Which site would be monitored for a pulse to assess the status of circulation to the foot?

Note: This guideline is currently under review. 

Introduction

Aim

Definition of Terms 

Assessment

Documentation

Management

Potential Complications

Discharge and Parent Information

Evidence Table

Introduction

Assessment of neurovascular status is essential for the early recognition of neurovascular deterioration or compromise. Delays in recognising neurovascular compromise can lead to permanent deficits, loss of a limb and even death. Neurovascular deterioration can occur late after trauma, surgery or cast application. 

Aim

The aim of this clinical practice guideline is to outline the required neurovascular assessment to recognise early compromise and prevent permanent damage to the limb(s). 

Definition of Terms

• Neurovascular: Is the structure and function of the vascular and nervous systems in combination. 
• Musculoskeletal: structurally includes a combination of muscles, bones and joints.
• Capillary refill: Is an assessment of arterial blood supply return and is performed by briefly interrupting blood supply in the capillary system and timing how long it takes for the blood to return. 
• Disproportionate Pain: Pain that exceeds what is expected post injury/surgery, which is not relieved by analgesia.
• Muscle compartment: A well-defined space in the body that consists of a group of muscles in a particular segment, the muscle compartment is bound by fascia. For example the lower leg contains four muscles compartments.
• Fasciotomy: Surgical incision made through the fascia and into a compartment due to increasing pressure. The aim of the procedure is to release pressure to improve peripheral neurovascular status and prevent long term complications. 
• Compartment syndrome: Increase in pressure of a closed muscle compartment that causes muscle and nerve ischemia.
• Active movement: Ability to voluntarily extend and flex an extremity or digit.
  
• Passive movement: Assessor able to extend and flex an extremity or digit. 
  

Assessment

Criteria for neurovascular assessment

Patients who require neurovascular assessment include but are not limited to: 

• Musculoskeletal trauma to the extremities
  
  • Fracture 
  • Crush injury 
    
• Post-operative
  
  • Internal or external fixation or fractures 
  • Orthopaedic surgery 
    
  • Spinal surgery 
    
  • Plastic surgery on extremities or phalanges 
    
  • Cardiac catheterisation
    
  • Tourniquet applied for long periods 
    
• Application of plaster cast
  
  • Restrictive dressing 
    
• Application of traction (skin and skeletal) 
  
• Burns patients 
  
  • Circumferential burns 
    
• Signs of infection in the limb
  

Frequency of observations

• 1 hourly for the first 24 hours post injury, surgery or application of cast.
• Then 4 hourly for a further 48 hours or as specified by the treating medical team. 
• More frequently if any deviations from baseline observations. 

For cardiac catheter patient’s: 

• Neurovascular observations, should be conducted on the affected limb / limbs with routine post anaesthetic observations and then with every set of observations.
  
• Sensation and motor function should be assessed appropriately according to the affected limb.
  
• With each set of neurovascular observations, the puncture site should be assessed for bleeding or ooze, colour, warmth and signs of infection.
  
• For further information please refer to the Care of the patient post cardiac catheterisation guideline.
  

Neurovascular assessment

A neurovascular assessment is required for each affected limb and includes assessment of

• Pain
  
• Sensation
• Motor function
• Perfusion (colour, temperature, capillary refill, swelling, pulses)

Pain 

The most important indicator of neurovascular compromise is pain disproportionate to the injury. Pain associated with compartment syndrome is generally constant however worse with passive movement to extension and is not relieved with opioid analgesia. Indication of pain in non-verbal patients includes restlessness, grimacing, guarding, tachycardia, hypotension, tachypnoea or diaphoresis. If pain is disproportionate to injury notify medical team

Please refer to the Pain Assessment and Measurement Clinical Guideline for further information regarding paediatric pain assessment.

Sensation & Motor function

If neurovascular status is compromised, patients may report decreased sensation, loss of sensation, dysesthesia, numbness, tingling or pins and needles. Altered sensation may be a result of a nerve block or epidural, this should be documented in the patient’s neurovascular assessment in the flowsheet in EMR.

Note amount of pain on movement of the limb, including if it was is active or passive movement. It is important to compare movement of digits bilaterally and to the baseline observations as some patients may have had limited or no movement previous to injury.

The medical team should be contacted immediately if the child experiences any deterioration or deviation from the baseline assessment.

* Capillary refill assessment is evaluated by firmly pressing down on the nail bed of fingers or toes, the nail bed will blanch and the colour should return within 2-3 seconds once the pressure is released.   

Documentation

• A baseline neurovascular assessment of both limbs is essential in recognising neurovascular compromise and should be documented on admission
  
• Neurovascular observations for both upper and lower limbs can be added into flowsheets in EMR for documentation
  
• Alterations in neurovascular status should be documented in flowsheets and the leading medical team should be notified immediately
  
• Photographs can be taken with permission/ consent from the parents/guardian and saved in the media file in EMR, to document any changes neurovascular status and allows the medical team to view progress 
  

Management

Ensure affected limb is elevated to minimise the risk of compartment syndrome. Lower extremities can be elevated with pillows or using bed mechanics; upper extremities can be elevated on either a pillow, sling or box sling. 

Management of Neurovascular Compromise 

• Elevate limb, no higher than heart level.
  
• Split plaster casts or cut/remove bandage.
  
• Maintain limb alignment.
• Notify treating team.

If neurovascular status improves keep affected limb elevated and continue to monitor closely. 

If neurovascular status does not improve or continues to deteriorate, the patient may need to attend theatre for pressure monitoring and/or fasciotomy. 

For cardiac catheter patients:

• If any changes to neurovascular observations (i.e. decrease in pulse pressure, change in limb colour or coolness of limb), escalate by notifying the treating team or catheterisation fellow. Consider need for an ultrasound conducted to confirm or rule out a thrombus.
  

Potential Complications

Compartment syndrome

Compartment syndrome is a serious complication of musculoskeletal injury. Compartment syndrome results from an increase in pressure inside a compartment which comprises of muscles and nerves and is enclosed by fascia, fascia is inelastic and does not expand to increased volume or pressure. When the compartment pressure increases, nerves and then muscles become compressed resulting in decreased blood flow and tissue perfusion, muscle ischemia and loss or altered sensation. Compartment syndrome is a surgical emergency to relieve the pressure or reduce volume within the compartment, which will preserve blood supply, tissue perfusion and function. Early recognition of neurovascular deterioration is crucial in limb salvage or survival.

The medical team should be contacted immediately as soon as compartment syndrome is suspected.

Indications of compartment syndrome

• Pain: The first and most reliable sign of compartment syndrome. Pain out of proportion to injury, extreme pain on passive movement and pain unrelieved with opioid analgesia. 
  
• Paralysis: Is generally a late sign of compartment syndrome and results from prolonged nerve compression or muscle damage. Paralysis presents with inability to actively move the limb and increased pain on passive movement that is not relieved in extension. 
  
• Paresthesia: Results from nerve compression and generally is indicated by pins and needles, tingling or numbness. 
  
• Pallor: Indicates arterial insufficiencies below the level of injury, below the level of injury will appear cold and pale. 
  
• Temperature: Coolness of the limb distal to injury indicates decreased arterial supply. 
  
• Capillary refill: Indicates limb perfusion, capillary refill more than 3 seconds indicates inadequate limb perfusion. 
  
• Pulselessness: Absent pulse is a late sign and indicates tissue death. 
  
• Swelling and Increased Pressure: Is a result increased inter-compartment pressure, skin presents tight and shiny. 
  

Discharge and Parent Information

For patients at risk of neurovascular compromise education on neurovascular assessment is crucial. Age appropriate education should be provided to the patient, including encouragement for the patient to move their digits regularly.

Educate parents on the importance of performing neurovascular assessment and why it is necessary to disturb the patient when sleeping while in hospital.

Many patients who are at risk of neurovascular compromise leave hospital before the risk of compartment syndrome is over. Parents should be educated regarding the signs and symptoms of neurovascular compromise and when to return to their GP/RCH if they are concerned.

Cardiac Catheter patients: Advise parents/carers to limit their child’s activity for the first 24 hours at home and avoid any strenuous lifting. 

Links Discharge Information

• Kids health information: plaster care: Plaster Care (RCH, 2012)
• Kids health information: Plaster Care at Home (RCH, 2012a)
  
• Kids health information: Wound Care (RCH, 2018)
• Cardiac Catheterisation: What to Expect
  

Evidence Table 

Click here to view the Evidence Table. 

Please remember to read the disclaimer. 

The development of this nursing guideline was coordinated by Alicia Waters, CNS, Platypus Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated May 2019.