hypothyroidism was admitted due to non-exertional chest pain. The patient underwent Coronary CT Angiography. The patient developed right forearm extravasation when the IV contrast was administered. You are the 1st call provider and were notified by the radiologist about the incident.

Answer the following questions:

1. Subjective
   • What pertinent information would you ask the radiologist?
   • What pertinent information would you ask the patient?
2. Objective:
   • What would be the focus of your assessment?
   • What tests or procedures (Lab or Diagnostic) would you perform or order for this patient?
3. Diagnosis:
   • What are the top 3 differential diagnoses you would consider for this patient, and what is your rationale?
   • You ordered to measure the Compartment Pressure, and the result was 28 mm Hg. What is your interpretation of the result?
   • What is the final diagnosis?
   • If the total CK result was 16,000 would you consider other diagnoses and plan of care? Discuss your rationale.
4. Plan:
   • What is the gold standard treatment for the patient’s final diagnosis?
   • When would you consider consulting other services? Discuss your rationale.
   • What is your disposition? Admit vs. Discharge? Why?

(Gabriela: Peer Discussion 1)

Hello class,

Case scenario 1: A 60-year-old female with PMH of HTN, HLD, DM, and Hypothyroidism was admitted due to non-exertional chest pain. The patient underwent Coronary CT Angiography. The patient developed right forearm extravasation when the IV contrast was administered. You are the 1st call provider and were notified by the radiologist about the incident.

Answer the following questions:

1. Subjective
   • What pertinent information would you ask the radiologist?
• What type of contrast was used?
• What volume of contrast was administered?
• How long did it take for the patient to develop extravasation?
• Extent of extravasation?
• Other relevant details about the incident, including IV catheter size, or injection technique?
• Any immediate measures taken to manage the extravasation?
• What pertinent information would you ask the patient?
• Do you have any pain, if so, describe location, characteristics, and intensity, as well as relieving and aggravating factors
• Can you describe your pain? Sharp, dull, stabbing, pressure?
• Is there anything making the pain worse? Does it radiate anywhere else?
• When did your symptoms started? What were you doing when the pain started?
• How long have you been experiencing these symptoms?
• Have you experience the same symptoms before? If so, how long ago, and did you seek medical care?Have you experience the same symptoms before? If so, how long ago, and did you seek medical care?
• Have you experienced palpitations, shortness of breath, fatigue, cold sweats, or nausea? If so, do symptoms appear independently or together?
• Do you have a history of heart disease, hypertension, pulmonary emboli, deep venous thrombosis, chronic lung diseases?
• When did you first notice the extravasation? Is the area painful?
• Do you have any numbness or tingling in your arm?
• Do you have any allergies or previous adverse reactions to medications or contrast dyes?
• Are you currently taking any prescribed medications? Have they been started, stopped or changed recently?
1. Objective:
• What would be the focus of your assessment?
• Monitoring vital signs, including blood pressure, heart rate and oxygen saturation
• Monitoring changes in pain level, swelling, numbness, and tingling in the affected arm.
• What tests or procedures (Lab or Diagnostic) would you perform or order for this patient?
• Compartment pressure measurement
• Complete blood count (CBC)
• Basic metabolic panel (BMP)
• Coagulation studies including PT, PTT, INR
• Troponin
• Creatinine kinase (CK) level
• Electrocardiogram (EKG)
• Chest X-ray
1. Diagnosis:
• What are the top 3 differential diagnoses you would consider for this patient, and what is your rationale?
• Acute coronary syndrome (ACS) should be prioritized as a major consideration due to the patient’s risk factors including hypertension (HTN), hyperlipidemia (HLD), and diabetes mellitus (DM), as well as the presence of chest discomfort and the requirement for coronary CT angiography.
• The occurrence of extravasation during contrast injection gives rise to concerns regarding extravasation injury, which has the potential to result in compartment syndrome as a consequence of heightened pressure within the compartments of the forearm. Considering the patient’s medical background involving the administration of intravenous contrast during a prior surgery, it is noteworthy that extravasation occurred immediately after the aforementioned intervention
• Musculoskeletal chest discomfort can arise from musculoskeletal sources, such as costochondritis or strain in the chest wall muscles.
• You ordered to measure the Compartment Pressure, and the result was 28 mm Hg. What is your interpretation of the result?

A compartment pressure measurement of 28 mm Hg indicates an increased pressure within the compartments of the forearm.A reading equal to or exceeding 30 mm Hg is indicative of compartment syndrome.Nevertheless, it is crucial to acknowledge that compartment pressures may exhibit normal values during the initial phases of compartment syndrome. Hence, it is imperative to consistently observe the patient for indications and manifestations of compartment syndrome, including escalating discomfort, swelling, and numbness (Torlincasi et al., 2023).

• What is the final diagnosis?

The final diagnosis for this patient would be contrast-induced extravasation with possible compartment syndrome

• If the total CK result was 16,000 would you consider other diagnoses and plan of care? Discuss your rationale.

In the event that the cumulative creatine kinase (CK) measurement indicated a value of 16,000, it would be necessary to contemplate alternative diagnoses such as rhabdomyolysis or myositis. Rhabdomyolysis is a pathological state characterized by the disintegration of muscle fibers, leading to the discharge of their intracellular contents into the circulatory system. Conversely, myositis refers to the inflammatory response occurring inside the muscular tissues. Both of these medical disorders manifest with symptoms such as muscular discomfort, edema, and diminished muscular strength.

In cases where there is suspicion of rhabdomyolysis or myositis, it is necessary to admit the patient to the hospital in order to conduct a comprehensive assessment and administer appropriate therapeutic interventions. The treatment regimen may encompass proactive administration of fluids to restore hydration, diligent monitoring of renal function and electrolyte levels, and the prescription of drugs aimed at managing muscular pain and inflammation. Furthermore, consultations with nephrology specialists may be sought to ensure comprehensive care ( Kley et al., 2018).

1. Plan:
• What is the gold standard treatment for the patient’s final diagnosis?

Early detection and intervention are considered the optimal approach for managing contrast extravasation injury. The recommended interventions encompass discontinuing the administration of contrast dye, removing IV, elevating the affected extremity, and employing cold compresses. In instances where the extravasation is of significant size or affects a vital anatomical region, such as the hand or foot, hospitalization may be necessary to provide additional therapeutic interventions. The course of action for this particular patient will be contingent upon the extent of the extravasation and the patient’s overall clinical status. In cases when the extravasation is of a minor nature and the patient does not exhibit any symptoms of discomfort, swelling, or numbness, it may be deemed appropriate to discharge the patient and provide them with instructions to elevate the afflicted leg and use cold compresses. In cases when the extravasation is of considerable size or the patient is presenting with notable pain, swelling, or numbness, hospital admission becomes necessary to facilitate additional therapeutic interventions. The potential treatment options provided in a hospital setting may encompass the administration of intravenous fluids to facilitate the elimination of contrast dye from the tissues, the provision of pain medication, the prescription of antibiotics as a preventive measure against infection, the elevation of the affected limb, the application of cold compresses, and the utilization of hyaluronidase injections to facilitate the breakdown of contrast dye and enhance its absorption into the bloodstream. In instances of significant severity, surgical intervention may be deemed necessary to excise impaired tissue or alleviate compression on the nerves and vasculature (Kim et al., 2020).

• When would you consider consulting other services? Discuss your rationale.

In cases of severe extravasation or the emergence of problems such as skin necrosis or compartment syndrome, it may be imperative to seek consultation from other medical services, including vascular surgery or plastic surgery.

• Vascular/plastic surgery consultation is indicated in cases where the patient exhibits substantial extravasation or has consequences such as skin necrosis or compartment syndrome.
• Nephrology consultation should be considered in cases where rhabdomyolysis is suspected if there is a decline in the patient’s renal function.
• What is your disposition? Admit vs. Discharge? Why?

It is recommended that the patient be admitted to the hospital for the purpose of observation and treatment. Contrast extravasation can result in significant consequences, including the development of compartment syndrome and skin necrosis. Admission to the hospital facilitates the opportunity for diligent observation of the patient’s state and prompt action in the event that issues arise. Furthermore, it is imperative to conduct a comprehensive assessment and implement appropriate measures to investigate and address the patient’s chest pain, with the aim of excluding or managing acute coronary syndrome. Hospitalization facilitates the close monitoring, implementation of suitable therapy, and coordination of care across several specialized fields.

References:

Kim, J. T., Park, J. Y., Lee, H. J., & Cheon, Y. J. (2020). Guidelines for the management of extravasation. Journal of Educational Evaluation for Health Professions, 17, 21. https://doi.org/10.3352/jeehp.2020.17.21

Kley, R. A., Schmidt-Wilcke, T., & Vorgerd, M. (2018). Differential diagnosis of hyperckemia. Neurology International Open. https://www.thieme-connect.com/products/ejournals/…

Torlincasi, A. M., Lopez, R. A., & Waseem, M. (2023). Acute Compartment Syndrome. In StatPearls. StatPearls Publishing.

(Leonardo: Peer Response 2)

Case Scenario 1:

Case scenario 1: A 60-year-old female with PMH of HTN, HLD, DM, and Hypothyroidism was admitted due to non-exertional chest pain. The patient underwent Coronary CT Angiography. The patient developed right forearm extravasation when the IV contrast was administered. You are the 1st call provider and were notified by the radiologist about the incident.

Answer the following questions:

1. Subjective

What pertinent information would you ask the radiologist?

• I would ask the radiologist about the extent and location of the extravasation, the amount and type of contrast used, the time of onset and duration of the extravasation, and any signs or symptoms of compartment syndrome or infection in the affected arm (Torlincasi et al., 2022).
• I would also ask the radiologist about the results of the Coronary CT Angiography and if there were any findings suggestive of coronary artery disease or other cardiac conditions.

What pertinent information would you ask the patient?

• I would ask the patient about their medical history, medications, allergies, and any previous reactions to contrast agents.
• I would also ask the patient about their chest pain, its onset, duration, frequency, quality, intensity, radiation, associated symptoms, and relieving or aggravating factors.
• I would also ask the patient about their right forearm pain, swelling, redness, warmth, numbness, tingling, weakness, or decreased range of motion (Torlincasi et al., 2022).
1. Objective:

What would be the focus of your assessment?

• Inspecting the right forearm for swelling, redness, bruising, blistering, or skin necrosis (Torlincasi et al., 2022).
• Palpating the right forearm for warmth, tenderness, firmness, or crepitus.
• Measuring the circumference of the right forearm and comparing it with the left forearm.
• Assessing the distal pulses, capillary refill, sensation, and motor function of the right hand.
• Checking the blood pressure and heart rate of both arms and noting any difference.

What tests or procedures (Lab or Diagnostic) would you perform or order for this patient?

• Complete blood count (CBC), basic metabolic panel (BMP), coagulation profile (PT/INR, PTT), creatine kinase (CK), troponin, and C-reactive protein (CRP) to evaluate the patient’s hematologic, renal, hepatic, cardiac, and inflammatory status (NHS Choices, 2019).
• Electrocardiogram (ECG) to rule out any acute cardiac ischemia or arrhythmia.
• Ultrasound of the right forearm to assess the extent of soft tissue damage and vascular compromise caused by the extravasation (Torlincasi et al., 2022).
• Compartment pressure measurement of the right forearm to diagnose or exclude compartment syndrome (NHS Choices, 2019).
1. Diagnosis:

What are the top 3 differential diagnoses you would consider for this patient, and what is your rationale?

1. Compartment syndrome: Occurs when there is increased pressure within a closed space compromising blood flow and tissue perfusion (NHS Choices, 2019). It can be caused by trauma, burns, fractures, infections, or extravasation of fluids or medications. The patient has risk factors such as hypertension, diabetes mellitus, hypothyroidism, and contrast administration (NHS Choices, 2019). The patient also has signs and symptoms such as pain out of proportion to injury, swelling, redness, warmth, numbness, tingling, weakness, and decreased range of motion in the affected arm (Radswiki, 2021). The diagnosis can be confirmed by measuring the compartment pressure, which is usually above 30 mm Hg in acute cases.
2. Allergic Reaction to Contrast: Evaluate for any signs of an allergic reaction.
3. Acute coronary syndrome: This is a spectrum of conditions that result from reduced blood flow to the heart muscle. It can manifest as unstable angina, non-ST segment elevation myocardial infarction (NSTEMI), or ST segment elevation myocardial infarction (STEMI) (Singh & Grossman, 2019). It can be caused by factors such as atherosclerosis, coronary artery spasm, thrombosis, embolism, or vasculitis. The patient has risk factors such as hypertension, hyperlipidemia, diabetes mellitus, hypothyroidism, and chest pain. The diagnosis can be confirmed by performing an ECG and measuring cardiac biomarkers such as troponin (Singh & Grossman, 2019).

You ordered to measure the Compartment Pressure, and the result was 28 mm Hg. What is your interpretation of the result?

A compartment pressure of 28 mm Hg is significantly elevated and close to the diagnostic threshold of 30 mm Hg suggesting compartment syndrome, particularly when combined with clinical findings. Therefore, it indicates that the patient is at high risk of developing compartment syndrome and requires close monitoring and intervention.

What is the final diagnosis?

Compartment syndrome of the right forearm due to contrast extravasation.

If the total CK result was 16,000, would you consider other diagnoses and plan of care? Discuss your rationale.

A high CK level indicates muscle damage and can be a sign of rhabdomyolysis, which is a serious condition in which muscle breakdown products such as myoglobin can cause kidney injury (Torres et al., 2015). Rhabdomyolysis can be caused by compartment syndrome or other factors such as trauma, ischemia, infection, drugs, or toxins (Torres et al., 2015). I would order urine analysis to check for myoglobinuria and monitor serum creatinine and urine output to assess renal function. I would also order electrolytes to check for hyperkalemia, hypocalcemia, or hyperphosphatemia that can result from rhabdomyolysis. I would initiate intravenous fluid resuscitation with normal saline to prevent acute kidney injury and correct electrolyte imbalances. I would also consult nephrology for possible renal replacement therapy if indicated.

1. Plan:

What is the gold standard treatment for the patient’s final diagnosis?

The gold standard treatment for acute compartment syndrome is surgical decompression by fasciotomy, which is an incision through the fascia to relieve the pressure within the muscle compartment (Torlincasi et al., 2022). This procedure should be done as soon as possible, preferably within 6 hours of symptom onset, to prevent irreversible nerve or muscle damage. The patient should also receive analgesia, elevation of the affected limb, and removal of any constrictive dressings or devices. Antibiotics may be given prophylactically to prevent infection.

When would you consider consulting other services? Discuss your rationale.

I would consider consulting other services such as:

1. Orthopedic surgery: This service should be consulted urgently for surgical decompression by fasciotomy. They can also evaluate the extent of tissue damage and provide wound care and reconstruction if needed.
2. Vascular surgery: This service may be consulted if there is any concern about vascular injury or compromise due to contrast extravasation or compartment syndrome. They can perform angiography, endovascular intervention, or bypass surgery if indicated.
3. Plastic surgery: This service may be consulted for wound closure, skin grafting, or flap coverage after fasciotomy. They can also provide cosmetic and functional restoration of the affected limb.
4. Cardiologist: if there was evidence of acute coronary syndrome or myocardial infarction that required PCI or coronary artery bypass grafting (CABG) (Singh & Grossman, 2019).
5. Infectious Disease Specialists: if there was evidence of infection or sepsis that required antibiotic therapy or source control.

What is your disposition? Admit vs. Discharge? Why?

I would admit the patient to the hospital for further management and observation. The patient has a serious condition that requires urgent surgical intervention and possible consultation with other services. The patient also has multiple comorbidities that increase the risk of complications such as infections, rhabdomyolysis, acute kidney injury, or Volkmann’s contracture and poor outcomes (Torlincasi et al., 2022). Moreover, the patient also needs close monitoring of vital signs, pain level. Therefore, the patient is not suitable for discharge.

References

Garner, M. R., Taylor, S. A., Gausden, E., & Lyden, J. P. (2014). Compartment Syndrome: Diagnosis, Management, and Unique Concerns in the Twenty-First Century. HSS Journal ®, 10(2), 143–152. https://doi.org/10.1007/s11420-014-9386-8

NHS Choices. (2019, September 17). Compartment syndrome. NHS. https://www.nhs.uk/conditions/compartment-syndrome/

Radswiki. (2021). Contrast media extravasation | Radiology Reference Article | Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/contrast-media-extravasation

Singh, A., & Grossman, S. A. (2019, November). Acute Coronary Syndrome. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459157/

Torlincasi, A. M., Lopez, R. A., & Waseem, M. (2022). Acute Compartment Syndrome. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448124/#:~:text=Classically%2C%20the%20presentation%20of%20acute

Torres, P. A., Helmstetter, J. A., Kaye, A. M., & Kaye, A. D. (2015). Rhabdomyolysis: pathogenesis, diagnosis, and treatment. The Ochsner Journal, 15(1), 58–69.