This is the HEART score, which be used to decide which patients require admission to the hospital for chest pain, and which ones can be safely discharged. It is recommended that the score (and criteria) be documented in your chart!
Compartment Syndrome is a known complaint of orthopedic injuries, fractures, and crush injuries, and is an often overlooked side effect of tight splint or cast application. Compartment syndrome can also be the result of space occupying lesions, infections, or fasciitis.
Classically, compartment syndrome presents with severe pain, out of proportion to examination, pallor or pale coloration to the distal extremities, pulslessness due to compression of blood vessels limiting distal blood flow and, in its late stages, paresthesia, or complete loss of sensation due to nerve ischemia.
Muscles should be viewed as bundled fibers wrapped in fascia, and injury to those muscles can cause swelling, edema, and pain. When swelling exceeds the limit of the fascia wrapping the muscles, the swelling becomes very tight, and begins to compromise blood vessels.
Any splint, cast, or bandage should be removed and the extremity should be examined for pain and vascular flow. Palpable pulses, capillary refill, and sensation, if present are reassuring. Formal evaluation should be performed by measuring compartment pressures, which can easily be performed by using a compartment pressure device. Compartment measurement devices use hydrostatic pressure to measure the compartment of a muscle. Values greater than 30mmH20 are highly suggestive of compartment syndrome and warrant immediate orthopedic evaluation. Once calibrated, the device needle should be injected into the compartment of concern. Great care should be taken to insert the needle deeply into the compartment. See the diagram below for instructions to set up compartment pressure device.
Compartment pressures between 20-30 should be repeated to evaluate for worsening pressure levels. The definitive management for compartment syndrome is surgical fasciotomy, which can be performed emergently at the bedside, but ideally should be performed under sterile conditions in the operating room.
Fasciotomy will require extensive plastic repair, skin grafting, and is best managed in a setting that provides specialized services for long-term repair. See photo below for example of open fasciotomy:
- No need to start antiepileptic drugs for resolved 1st unprovoked seizure without evidence of brain disease/injury
- When restarting / loading antiepileptic drugs the route is not important unless status epilepticus
- If status epilepticus refractory to benzodiazepines, add IV antiepileptic
- Unprovoked seizures are considered a seizure without a precipitating factor in the last 7 days (nuerological/systemic/metabolic/toxic insult)
Start your treatment plan based on patient type:
Patient returned to baseline LOC with 1st generalized seizure that was UNPROVOKED
- Admission is not required and do not initiate antiepileptic drugs
- If returned to baseline with 1st generalized seizure but had prior precipitating factors that were greater than 7 days the admission is still NOT required. You may initiate antiepileptic drugs or refer to neurology
Patient returned to baseline LOC with 1st generalized seizure that was PROVOKED
- Identify and manage the precipitating condition (hyponatremia, electrolyte abnormalities, withdrawal, toxins, encephalitis, lesions, etc)
- You do not have to start antiepileptics, the goal is to treat the condition that cause the seizure
Patient returned to baseline LOC with known seizure disorder
- Resume usual antiepileptics
- Consider IV or PO load
- Evidence lacks to support either PO or parental route
- Carbamazepine 8mg/kg PO
- Gabapentin 300mg PO TID x 3 days
- Lacosamide PO or IV ( loading dose has not been studied)
- Lamotrigine 6.5mg/kg PO (if tolerated, no rash in last 6 months and only off of drug for less than 5 days)
- Levetiracetam 1500mg PO or rapid IV (up to 60mg/kg)
- Phenytoin 20mg/kg in 3 diviided doses Q2H PO (max 400mg per dose)
- Phenytoin 18mg/kg IV
- Fosphenytoin 18 PE/kg IV
- Valproate up to 30mg/kg IV
Patient NOT returning to baseline LOC (status epilepticus)
- Seizure lasting 20 min or more or intermittent seizures without regaining full consciousness
- First line treatment is to dose patient optimally with benzodiazepines
- Next you should identify and manage the underlying cause
- Second line treatment is to add antiepileptics if refractory to benzodiazepines
- Phenytoin 18-20mg/kg IV
- Fosphenytoin 18-20 PE/kg IV
- Valproate 20-30mg/kg IV at 40mg/min
- Levetiracetam 30mg-50mg/kg IV at 100mg/min
- Propofol 2mg/kg IV, may repeat dose in 3-5min; maintenance 5mg/kg/h
- Phenobarbital 10-20mg/kg IV, may repeat 5-10mg/kg at 10min
* Although neuroimaging is not discussed, immediate non contrast CT of the head is possibly useful when there is an abnormal physical exam, predisposing history, or focal onset of seizures. If the patient has new onset of seizures a baseline CT of the head should be completed. If a structural lesion is found on imaging this can be helpful with decision making.
And so the rest of this blog post comes to you – the biggest investment in healthcare.
Physicians, Physician Assistants, Nurse Practitioners – anyone who is considered a provider in healthcare, is now having their own quality measures applied to their care delivery. As part of the permanent “Doc Fix” the Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015. CHIP is the Children’s Health Insurance Plan that provides matching federal payments to state-funded children’s insurance programs. MACRA is designed to shift the healthcare fee-for-service model of payments to the value-based payment (quality) payment model through Merit-based Incentive Programs (MIPs), which are designed to focus on quality measures at the provider level. Each specialty will have different requirements. The intent of these quality measures is aimed at reducing cost, but their application to current medical standards is debatable.