Time is of the Essence: Compartment Syndrome

Objectives At the completion of this course the learner will be able to: Discuss the risk factors associated with compartment syndrome Verbalize at least two symptoms associated with compartment syndrome Verbally Identify diagnostic interventions and techniques for compartment syndrome Discuss discharge planning and instructions for compartment syndrome

Compartment Syndrome Serious condition in which increased pressure within one or more compartments causes massive compromise of circulation and function of tissues within that limited space. Reduces tissue perfusion – ischemia Results in cell death - necrosis True Orthopaedic Emergency

COMPARTMENT As these fascial compartments have a limited ability to expand and accommodate the increased muscle volume, the pressure inside these compartments increases with strenuous exercise.

Etiology Direct trauma to the tissue Tight dressings/cast Initial injury can lead to swelling within the compartment Closing of the fascia Bleeding into the compartment Capillary Permeability Ischemia / Trauma / Burns / Exercise / Snake Bite / Drug Injection / IVF

Compartment Syndrome Etiology Fractures-closed and open IV/A-lines Blunt trauma Vascular occlusion Cast/dressing Closure of fascial defects Burns/electrical GSW Hemophiliac/Coag Intraosseous IV (infant) Snake bite Arterial injury

Causes Fractures to Extremities: Injury to the soft tissue Blunt trauma – 25% direct Shock Fat embolism Fracture blisters McQueen et al; JBJS Br 2000

Diagnosis Pain (Disproportionate to injury) Pressure (palpable tense compartment) Paresthesia Pallor Pulse Paralysis Polar Increased leg girth Interdepartmental readings

Treatment Modalities Infusion Catheter Arterial line Stryker device manometer saline 3-way stopcock Catheter wick slit wick Arterial line 16 - 18 ga. Needle (5-19 mm Hg higher) transducer monitor Stryker device Side port needle

Pressure Measurements Arterial line Zero at the level of the affected limb

Pressure Measurements Simple Needle 18 gauge Least accurate Usually gives falsely higher reading Slit Catheter and Side ported needle No significant difference More accurate Side port Moed et al JBJS 1993

Assessment History Mechanism of injury Treatment or splinting before arrival Previous orthopedic problems

Physical Assessment Inspection Palpation: Appearance of extremity Differences between the injured and non-injured extremities Integrity of injured area Deformity and/or angulation Palpation: Seven P’s Pelvis

Nerve Damage Assess for Nerve Damage: Hand Foot Radial: Dorsiflex the wrist Medial: Thumb to fingers Ulnar: Abduction or Adduction Foot Tibial Nerve: Dorsiflexion of foot Lateral Plantar: Separation of little toe from 4th toe Medial Plantar: Separation of Big toe from 2nd toe

Diagnostics Plain films CT scans Angiography

Planning/Implementation Control bleeding Splint and immobilize the affected extremity Apply ice Elevate the extremity to the level of the heart Administer medications Assist with Compartment measures Reassess neurovascular status Prepare for definitive stabilization Prepare for operation, admission, or transfer

Evaluation Reassess Pain Management Maintain positioning Measure girths Reassess neurovascular status Assure specialty consultation Prevention nosocomial infection post-faciotomy Assess Vital signs

References American College of Emergency Physicians. Guidelines for Trauma Care Systems. Dallas, Texas The College, September 16, 2002 Bartlet & Jones. Florida Region Common EMS Protocols. London, UK.. Revised July 2004 Emergency Nurses Association: Course in Advanced Trauma Nursing II: A Conceptual Approach. Park Ridge IL, Emergency Nurses Association, 2001 Emergency Nurses Association: Emergency Nurse Pediatric Course: Provider Manual. Park Ridge, IL; Emergency Nurses Association 2003. Emergency Nurses Association: Trauma Nurse Core Course Manual.Park Ridge, IL. Emergency Nursing Association 2005