1. Time is of the Essence:
Compartment Syndrome

2. 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

3. 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

4. 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.

5. 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

6. 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

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

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

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

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

11. 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

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

15. 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

16. 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

17. Diagnostics
Plain films
CT scans
Angiography

18. 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

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

20. 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