Compartment Syndrome :Compartment Syndrome


Definition :Definition Compartment syndrome involves the compression of nerves and blood vessels within an enclosed space This leads to impaired blood flow and muscle and nerve damage.


INTRODUCTION :INTRODUCTION Compartment syndrome (CS) is a limb-threatening and life-threatening condition observed when perfusion pressure falls below tissue pressure in a closed anatomic space. Untreated CS leads to : Tissue necrosis Permanent functional impairment If severe : Renal failure and death


INTRODUCTION :INTRODUCTION Compartment Syndrome has been found wherever a compartment is present: Hand Forearm upper arm Abdomen Buttock lower extremity Almost any injury can cause this syndrome, including injury resulting from vigorous exercise


Pathophysiology :Pathophysiology Compartment Syndrome pathophysiology follows the path of ischemic injury. Intracompartmental structures cannot withstand infinite pressure. If fluid is introduced into a fixed volume, pressure rises. Various osseofascial compartments have a relatively fixed volume: Introduction of excess fluid or extraneous constriction increases pressure and decreases tissue perfusion, until no oxygen is available for cellular metabolism.


Pathophysiology :Pathophysiology Elevated perfusion pressure is the physiologic response to rising intracompartmental pressure. Tissue perfusion is determined by measuring capillary perfusion pressure (CPP) minus the interstitial fluid pressure.


Pathophysiology :Pathophysiology Normal cellular metabolism requires 5-7 mm Hg oxygen tension. Capillary perfusion pressure (CPP) averaging 25 mm Hg . Interstitial pressure 4-6 mm Hg.


Pathophysiology :Pathophysiology Matsen demonstrated that as intracompartmental pressure rises, venous pressure rises. When venous pressure is higher than CPP, capillaries collapse. Intracompartmental pressures greater than 30 mm Hg are generally agreed to require intervention.


Pathophysiology :Pathophysiology If Intracompartmental pressures greater than 30 mm Hg : Blood flow through the capillaries stops . In the absence of flow, oxygen delivery stops. Hypoxic injury causes cells to release vasoactive substances (eg, histamine, serotonin), which increase endothelial permeability. Capillaries allow continued fluid loss, which increases tissue pressure and advances injury. Nerve conduction slows Tissue pH falls due to anaerobic metabolism, Surrounding tissue suffers further damage and muscle tissue suffers necrosis, releasing myoglobin. The end result is loss of the extremity and, possibly, the loss of life.


Myoglobin :Myoglobin Myoglobin is found in muscle cells. Muscle cells, when put into action, can quickly require a large amount of oxygen for respiration because of their high demand for energy. Therefore, muscle cells use myoglobin to accelerate oxygen diffusion and act as localized oxygen reserves for times of intense respiration.


Frequency :Frequency Vascular injury ? 30% Fracture ? 70% Anterior distal lower extremity is the most common site of C.S.


Mortality/Morbidity :Mortality/Morbidity CS outcome depends on both the : Diagnosis and the time from injury to intervention. Rorabeck and Macnab reported almost complete recovery of limb function if fasciotomy was performed within 6 hours. Sex : CS was diagnosed more often in men than in women; since men are more often patients with traumatic injuries.


History :History Suspect CS whenever significant pain occurs in an extremity following an injury. Pressure rises and ischemic injury begins to impair nerve function. Nerve impairment will often cause the patient to complain of severe pain. Maintain a high level of suspicion in any injury that causes limb pain.


History :History Long bone fractures High-energy trauma Penetrating injuries (eg, gunshot wounds, stabbings) - Often cause arterial injury, which can quickly lead to CS Venous injury Crush injuries


Attention :Attention CS has been found in soldiers and athletes without any trauma If CS is suspected, check intracompartmental pressure, even with no presence of any trauma.


Symptoms :Symptoms The 5 Ps Pain Paraesthesia Pallor Paralysis Pulselessness


Symptoms :Symptoms After initial symptoms of pain, decreased strength and finally paralysis of the affected extremity occur. Follow-up physical examinations are important to determine if any progression of symptoms exists.


Symptoms :Symptoms Severe pain at rest or with any movement should raise suspicion. Pain with certain movements, particularly passive stretching of the muscles, is the earliest clinical indicator of CS. A patient may report pain with active flexion.


Symptoms :Symptoms If a patient complains of pain, determine if any neural compromise exists. Sensory nerves begin to lose conductive ability. Some nerves may reveal effects of increasing pressure before others. For example, in the anterior compartment of the lower leg, the deep peroneal nerve is quickly affected, and sensation in the web space between first 2 toes may be lost. The affected limb may begin to feel tense or hard, as if filling with fluid. Compare the affected limb to the unaffected limb.


Causes :Causes The cause of CS is extremely simple: The pressure is too high Increased fluid content or decreased compartment size


Increased fluid content :Increased fluid content Intensive muscle use (eg, tetany, vigorous exercise, ) Everyday exercise activities (eg, stationary bicycle use) Burns Intraarterial injection (frequently iatrogenic) Decreased serum osmolarity (eg, nephrotic syndrome) Infiltrated infusion Hemorrhage (particularly from a large vessel injury)


Decreased compartment size :Decreased compartment size Decreased compartment size can be caused by the following: Military antishock trousers (MAST) Burns Casts


Other Cause :Other Cause Lying on a limb can cause CS. : Average pressures of 48 mm Hg with the head resting on forearm, 178 mm Hg when the forearm was under ribcage 72 mm Hg when one leg was folded under the other were reported


Prehospital Care: :Prehospital Care: Prehospital Care: CS can develop rapidly after an arterial injury. Therefore, speed of transport is essential. Perform only the necessary lifesaving procedures in the field if CS is suspected. Decreased pressure on affected limb Do not elevate the affected extremity. Styf and Wiger (1998) measured, after an elevation of 35 cm, a decrease in the mean arterial perfusion pressure of 23 mm Hg and no change in intracompartmental pressure.


Emergency Department Care :Emergency Department Care Time is of the essence in diagnosing and treating compartment syndrome. Irreversible nerve damage begins after 6 hours of intracompartmental hypertension. If CS is suspected, pressure measurements and appropriate consultation must be performed quickly.


Emergency Department Care :Emergency Department Care Many cases of CS are due to trauma. Ischemic injury is the basis for CS. Additional oxygen should be administered because it slightly increases partial pressure of oxygen (PO2).


Surgery :Surgery Consultations : General surgeon Orthopedic surgeon Vascular surgeon


Treatment :Treatment Treatment is usually surgery Fasciotomy Long incisions are made in the fascia to release the pressure building inside The wounds are generally left open (covered with a sterile dressing) and closed during a second surgery, usually 48-72 hours later Skin grafts may be required to close the wound


Postoperative care after Fasciotomy :Postoperative care after Fasciotomy Bulky???? dressing to promote edema reduction Extremity elevated Wound are checked in 3 to 5 days Skin graft when edema resolved if needed Active & passive motion of digits while the bulky dressing is still in place Shoulder & elbow are mobilized to prevent stiffness


Treatment :Treatment If a cast or bandage is causing the problem: The dressing should be loosened or cut down to relieve the pressure


Complications 1/2 :Complications 1/2 If there is a delay in diagnosis, there can be permanent????? : Nerve injury Loss of muscle function This is more common when injured person is: Unconscious Heavily sedated Incapable of complaining?????. Permanent nerve injury can occur after 12-24 hours of compression.


Complications 2/2 :Complications 2/2 Complications include: Permanent injury to: Nerves Muscles that can dramatically impair function In more severe cases limbs may need to be amputated because all the muscles in the compartment have died from lack of oxygen


Nursing diagnosis & care :Nursing diagnosis & care People placed in casts need to be made: Aware of the risk of swelling Aware of the S&S Go to the emergency room if: They have increasing pain under the cast despite elevation and pain medicine.