Failure to recognize and diagnose compartment syndrome

On August 4, a 39-year-old woman came to Hospital A for induction of labor due to Rh isoimmunization and polyhydramnios. The patient was at 37 weeks’ gestation and her expected due date was August 18.The patient had a history of hypertension and uterine fibroids, and she had a BMI of 44.5.

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Read the full case study below.

by Wayne Wenske, Senior Marketing Strategist

Presentation

On August 4, a 39-year-old woman came to Hospital A for induction of labor due to Rh isoimmunization and polyhydramnios. The patient was at 37 weeks’ gestation and her expected due date was August 18. The patient had a history of hypertension and uterine fibroids, and she had a BMI of 44.5.

Physician action

Upon admission, the patient became increasingly argumentative with her obstetrician-gynecologist (ob-gyn) regarding treatment recommendations and care. She refused blood work-up and medication to treat her hypertension, even though her blood pressure was 170/90 mmHg the previous day.

The patient’s cervix was described as 'unfavorable' at the time of induction. She was counseled on the need for a cesarean delivery if her cervix remained unchanged or if fetal indications required one. The patient refused the idea of a cesarean delivery unless there were fetal complications.

On August 5, the patient went into labor and became tachycardic, with a deceleration of the fetal heart rate to the 60s. The patient passed out and was taken for an emergency cesarean delivery.

While in the OR, the patient went into a ventricular tachycardia cardiac arrest. She was given epinephrine, calcium bicarbonate, and was intubated. An IV was found to be infiltrated and then restarted. A boy was delivered and taken to the neonatal intensive care unit (NICU).

While the ob-gyn was closing the patient’s uterine incision, the patient was noted to be hemorrhaging vaginally and oozing from IV sites. A coagulation assessment showed signs of disseminated intravascular coagulation(DIC), secondary to a possible amniotic fluid embolism.

The patient was started on vasopressors and a massive blood transfusion protocol was ordered. As she was still hemorrhaging vaginally, an intrauterine balloon tamponade device was also placed and distended with 400ccs of saline. She remained stable for several hours in the OR, and was transferred to the ICU.  

The patient’s blood pressure was 135/69 mmHg. Her lab studies revealed severe coagulopathy. The transfusion protocol was continued in the ICU, as the patient continued to bleed from the abdomen, vagina, and mouth.The patient also experienced acute respiratory failure and acute renal failure.The ob-gyn’s documented care plan was to continue the vasopressors and full ventilator support and to repeat lab studies to manage her acute respiratory failure.  

A critical care physician monitored the patient in the ICU and documented that she remained coagulopathic. No cyanosis or edema was observed in her arms and legs. The physician noted the patient was 'very critically ill' and her prognosis was grave.

The patient’s condition deteriorated and she was taken to the OR for an exploratory laparotomy to evacuate blood and to identify and address any sources of bleeding.  

During the procedure, the ob-gyn found 850mL of fresh blood and clots in the abdominal cavity, although no definite bleeding vessels were identified. The clots were evacuated, but the patient continued to bleed. She underwent an evacuation of the hemoperitoneum, supracervical hysterectomy, left salpingo-oophorectomy, and right salpingectomy. Post surgery, the patient’s lower abdominal incision and vaginal cavity continued to ooze blood, and her left hand became swollen and taut.

For the next few days, the patient remained in the ICU on a ventilator. She was given additional blood transfusions, IV fluids, fentanyl for pain, and metoprolol. Eventually, her DIC, bleeding, and breathing improved, but her high blood pressure persisted. She remained intubated. The ob-gyn documented concern for a 'left hand DVT with several bullous lesions.'The left thumb and index fingertip were noted as looking 'purplish' and swollen.

By August 10, the patient’s bleeding had stopped and her DIC and renal failure had improved, though she remained intubated. She was treated for an open and oozing blister on her left hand. A physical exam that evening showed 1+ edema in her arms and legs, along with a deep vein thrombosis (DVT)and blisters on her left arm.  

Three days later, the patient was extubated. A chest x-ray revealed basilar atelectasis, with no evidence of acute pulmonary infiltration.

A wound care consultant examined the patient’s left hand and noted that the infusion of vasopressors resulted in blister formation on her left hand.

On August 15, nursing staff documented that the patient’s left hand was 'black with blisters' and her IV site was leaking fluid. Left radial brachial pulses were palpable, and she denied having any pain. An ultrasound of her left arm showed flow to the wrist from both the radial and ulnar arteries.

A vascular surgeon evaluated the patient’s arm and documented that the blistering began after the vasopressors were reduced. He noted swelling and that her left hand had blistering, no movement, limited gross sensation, and had contracted into a claw formation. The blistering extended to her wrist, and her distal forearm was swollen to the elbow.

The vascular surgeon documented that compartment syndrome had developed at least three to five days earlier. His plan was to perform a decompressive fasciotomy of the hand and forearm the next day. He further noted that the procedures were not required emergently as 'whatever damage [as a result of compartment syndrome] is done and is irreversible.' 

This is the first note of compartment syndrome in the patient’s record.

Early on August 16, the patient reported intense pain (9/10)in her left arm. The vascular surgeon performed a four-compartment fasciotomy on her left forearm, a fasciotomy of the five digits on her left hand, and a fasciotomy of the left hand. The surgeon planned to close the wounds in five to10 days, after the swelling had gone down. Enoxaparin sodium was given to treat the DVT.

A week later (August 23), the vascular surgeon performed an exploration and debridement of the patient’s left hand and arm. Significant ischemic change was seen in the hand and wrist, and he noted that the hand might require amputation. He completed a partial complex closure of the proximal left forearm wound.

A plastic surgeon was consulted for a second opinion and agreed that significant ischemic change was present and consistent with compartment syndrome. The plastic surgeon noted that the ischemic change was consistent with compartment syndrome/reperfusion injury and that the patient’s left-hand digits, hand, and wrist were not salvageable.

On September 2, the plastic surgeon performed a left trans-radial amputation using a wound vacuum-assisted closure (VAC). The amputation was intended to prevent sepsis and osteomyelitis and to preserve the remainder of her left arm.

After surgery, the patient attended physical and occupational therapy. She was discharged on September 24 with an at-home woundVAC.

Allegations

The patient filed a lawsuit against the ob-gyn and critical care physician for failure to recognize the signs and symptoms of compartment syndrome and order a consultation with a vascular surgeon in a timely manner. It was alleged these failures led to the patient’s left hand being amputated.

Legal implications

Overall, expert consultants for the defense were supportive of the care provided in this case. These consultants agreed that the diagnosis of acute compartment syndrome (ACS) is often difficult and was even more difficult in this case. To diagnose ACS, the providers must suspect ACS based on certain risk factors, including:

1. leaking of fluids through an IV on the affected side (left in this case);
2. pain;
3. a tense, firm compartment;
4. paresthesias and decreased sensation and
5. weakness.

These risk factors were not known due to the patient’s sedation, obesity, and use of propofol and fentanyl. In addition, when the patient arrived in the ICU, all fluids were being administered through aright-side internal jugular central venous catheter.

There was concern that the vascular surgeon did not see the patient until 24 hours after the consult was ordered. An earlier consult may have led to a quicker diagnosis and prevented loss of the patient’s hand. The patient record was unclear about when the consult was ordered and when symptoms of compartment syndrome first appeared.

A vascular surgeon who reviewed this case stated that it can be difficult to distinguish between the early symptoms of compartment syndrome and pressor-induced ischemia. However, this consultant said the care team should have been watching for development of compartment syndrome because of the patient’s swollen, taut, and discolored hand.

The plaintiff’s experts argued that the vascular surgery consult should have been ordered on August 10 instead of a wound consult. If the vascular surgery consult had occurred earlier, they believe the compartment syndrome could have been diagnosed and the hand amputation avoided.

Disposition

This case was settled on behalf of the ob-gyn and critical care physician.

Risk management considerations

In this case, the defendant physicians argued that the failure to recognize the patient's compartment syndrome had more to do with placing priority on saving the patient’s life over treating a complication, however serious. Yet, this case contained issues with incomplete documentation when it came to observing symptoms and delays in attaining specialist consultation.

 By seeking consultations in a timely manner, a physician gains a specialist’s expertise and focused perspective. In this case, had the ob-gyn sought a consult with the vascular surgeon shortly after the patient'sAugust 5 hysterectomy, the patient’s symptoms may have been treated and the compartment syndrome and eventual amputation avoided.

Clear, contemporaneous documentation helps to ensure that critical data is not lost between providers. Together, timely consults and comprehensive medical records, that are accessible by the entire care team, can help catch potential diagnostic errors or oversights before they negatively affect patient outcomes.

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