compartment syndrome

I always think abdominal compartment syndrome in an interesting phenomenon. We haven't had a case of it for a very long time, and it seems to be pretty rare from my experience, but still interesting. What made me think of it was a recent patient that thought he had compartment syndrome of his leg. Although compartment syndrome is well recognized in the extremities, this guy DID NOT have it. I'm not sure if someone told he has or may get it when he first came in, but his leg was a soft as could be. Nonetheless, he got me thinking about it and how it can also occur in the abdomen.

Compartment syndrome occurs when there is increased pressure within a fixed compartment that is usually limited by bone and/or fascia. In the abdomen, the result of this is organ dysfunction, such as decreased urine output from decreased renal perfusion or respiratory distress from decreased tidal volumes. It may seem a little strange to think of the abdomen as a fixed compartment. An extremity presents a clearer picture because its ability to distend is pretty limited. But even the abdomen will reach an endpoint in its ability to distend, as the picture above shows.

The abdomen can be at risk for compartment syndrome in an acute setting from an internal source such as intraperitoneal hemorrhage, an external factor that limits the belly from distending such as debris or structures crushing the patient, or even large volume resuscitation. An example of a chronic cause would be ascites from cirrhosis.

The key to resolving the sequela is to remove the pressure. This can be done by removing the external source or draining the internal source. Although patients with chronic ascites often undergo paracentesis (get "tapped"), this is probably not the best solution for someone who came in as a trauma patient. Most likely there is extensive internal bleeding, and merely draining the blood will not solve the problem. This would be a clear indication for going to the OR for an ex-lap to find the source of bleeding and repair it. But if there's that much blood, in some ways the pressure may be tamponading the source. In which case, once the belly opens, surgery could be quite tenuous and possibly a time when a patient "bleeds out."

Inmate trauma

I thought I'd cover the orange jumpsuit population since I work at the only hospital contracted to accept these patients in our county. Although it isn't the bulk of our patient population, we certainly do get incarcerated victims. Interestingly, the most common trauma mechanism in jail is blunt assault, whereas it is penetrating trauma (stab wounds) in state prison. The second most common mechanism is fall in jail and blunt assault in prison.

A common co-morbidity for both facility types is seizures. Psychiatric history is also common. Oftentimes these co-morbidities play a role in the inmate's trauma admission. For example, it is relatively common for an inmate to come in as a fall secondary to a seizure. Psychiatric illness can propagate an assault.

Sometimes we get inmates that come with a shady story about mechanism. You'll get a guy telling an elaborate story about how he fell getting out of the shower cell and yet his injuries are highly consistent with assault (like bilateral facial fractures!).

You also get often mysterious "fall from bunk" followed by an endless complaint of parasthesias. Of course everything must be taken seriously, just in case, so they get a full workup in hospital that include MRIs, neurology consults, neuro checks and observation. After days in hospital and the results are negative, as they often are, they go back to jail/prison.

But, despite their tendency to want to linger in the hospital, they are more often than not very polite and friendly! Perhaps it's because the environment is so different from their ususal day-to-day.

cactus trauma?

Who would think, right? I'm not sure if I'd go so far as to say trauma, but apparently anything goes. So what happens if you have a traumatic encounter with a cactus? It is probably pretty unlikely that you will suffer penetrating trauma unless you find a cactus with particularly long spines. But what you may get is dermatitis. The picture of papules above is typical of dermatitis secondary to cactus pricks.

Dermatitis from a cactus generally occurs because of the mechanical irritation. There can be immunologic or infectious reactions as well, though. The cactus spines can scratch the skin causing wounds or excoriations, and the spines may break off in the skin or subcutaneous tissue causing papules or nodules.

Apparently it is the smaller spines that are more troublesome than the long scary ones. This is because the little ones can be barbed, making removal difficult. If they aren't removed, dermatitis can persist for months. A popular and successful method for removing this tricky bristles is to cover the area with sticky plaster or hot wax and then quickly removing it.

I have to say this is a new one for me. I didn't know this much about a cactus or cactus care until I had a recent clinical encounter with a cactus run-in. But now we all know a little more!

mixed results in articles

It appears to be a big month for discussing the nursing career in general nursing journals and magazines. Advance for Nurses highlighted "2010 Nursing Forecast" on their cover, Advance for Nurse Practitioners released their salary results in "Salary Survey Results: good news despite economy," and there's Lippincott's 2010 Nursing Career Directory that came out.

Kind of interesting to read them and come away with mixed reviews. The article Nursing (Job) Shortage discussed the difficulties new nursing grads are having in finding jobs because older nurses aren't retiring in this economy, seasoned nurses aren't venturing out for a position change right now, and the regular workers are picking up extra shifts.

On the flip side, the NP salary results article painted a different impression of the nursing profession. It discussed how healtcare jobs appeared strong, while overall other employment was bleak. It stated that healthcare actually added almost 600,000 positions and the overall NP salary increased yet again (up by >$8000).

Perhaps the difference is in being a new grad vs. already in a position. Perhaps the difference is between finding an RN job vs. an NP job. Maybe there's some bias in the articles. I'm not trying to compare apples and oranges. But I did feel there was a discrepancy among the articles in the overall outlook and impression of where our discipline stands in this economy right now.

From my standpoint, I don't feel largely impacted by the economy. I heard our hospital did a hiring-freeze, which has now been lifted. We did miss our annual pay raise, which I suppose does count for something. But I don't know of anyone who lost a job in our hospital or suffered a pay cut or cut in hours. I suppose even if I took the position that nursing has hit hard times, I have no doubt it will bounce back. The old are getting older, and there will be more and more of them to take care of. Nursing will be needed.

Head Bleeds

Yesterday we had a discussion about a case involving a significant head injury resulting in death. We ended up talking about different types of head bleeds and I thought it would be good to do a refresher.


Subdural hematoma/hemorrhage (SDH): This is when blood collects within the inner meningeal layer of the dura mater, the outer protective covering of the brain. The picture to the right is a CT scan showing a good sized left SDH, which you can see is also exerting midline shift to the right. (Of note when looking at CT scans, blood shows up white, air is black, brain matter grey, and the image is reversed- like a chest x-ray).



Subarachnoid hemorrhage (SAH): This is bleeding into the subarachnoid space, which is the area between the arachnoid membrane and the pia mater surrounding the brain (meaning the area between the brain and the thin tissues that cover the brain). The SAH image to the left shows blood in bilateral sylvian fissures and down the center interhemispheric fissure. The 2 white spots toward the back are not blood but rather normal calcifications.


Intraparenchymal hemorrhage (IPH): This is where there is bleeding into the tissue of the brain. Pretty obvious, that white blotch on the left.


Epidural hematoma (EDH): This is where blood collects between the dura mater and the skull. This is outside the dura, whereas the SDH was below the dura. It's pretty hard to miss that EDH imaged to the right, which is causing midline shift and compression of the left ventricle.


Question: How can someone status post craniectomy (bone flap NOT replaced) still have elevated ICPs?
Answer: Even with a bone flap missing, neurosurgeons almost always still close the dura, which is that tough outer membrane. The dura is tough enough to still limit significant cerebral edema and impose pressure, therefore raising ICP (intracranial pressures).

Haiti Relief

As we all know, unless you're under a rock, there was a large earthquake in Haiti earlier this week that resulted in thousands of deaths and massive destruction. Well, does anyone remember my blog about the new nursing super-union? In response to this tragedy, they have issued an urgent call for nurse volunteers to help in "Earthquake Ravaged Haiti." The National Nurses United activated its nationwide disaster relief program to recruit nurse volunteers to help residents of Haiti following the earthquake devastation. Just to remind everybody, the 150,000-member NNU was formed last month through the unification of California Nurses Association/National Nurses Organizing Committee, United American Nurses, and Massachusetts Nurses Association.

“Nurses will be fundamental to the disaster relief process, to provide immediate healing and therapeutic support to the patients and families facing the devastation from this tragic earthquake,” the Co-Executive Director, Rose Ann DeMoro, said. They are working on sending nurses to provide emergency short and long term medical support, as they have done in previous major disasters, such as Katrina.

What else can I be?

I get asked a lot about my job. What is a nurse practitioner? What do you do? How are you different than a doctor? How are you different than a nurse? And in one of my first blogs I discussed a lot of this. But I also get asked what career alternatives are out there. So I thought I'd mention a few other career options if you think healthcare is for you but not sold on being an NP.

Probably the most similar job is a physician assistant, aka a PA. Like NPs, they diagnose, treat, manage patient's care, prescribe, and order and analyze labs and studies. The main difference is that NPs practice under the nursing model and PAs practice under the medical model, like physicians. Training is also different. NP programs entail earning an MSN (master's in nursing) degree in an area of specialty (acute care, adult, pediatric, etc). PAs spend generally 2 years studying general medical and surgical care.

If you are interested in anesthesia, you should definitely consider becoming a Certified Registered Nurse Anesthetist (CRNA). This is also an advanced practice nurse, requiring a master's degree, and that allows you to deliver anesthesia. Of the practicing CRNAs they are 51% females and 49% males. This is the nursing version of an anesthesiologist.

If you are interesting in delivering babies, you should consider being a nusre midwife. Once again, this is a master's prepared advanced practice nurse, and is similar to an OB/GYN physician. Midwives tend to care for the pregnancies in the no to low-risk category and practice under the nursing model.

There are far more options for a career in healthcare other than these mentioned, but these are options that could be considered largely on par with choosing a career as a nurse practitioner. You could also work as a registered nurse, physician, clinical nurse specialist, nurse researcher, physical or occupational therapist, respiratory therapist, and more. With so many options, you're bound to find a niche that works for you!