Friday, September 20, 2019
An Overview of Consent and Restraint
An Overview of Consent and Restraint Consent, Deliberate or implied affirmation; compliance with a course ofà proposed action. Consent is essential in a number of circumstances. For example,à contracts and marriages are invalid unless both parties give their consent. Consentà must be given freely, without duress or deception, and with sufficient legalà competence to give it (see also INFORMED CONSENT). In criminal law, issues of consentà arise mainly in connection with offences involving violence and *dishonesty. Forà public-policy reasons, a victims consent to conduct which foreseeably causes himà bodily harm is no defence to a charge involving an *assault, *wounding, orà *homicide; in other cases the defendant should be acquitted if the magistrates orà jury have a reasonable doubt not only as to whether the victim had consented butà also as to whether he thought the victim had consented. Restraint,à assault andà an intentional or reckless act that causes someone to be put in fear ofà immediate physical harm. Actual physical contact is not necessary to constitute anà assault (for example, pointing a gun at someone is an assault), but the word is oftenà loosely used to include both threatening acts and physical violence (see BATTERY).à Words alone cannot constitute an assault. Assault is a form of *trespass to theà person and a crime as well as a tort: an ordinary (or common) assault, as describedà above, is a *summary offence punishable by a *fine at level 5 on the standard scaleà and/or up to six months imprisonment. Certain kinds of more serious assault areà known as aggravated assaults and carry stricter penalties. Examples of these areà assault with intent to resist lawful arrest (two years), assault occasioning *actualà bodily harm (five years), and assault with intent to rob (life imprisonment).à battery The intentional or reckless application of physical force to someoneà without his consent. Battery is a form of *trespass to the person and is a *summaryà offence (punishable with a *fine at level 5 on the standard scale and/or six monthsà imprisonment) as well as a tort, even if no actual harm results. If actual harm doesà result, however, the *consent of the victim may not prevent the act from beingà criminal, except when the injury is inflicted in the course of properly conductedà sports or games (e.g.rugby or boxing) or as a result of reasonable surgicalà intervention. Duty of care, The legal obligation to take reasonable care to avoid causing damage. There is no liability in tort for *negligence unless the act or omission that causesà damage is a breach of a duty of care owed to the claimant. There is a duty to takeà care in most situations in which one can reasonably foresee that ones actions mayà cause physical damage to the person or property of others. The duty is owed toà those people likely to be affected by the conduct in question. Thus doctors have aà duty of care to their patients and users of the highway have a duty of care to allà other road users. But there is no general duty to prevent other persons causingà damage or to rescue persons or property in danger, liability for careless words isà more limited than liability for careless acts, and there is no general duty not toà cause economic loss or psychiatric illness. In these and some other situations, theà existence and scope of the duty of care depends on all the circumstances of theà relationship between the parties. Most duties of care are th e result of judicialà decisions, but some are contained in statutes, such as the Occupiers Liability Actà 1957 Negligence andà Carelessness amounting to the culpable breach of a duty: failureà negligent misstatement 328 329 NHS Trustà to do something that a reasonable man (i.e. an average responsible citizen) would do, or doing something that a reasonable man would not do. In cases of professional negligence, involving someone with a special skill, that person is expected to showà the skill of an average member of his profession. Negligence may be an element in aà few crimes, e.g. *careless and inconsiderate driving, and various regulatory offences,à which are usually punished by fine. The main example of a serious crime that mayà be committed by negligence is *manslaughter (in one of its forms). When negligenceà is a basis of criminal liability, it is no defence to show that one was doing ones bestà if ones conduct still falls below that of the reasonable man in the circumstances. Seeà also GROSS NEGLIGENCE. 2. A tort consisting of the breach of a *duty of care resultingà in damage to the claimant. Negligence in the sense of carelessness does not give riseà to civil liability unless the defendants failure to conform to the standards of theà reasonable man was a breach of a duty of care owed to the claimant, which hasà caused damage to him. Negligence can be used to bring a civil action when there isà no contract under which proceedings can be brought. Normally it is easier to sue forà *breach of contract, but this is only possible when a contract exists. Generally, fewerà heads of damage can be claimed in negligence than in breach of contract, but theà rules limiting the time within which actions can be brought (see LIMITATION OFà ACTIONS) may be more advantageous for actions in tort for negligence than forà actions in contract. See also CONTRIBUTORY NEGLIGENCE; RES IPSA LOQUITUR.à vicarious liabilityà Legal liability imposed on oneà person for torts or crimes committed by another (usually an employee butà vicarious performance 526 527 violent disorderà sometimes an *independent contractor or agent), although the person madeà vicariously liable is not personally at fault. An employer is vicariously liable forà torts committed by his employees when he has authorized or ratified them or whenà the tort was committed in the course of the employees work. Thus negligentà driving by someone employed as a driver is a tort committed in the course of hisà employment, but if the driver were to assault a passing pedestrian for motives ofà private revenge, the assault would not be connected with his job and his employerà would not be liable. The purpose of the doctrine of vicarious liability is to ensureà that an employer pays the costs of damage caused by his business operations. Hisà vicarious liability, however, is in addition to the liability of the employee, whoà remains personally liable for his own torts. The person injured by the tort may sueà either or both of them, but will generally prefer to sue the employer.à Vicarious criminal liability may effectively be imposed by statute on an employerà for certain offences committed by an employee in relation to his employment. Thusà it has been held that an employer is guilty of selling unfit food under the Food Actà 1984 when his employee does the physical act of selling (the employee is also guilty,à though in practice is rarely prosecuted). Likewise, an employer may be guilty ofà supplying goods under a false trade description when it is his employee whoà actually delivers them. For an offence that normally requires mens rea,an employerà will only be vicariously liable if the offence relates to licensing laws. For example, ifà a licensee has delegated the entire management of his licensed premises to anotherà j:letson, and that j:letson has committed the offence with the nec~ssatymens YeQ, th~à licensee will be vicariously liable.à Vicarious liability for crimes may be imposed in certain other circumstances. Theà registered owner of a vehicle, for example, is expressly made liable by statute forà fixed-penalty and excess parking charges, even if the fault for the offence was notà his. If the offence is a regulatory offence of *strict liability, the courts often alsoà impose vicarious liability if the offence is defined in the statute in a way that makesà this possible.à Scope of practice (the legal and professional boundaries imposed upon you as a nurse)à Advocacy (the nurses role as an advocate for the client)à Documentationà Open disclosureà The Coronerà An officer of the Crown whose principal function is to investigateà deaths suspected of being violent or unnatural. He will do this either by ordering anà *autopsy or conducting an *inquest. The coroner also holds inquests on *treasureà trove. Coroners are appointed by the Crown from among barristers, solicitors, andà qualified medical practitioners of not less than five years standing.à Colour. The normal colour of urine is pale straw or light yellow.Ãâà It is mainly due to the pigment urochrome and partly to urobilin.Ãâà Womens urine is slightly lighter.Ãâà If the quantity of urine is increased or there is a diminution or dilution of urinary pigments, it becomes lighter and rendered very pale as in excessive drinking, nervousness, anaemia, chlorosis, diabetes, hysteria, epilepsy, poluria, in general debility and in chronic interstitial nephritis. The colour of the urine will depend on the degree of concentration; the more concentrated-the darker; the greater the quantity of water -the lighter.Ãâà Acid urine is slightly darker than alkaline urine. Urine becomes deeper in colour, like orange or dark yellow or brownish red generally known as high coloured or concentrated urine and is due to uroerythrin and urobilin produced by increased haemolysis, as in. fevers, after journeys, in hot days, in nervous excitability and after bodily exercises. N ormal urine on standing for a time will have a white or sometimes a bluish white scum on the surface due to contamination and putrefaction.Ãâà Urine glairy, whitish in colour indicates admixture with pus or leucorrhceal discharges. Urine coloured smoky, brown, reddish, brownish black or black indicates admixture with blood and denotes haemorrhage. Urine coloured greenish yellow or greenish brown indicates admixture with bile and denotes jaundice and other affections of the liver. Urine coloured milky indicates admixture with fat or pus and denotes chyluria or any purulent disease of the genitourinary tract.Ãâà Urine coloured blue indicates typhus fever, admixture with methylene blue or when there is excess of indigogens. Many drugs after absorption colour the urine, such as yellowish orange by santonin and chrysophanic acid; reddish or orange brown by senna and rhubarb; dark olive green or black by carbolic acid and other coaltar derivatives while antipyrin reddens the u rine. Odour.Ãâà When just voided urine is faintly aromatic but after a few minutes its characteristic odour is urinous.Ãâà The odour of urine is due to phenol.Ãâà It becomes pungent in concentrated urine, when urea is liberated in excess.Ãâà It becomes ammoniacal and putrescent and the reaction becomes alkaline after sometime when this excess of urea takes up water and is converted into ammonium carbonate.Ãâà It occurs quickly in urine from chronic cystitis or from suppurating diseases of kidney and bladder i.e., when urine is mixed with pus; blood or excessive phosphates.Ãâà The odour of urine in diabetes and in acetonuria is slightly sweetish.Ãâà The characteristic odour of garlic, sandal oil, cubebs, copaiba are given off when they are taken internally.Ãâà Turpentine gives an odour of violets. Appearance, physical character or transparency is the naked eye appearance of urine. Normal urine is always clear when voided but when allowed to stand for sometime it becomes slightly hazy or turbid due to suspended particles or from a slight cloud of mucus and epithelium. After sometime there may be sediments at the bottom due to gravity. If the urine is ammoniacal or decomposed a white turbidity forms due to sedimentation of phosphates or from bacterial activity. The turbidity or sediment is due mainly to the following suspended particles:- Urates. Uric Acid. Albumin. Phosphate. Mucus. Oxalate. Pus. Blood. Micro-organisms. To distinguish one from another, first of all fill three fourths of a test tube with urine and very gently heat the upper portion of the urine, holding the test tube by the bottom.Ãâà Now note whether the urine becomes clear or a cloudiness appears in the boiled portion, comparing with the lower unboiled portion of the test tube.Ãâà If the urine is turbid and clears up on heating then it contains Urates.Ãâà If the urine is clear and becomes cloudy with heat, before boiling point, then it is Albumen.Ãâà If the urine is clear and becomes cloudy at the boiling point, then it is Phosphate.Ãâà To distinguish between albumin and phosphate add 3 or 4 drops of acetic acid on the cloudy urine.Ãâà If the cloudiness disappears, then it is phosphate; but if the cloudiness remains or thickens, then it is albumin.Ãâà Lastly to distinguish between albumin and mucin add 2 drops of nitric acid, if the cloudiness disappears, then it is Mucin, but if the cloudi ness still persists, it is albumin. The turbidity of carbonates will clear up with effervescence on addition of nitric acid whereas heat and acid increases the turbidity due to albumin. To distinguish between phosphate and oxalate take some fresh urine and add ammonia, when there will be a precipitate. If on the addition of a few drops of acetic acid, the precipitates disappear, then it is phosphate, if it remains it is Oxalate. Failing the heat test take some urine in a test tube, preferably from the bottom and add a few drops of Liquor Potassae. Mix it thoroughly and if it clears up, then it is mucus; but if it becomes gelatinous or ropy, it is Pus. Next, if the deposit is coloured then take some urine in a test tube, preferably from the bottom and add a few drops of caustic potash and gently heat a little.Ãâà If it is dissolved, then it is Uric acid but if there is a precipitate, note the colour of the coagulum; if it is reddish brown or bottle green, it is Blood. If the urine is turbid and there is no change either by heat or by addition of caustic potash and heat, then the turbidity is due to Micro-organisms.Ãâà They generally clear up on the addition, of watery solution of ferric chloride and ammonium hydrate and then filter the urine.Ãâà Sometime the character, colour and reaction will roughly denote the element. Urates-They look like moss and are yellowish white or pink in colour.Ãâà Reaction is generally acid. They deposit when the urine becomes cold.à Uric Acid-It is crystalline and reddish brown in colour, resembling a shower of cayenne pepper grains. Reaction is moderately acid.à Phosphate-It forms a thin deposit and is white or yellowish white in colour.Ãâà Reaction may be slightly acid, alkaline or neutral.à Mucus-It is a cloudy or woolly looking white deposit. Reaction is slightly acid.à Oxalate-It is soft, shining and white in colour. Reaction is generally slightly acid. Pus- It looks like a ropy or creamy deposit, and is white in colour.Ãâà Reaction is slightly acid orà alkaline. Blood-It is clotted or thready and is red smoky or brownish in colour.Ãâà Reaction generally alkaline or may be slightly acid. Micro-organisms-The deposit is slightly hazy and white in colour.Ãâà They generally stick to the sides of the glass. COMPLICATIONS OF FRACTURES The majority of fractures heal without complications. If death occurs after a fracture, it is usually the result of damage to underlying organs and vascular structures or from complications of the fracture or immobility. Complications of fractures may be either direct or indirect. Direct complications include problems with bone infection, bone union, and avascular necrosis. Indirect complications are associated with blood vessel and nerve damage resulting in conditions such as compartment syndrome, venous thromboembolism, fat embolism, rhabdomyolysis (breakdown of skeletal muscle), and hypovolemic shock. Although most musculoskeletal injuries are not life threatening, open fractures, fractures accompanied by severe blood loss, and fractures that damage vital organs (e.g., lung, heart) are medical emergencies requiring immediate attention. Compartment Syndrome Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) press on and compromise the function of blood vessels, nerves, and/or tendons that run through that compartment. Compartment syndrome causes capillary perfusion to be reduced below a level necessary for tissue viability. Compartment syndrome usually involves the leg, but can also occur in the arm, shoulder, and buttock. Thirty-eight compartments are located in the upper and lower extremities. Two basic causes of compartment syndrome are (1) decreased compartment size resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia; and (2) increased compartment contents related to bleeding, inflammation, oedema, or IV infiltration. Oedema can create sufficient pressure to obstruct circulation and cause venous occlusion, which further increases oedema. Eventually arterial flow is compromised, resulting in ischemia to the extremity. As ischemia continues, muscle and nerve cells are destroyed over time, and fibrotic tissue replaces healthy tissue. Contracture, disability, and loss of function can occur. Delays in diagnosis and treatment cause irreversible muscle and nerve ischemia, resulting in a functionally useless or severely impaired extremity. Compartment syndrome is usually associated with trauma, fractures (especially the long bones), extensive soft tissue damage, and crush injury. Fractures of the distal humerus and proximal tibia are the most common fractures associated with compartment syndrome. Compartment injury can also occur after knee or leg surgery. Prolonged pressure on a muscle compartment may result when someone is trapped under a heavy object or a persons limb is trapped beneath the body because of an obtunded state such as drug or alcohol overdose. Clinical Manifestations. Compartment syndrome may occur initially from the bodys physiologic response to the injury, or it may be delayed for several days after the original insult or injury. Ischemia can occur within 4 to 8 hours after the onset of compartment syndrome. One or more of the following six Ps are characteristic of compartment syndrome: (1) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment; (2) increasing pressure in the compartment; (3) paraesthesia (numbness and tingling); (4) pallor, coolness, and loss of normal colour of the extremity; (5) paralysis or loss of function; and (6) pulselessness, or diminished or absent peripheral pulses. Collaborative Care. Prompt, accurate diagnosis of compartment syndrome is critical.17 Perform and document regular neurovascular assessments on all patients with fractures, especially those with an injury of the distal humerus or proximal tibia or soft tissue injuries in these areas. Early recognition and effective treatment of compartment syndrome are essential to avoid permanent damage to muscles and nerves. Carefully assess the location, quality, and intensity of the pain (see Chapter 9). Evaluate the patients level of pain on a scale of 0 to 10. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. Notify the health care provider immediately of a patients changing condition. Because of the possibility of muscle damage, assess urine output. Myoglobin released from damaged muscle cells precipitates and causes obstruction in renal tubules. This condition results in acute tubular necrosis and acute kidney injury.Ãâà Common signs are dark reddish brown urine and clinical manifestations associated with acute kidney injury (see Chapter 47). Elevation of the extremity may lower venous pressure and slow arterial perfusion. Therefore the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. It may also be necessary to remove or loosen the bandage and split the cast in half (bivalving). A reduction in traction weight may also decrease external circumferential pressures. Surgical decompression (e.g., fasciotomy) of the involved compartment may be necessary (Fig. 63-15). The fasciotomy site is left open for several days to ensure adequate soft tissue decompression. Infection resulting from delayed wound closure is a potential problem after a fasciotomy. In severe cases of compartment syndrome, an amputation may be required. DEFINITION Compartment syndrome is a condition thatà occurs when elevated pressure within a limitedà space compromises the circulation, withà increased risk of irreversible damage to itsà contents and their function. Acute compartmentà syndrome is a surgical emergency.à ICD-10CM CODES 958.90 Compartment syndrome unspecifiedà 958.90 Compartment syndrome, notà otherwise specified T79.A0 Compartment syndrome,à unspecified, initial encounterà M79.A11 Nontraumatic compartmentà syndrome of right upper extremityà M79.A12 Nontraumatic compartmentà syndrome of left upper extremityà M79.A19 Nontraumatic compartmentà syndrome of unspecified upperà extremityà M79.A21 Nontraumatic compartmentà syndrome of right lower extremityà M79.A22 Nontraumatic compartmentà syndrome of left lower extremity M79.A29 Nontraumatic compartmentà syndrome of unspecified lowerà extremityà M79.A9 Nontraumatic compartmentà syndrome of other sitesà T79.A19A Traumatic compartment syndromeà of unspecified upper extremity,à initial encounterà T79.A21A Traumatic compartment syndromeà of right lower extremity, initialà encounterà T79.A22A Traumatic compartment syndromeà of left lower extremity, initialà encounterà T79.A29A Traumatic compartment syndromeà of unspecified lower extremity,à initial encounterà EPIDEMIOLOGY à DEMOGRAPHICSà Occurs most commonly after acute trauma,à especially with long bone fractures, comprisingà 75% of cases.à It usually occurs in persons Incidence is higher in males.à It can occur in other parts, such as the foot,à thigh, gluteal region, and abdomen.à Supracondylar fractures in children can commonlyà lead to compartment syndrome.à 6% to 9% of open tibial fractures are complicatedà by compartment syndrome.à It is seen in all races and ethnicities.à PATHOPHYSIOLOGYà Compartment syndrome occurs when the bloodà flow is less than the tissue metabolic demands,à causing tissue injury. It occurs when the intracompartmentalà pressure increases limitingà venous outflow with rising venous pressure,à resulting in compromise of the local circulationà and tissue hypoxia with decreased arteriovenousà pressure gradient. Venous congestion additionallyà leads to tissue edema and interstitial pressure,à and the compartment pressure continues toà increase. Compartment pressure ranges betweenà 10 and 30 mm Hg of diastolic pressure are ableà to cause the condition.à Different conditions are known to cause compartmentà syndrome:à Conditions that limit compartment volume, suchà as when patients have fracture casts, whenà sedated or comatose patients lie on a limb forà a prolonged period, or when patients have tightà dressings that are applied externally.à Conditions that cause increased compartmentà content, such as bleeding in the compartmentà from vascular injury or diathesis, fractures orà finger injuries, reperfusion after ischemic injuryà such as embolectomy and arterial bypassà grafting, severe bruising of muscle, and thermalà or electrical burn injuries.à Other injuries, such as extravasation of intravenousà fluids, injection of recreational drugs,à and snake bites.à PHYSICAL FINDINGS CLINICALà PRESENTATION Signs and symptoms are usually apparent butà can be unreliable and can lead to delayedà diagnosis. Acute compartment syndrome canà worsen within hours; therefore serial examinationà is important in a patient with suspectedà compartment syndrome. Patients with tenseà painful limbs are considered to have acuteà compartment syndrome; however, diagnosisà is confirmed with the assessment of elevatedà compartment pressure. Clinical signs andà symptoms include the following:à Pain disproportional to injury (the earliest sign)à Constant deep pain and pain that is referredà to the compartment on passive stretchingà of the muscles of the affected compartmentà (Fig. E1C-84, A) Reduced sense of touch or sensation (hypesthesia) within the territory of the nerve passing the compartment (in acute anteriorà compartment syndrome, the patient mayà have hypesthesia in the territory of the firstà webspace)à Tense and swollen compartment (Figs. E1C-à 84, B and 1C-84, C)à Muscle weaknessà Paresis (late finding) that suggests permanentà muscle damageà Capillary refill can be slow but normal.à Peripheral pulses that are normally palpableà even in severe conditionsà Tingling and numbness in the affected limb.à Hypesthesia or paresthesia should be evaluatedà with pinprick, light touch, and two-pointà discrimination tests.à Difficulty moving the extremities.à DIAGNOSIS Diagnosis is based on clinical signs andà symptoms along with compartment pressure.à Compartment pressure testing may be unnecessaryà if the diagnosis is clinically obvious.à DIFFERENTIAL DIAGNOSIS Muscle strainsà Cellulitis Gangrene Peripheral vascular injury Necrotizing fasciitis Stress fractures Deep vein thrombosis and thrombophlebitis Tendinitis Muscle contusion Tarsal tunnel syndrome Posterior ankle syndrome Popliteal artery impingement Claudication Tumor Venous insufficiency LABORATORY TESTS Diagnosis is based on clinical findings andà the measurement of compartment pressures.à Laboratory values are not useful in the diagnosisà of compartment syndrome but are importantà for other diagnoses or associated conditions.à CBC with differential for evaluation of infectionà Creatine phosphokinase (CK) levels, whichà can rise as muscle injury developsà Metabolic panel for the assessment of electrolytesà and renal functionà Coagulation profile for bleeding diathesisà Urinalysis for rhabdomyolysisà Urine and serum myoglobin levelsà Compartment Syndromeà A B FIGURE 1C-84 C: A, Severe calf swelling due toà anterior and posterior compartment syndromesà after ischemia-reperfusion. B, Appearance afterà emergency fasciotomy. Note edematous muscleà and hematoma. (Courtesy Michael J. Allen, FRCS,à Leicester, UK. From Floege J et al: Comprehensiveà clinical nephrology, ed 4, Philadelphia, 2010,à Saunders.) http://internalmedicinebook.comà Compartment Syndrome 307 Diseases and Disorders IMAGING STUDIES Direct intracompartmental pressure measurementà can be done by handheld manometer,à wick or slit catheter technique, and simpleà needle manometer system. Compartment à syndrome is diagnosed when the differenceà between diastolic blood pressure and compartmentà pressure (ÃŽâ⬠pressure) is à ¢Ã¢â¬ °Ã ¤30 mm Hg.à Ultrasonography can be used to rule out deepà vein thrombosis, or Doppler ultrasonographyà can be used to evaluate blood flow to theà extremity. Arteriography should be used toà evaluate the adequate blood flow through aà compartment. Near-infrared spectroscopy and technetium-à 99m methoxyisobutylisonitrile scintigraphyà can also be used.à Radiography can be used on the affectedà limb for fracture or foreign body evaluation.à TREATMENTà Treatment goal is to keep intracompartmentalà pressure low and prevent tissue injury (Fig.à 1C-84, D). NONPHARMACOLOGIC THERAPY Immediate relieving of all external pressureà on the affected compartmentà Removal of casts, splints, and dressingsà Placing limb at heart level to avoid decreasedà or increased blood flowà ACUTE GENERAL Rxà Analgesics for pain Hyperbaric oxygen Hypotension can worsen tissue ischemia andà thus should be treated with IV isotonic saline. Fasciotomy of the affected compartmentà is indicated if there has been >6 hr ofà limb ischemia, or immediate decompressionà should be performed when the compartmentà pressure > 30 to 35 mm Hg.à Measurement of compartment pressure isà not necessary to perform fasciotomy if clinicalà suspicion is high depending on historyà and clinical examination.à When compartment pressures are trendingà downward, it is often safe to delay emergentà fasciotomy, provided the ÃŽâ⬠pressure is alsoà improving. CHRONIC Rxà Aftercare of fasciotomy wound: Wound isà inspected after 48 hours and dead tissue isà removed.à Wounds are left open, requiring later skinà grafting or delayed wound closure.à Opsite sheet and boot lace techniques areà also used for closing fasciotomy wounds.à Concomitant fractured bones should also beà stabilized with plating, external fixation, orà intramedullary nailing.à DISPOSITION With early diagnosis and treatment, the prognosisà is excellent for recovery of the muscles andà nerves inside the compartment. The followingà conditions can be prevented:à Permanent nerve damage/paralysisà Muscle contracture Gangrene Amputation Muscle necrosis Fracture nonunion Rhabdomyolysis that leads to renal failure Compartment syndrome that can occur inà open fractures Permanent nerve injury, which can occur afterà 12 to 24 hr of compression; mortality rates inà patients who need fasciotomy is à ¢Ã¢â¬ °Ãâ 15%. REFERRAL Patients with suspected compartment syndromeà should be referred promptly to orthopedicà and general surgery. PEARLS CONSIDERATIONS Universal precautions and aseptic measures are necessary for patients undergoing fasciotomy because the risk of local and systemic infection is high with the procedure. Invasive monitoring techniques should be undertaken with adequate analgesia so that patient immobility is ensured while the pressure is measured. Injection of local anaesthetics into the compartment can increase the pressure and pain and therefore should be avoided. Patients with fracture casts should be informed about the risks of swelling, and patients should also be encouraged to wear appropriate equipment while playing sports. A history of coagulation disorders and the use of anticoagulants should be mentioned in a patients medical history. Assault Assault has two different interpretations. 1. Traditionally called common assault and consisting of the making of an unlawful and intentional (or possibly only reckless) threat to inflict imminent force against the person where the victim was aware of the threat.Ãâà A distinction was previously maintained at common law between common assault and battery.Ãâà Increasing codification of criminal law has resulted in abandonment of this distinction and in Australia assault now commonly refers both to common assault and actual infliction of force.Ãâà Statutory provisions for the different states are numerous and terminology varies (e.g. offences of causing injury or threatening). 2. One of three ma
Subscribe to:
Post Comments (Atom)
No comments:
Post a Comment