Question

20-year-old male came into the ED s/p a stab wound to the left lateral side after an evening of partying and cocaine use. He had an open repair of the left popliteal artery and vein after discovering they had been transected. A superficial and deep compartment fasciotomy and lateral compartment mini fasciotomy was also done.

In PACU patient noted to have non- palpable and non-dopplerable DP/PT pulses. Left foot is cool and he has left foot drop. An arterial duplex of LLE and CTA LLE was done. Coags were drawn and Heparin drip started with orders to maintain APTT between 60-90. Later on that day patient was evaluated and some strikethrough was noted on dressing. LLE edema noted but leg warming up. Faint dopplerable PT pulse noted but no motor function. Neuro consult called and patient continues on Heparin, Ancef and IV Tylenol. Leg kept flexed at a 30-degree angle.

Patient was brought back a day later to the OR for LLE critical limb ischemia. The procedure done was a left lower extremity angiogram, tibial arteries embolectomy, popliteal artery biological patch placement, and completion of fasciotomies after noted myonecrosis. At this time the patient had dopplerable left DP and PT pulses, left foot is warm with good capillary refill. Neurovascular checks q1hour for the next 24 hours were ordered. For pain tramadol, gabapentin and morphine added.

Some days later the tissue is non-viable up to the ankle. The foot is blistered with fixed bluish discoloration of thrombosis. The anterior compartment is necrotic with nonviable muscle. The skin over the whole area is necrotic with edema of the foot. Some days later the patient has been tachycardic and has begun to spike intermittent fevers. The belief is that this is secondary to systemic toxicity from the ischemic portion of his LLE. Patient is now on a ketamine drip, lidocaine drip and a hair follicle test has been done for assessment of cocaine use.

Patient started to hallucinate and ketamine and lidocaine drip discontinued. He is currently on Vancomycin, Meropenem and Clindamycin and his last Vanco trough was 1.5. The Vascular Surgery Team has determined that delaying definitive amputation in favor of watchful waiting for a more definitive level of demarcation to occur is in the patients best interest. This is done in order to maximize tissue preservation in hopes of preserving the patient’s knee joint.

Left foot edematous with blisters. Cold to touch. Unable to obtain dorsal pedal pulse with doppler. Dorsal aspect of the left foot is dusky, cold, and mottled. Unable to move or wiggle toes of Left foot from nerve ischemia. Patient taken following day for a left lower extremity guillotine amputation just proximal to the ankle. Muscle was also debrided. LLE amputation revision will be planned once edema has resolved.

Patient has Amitriptyline, amlodipine, rituvostatin, MVI, Vitamin C and cyclobenzaprine added to medication regimen with linezolid for VRE and flagyl. 3 days later he had a left BKA.

Instructions:

We need you to critically think throughout the case study and question why. Then research to find out why. For example, “In PACU patient noted to have non- palpable and non-dopplerable DP/PT pulses. Left foot is cool and he has left foot drop. An arterial duplex of LLE and CTA LLE was done”, why? What are they looking for? What do those diagnostic tests reveal? Is it normal to come out of surgery and have foot drop and a cold foot? These are elements to developing your critical thinking.

1. Explain ALL medications, possible interactions, side effects and nursing considerations.

Heparin⇒ Anticoagulant, used to treat and prevent blood clots, taking an NSAID with this may cause bruising and easy bleedin xcdeg, negative in

2. Describe ALL diagnostic testing and what they are used to determine.

3. Explain ALL procedures

4. Why is the leg kept flexed at 30 degrees?

5. What is non- palpable and non-dopplerable DP/PT pulses?

6. Why is the left foot cool?

7. Why does he have foot drop?

8. What is the relationship between the APTT and Heparin?

9. How often is the blood drawn in order to titrate properly?

10. Do pathophysiology for all disease processes.

11. What and why was a hair follicle test ordered? What is the significance?

12. What are neurochecks and what does it dignify?

Answer 1

1. Mediation used are: HEPARINE, ANCEF, TYLENOL, VANCOMYCIN, MEROPENUM. CLINDAMYCIN, AMITRIPHYLINE, AMLODIPINE, MVI, VITAMIN C, CYCLOBENZAPINE.

a. HEPARIN: anti-caogulant in action

side effect: redness,pain, brushing in injecting side, unusual bleeding, nausea vomiting, itching, etc

possible interaction : other anticaogulants, aspirin, degoxin, hydrocloroquine, tetracycline antibiotic, smoking also should avoided

nursing intervention: check for any unusual bleeding in the body

provide correct dose.

discontinue if any reaction occurs

b. ancef : it is cephalosporin antibitic

side effects: bluish color of skin, pain, swelling in the foot,

drug interaction: amlodipine, lidicaine , lasix

nursing intervention: Test dose should be done before giving it.

c. telenol: to reduce pain

side effect: drowziness, nausea, vomiting, allergic reaction, rashes, itching

drug interaction: ketaconazole

nurse intevention: proper dose should be given

check for side efeects

d. vancomycin, clindamycin: antibiotic

side effect: nausea , vomiting, dizzines, trouble in breathing, rashes, swelling, allergic reaction,irrigular heart beat

drug interaction: ibrupofen, lonezepam

nurse intervention: test dose should be done before administering it.

e. amlodipine: to lower blood pressure

side effects: dizziness, ligh headache, irregular heart beat, fainting

drug interaction: NSAIDS

nurses intervention: avoid alcohol or cocain using during this time.

correct dose should be administered.

f. cyclobenzapine: muscle relaxant

side effect: clumsiness, confusion, fainting, problem in urination, mental depression

drug interaction: isocarboxazid, phelenzine, tranylcypromine

nurses intervention:

prevent overdose

proper dose should be given

check for allergic reaction

QUESTION 5:

ANSWER: DP means dorsalis pedis and PT means posterior tibial pulse is not palpable or not found by manual cheching of pulse. Non droppler means by using doppler examination the pulse are not able to found out.

QUESTION 6:

ANSWER: because of lack of blood suppy in the left foot.

question 7:

ANSWER: because of nerve damage.

QUESTION 8:

ANSWER: APTT means activated partial thromboplastine time measures how much time needed to clot the blood, heparin is anticaogulant, so heparin leads to increase APTT