Emergency Strategy - How to treat compartment syndrome
Emergency Strategy - How to treat compartment syndrome
The initial step is to perform the airway ( opening and maintaining the airway)), breathing ( assisting ventilation) and circulation ( monitor circulatory status) , disability ( difficulty in movement ) assessments.
Acute compartment syndrome is a surgical emergency. It is important to measure the intracompartmental pressure. If compartment pressure is between 15 and 20 mmHg , repeated measurements and close monitoring are required. The patient is admitted if the compartment pressure is more than 20 mmHg and less than 30 mmHg an surgical evaluation is required. If the compartment pressure is more than 30mmHg, consider surgical or orthopedic urgent consultation. Care should be taken not to cause injury to the blood vessel, tendon and nerves.
How to measure compartment syndrome? Intracompartmental pressure is monitor using the Stryker IC pressure monitor system. 18 gauge needle or indwelling catheter ( continuous pressure monitoring is considered). The overlying skin is prepared with antiseptic solution. Local anesthetic is given subcutaneously . The needle for measuring the intracompartmental pressure is advanced through the skin. A popping sensation indicates that the needle has pierced the fascia and stop advancing the needle. 0.2 ml saline solution is inserted through the lumen of the needle and the intracompartmental pressure is measured.Passively stretch the muscle or applying the external pressure over the muscle compartment may lead to an increase in the intracompartmental pressure transiently. This will confirm the correct placement of the needle.
The injured extremities should be kept at the same level as the heart to promote arterial flow and maintaining venous return. In acute cases, the injured casted, extremities should be univalved and spread. Remember to cut the underlying cast paddling. Do not apply ice as it may affect the microcirculation.
Generally medication such as vasolidator or steroids are not useful. Pain /analgesic medication is only given after consultation and advice from the surgical consultant. IV narcotic analgesic may be given with little benefit. The main treatment of compartment syndrome is fasciotomy /decompression. Fasciotomy usually performed if compartment pressure is more than 30 - 40 mmHg. Patient will be discharged if the compartment pressure is 10 - 15 mmHg. Symptomatic treatment is given. Patient should return and admitted if suffer from swelling, paraesthesia and increase in intensity of the pain. Any suspicion of chronic compartment syndrome should be refer to orthopedic surgeon.
Patient with compartment syndrome may complain or present with muscle weakness, increasing pain with passive stretching and active contraction or severe pain that is disproportionate to the extent of the injury. Patient may also present with hyperesthesia or paraesthesia, pressure, pain, paresis and pulseless. The patient’s motor and neurologic condition /function are also assessed. Look for any signs of fracture. Imaging studies are performed.
The differential diagnosis of compartment syndrome are deep vein thrombosis, neuropraxia, occlusion of the artery, stress fracture, synovitis, tenosynovitis, osteomyelitis , fascial hernia and cellulitis.
What is compartment syndrome? Normal pressure of the tissue is less than 10mmHg. Compartment syndrome occur when there s an elevation of tissue pressure in closed space which affect the flow of blood through the capillaries. The pressure of more than 20mmHg will compromise the capillary blood flow in compartment. While pressure of more than 30 mmHg may lead to ischemic necrosis of muscle and nerves. Muscle necrosis is confirmed when distal pulses are absent on examination. Compartment syndrome usually affect the four compartment of the leg. However, other part of the body such as buttocks, thigh, shoulder, foot, hand, arm and forearm may also be affected.
The causes of compartment syndrome are increase in the content of the compartment due to compression by hematoma from trauma directly, edema, fracture, compression of the limb due to long recumbency and overextension of the limb. Decreased the sizes of the compartment due to military anti shock trouser, burn eschar or circumferential cast may also lead to compartment syndrome.
References
1.Rorabeck, C. H. “The Treatment of Compartment Syndromes of the Leg.” Journal of Bone & Joint Surgery, British Volume 66-B, no. 1 (January 1, 1984): 93–97.
2.McQueen, M. M., P. Gaston, and C. M. Court-Brown. “Acute Compartment Syndrome WHO IS AT RISK?” Journal of Bone & Joint Surgery, British Volume 82-B, no. 2 (March 1, 2000): 200–203.
3.Whitesides, T. E., and M. M. Heckman. “Acute Compartment Syndrome: Update on Diagnosis and Treatment.” Journal of the American Academy of Orthopaedic Surgeons 4, no. 4 (July 1, 1996): 209–218.
4.Gw, Sheridan, and Matsen FA 3rd. “Fasciotomy in the Treatment of the Acute Compartment Syndrome.” The Journal of Bone and Joint Surgery. American Volume 58, no. 1 (January 1976): 112–115.
The initial step is to perform the airway ( opening and maintaining the airway)), breathing ( assisting ventilation) and circulation ( monitor circulatory status) , disability ( difficulty in movement ) assessments.
Acute compartment syndrome is a surgical emergency. It is important to measure the intracompartmental pressure. If compartment pressure is between 15 and 20 mmHg , repeated measurements and close monitoring are required. The patient is admitted if the compartment pressure is more than 20 mmHg and less than 30 mmHg an surgical evaluation is required. If the compartment pressure is more than 30mmHg, consider surgical or orthopedic urgent consultation. Care should be taken not to cause injury to the blood vessel, tendon and nerves.
How to measure compartment syndrome? Intracompartmental pressure is monitor using the Stryker IC pressure monitor system. 18 gauge needle or indwelling catheter ( continuous pressure monitoring is considered). The overlying skin is prepared with antiseptic solution. Local anesthetic is given subcutaneously . The needle for measuring the intracompartmental pressure is advanced through the skin. A popping sensation indicates that the needle has pierced the fascia and stop advancing the needle. 0.2 ml saline solution is inserted through the lumen of the needle and the intracompartmental pressure is measured.Passively stretch the muscle or applying the external pressure over the muscle compartment may lead to an increase in the intracompartmental pressure transiently. This will confirm the correct placement of the needle.
The injured extremities should be kept at the same level as the heart to promote arterial flow and maintaining venous return. In acute cases, the injured casted, extremities should be univalved and spread. Remember to cut the underlying cast paddling. Do not apply ice as it may affect the microcirculation.
Generally medication such as vasolidator or steroids are not useful. Pain /analgesic medication is only given after consultation and advice from the surgical consultant. IV narcotic analgesic may be given with little benefit. The main treatment of compartment syndrome is fasciotomy /decompression. Fasciotomy usually performed if compartment pressure is more than 30 - 40 mmHg. Patient will be discharged if the compartment pressure is 10 - 15 mmHg. Symptomatic treatment is given. Patient should return and admitted if suffer from swelling, paraesthesia and increase in intensity of the pain. Any suspicion of chronic compartment syndrome should be refer to orthopedic surgeon.
Patient with compartment syndrome may complain or present with muscle weakness, increasing pain with passive stretching and active contraction or severe pain that is disproportionate to the extent of the injury. Patient may also present with hyperesthesia or paraesthesia, pressure, pain, paresis and pulseless. The patient’s motor and neurologic condition /function are also assessed. Look for any signs of fracture. Imaging studies are performed.
The differential diagnosis of compartment syndrome are deep vein thrombosis, neuropraxia, occlusion of the artery, stress fracture, synovitis, tenosynovitis, osteomyelitis , fascial hernia and cellulitis.
What is compartment syndrome? Normal pressure of the tissue is less than 10mmHg. Compartment syndrome occur when there s an elevation of tissue pressure in closed space which affect the flow of blood through the capillaries. The pressure of more than 20mmHg will compromise the capillary blood flow in compartment. While pressure of more than 30 mmHg may lead to ischemic necrosis of muscle and nerves. Muscle necrosis is confirmed when distal pulses are absent on examination. Compartment syndrome usually affect the four compartment of the leg. However, other part of the body such as buttocks, thigh, shoulder, foot, hand, arm and forearm may also be affected.
The causes of compartment syndrome are increase in the content of the compartment due to compression by hematoma from trauma directly, edema, fracture, compression of the limb due to long recumbency and overextension of the limb. Decreased the sizes of the compartment due to military anti shock trouser, burn eschar or circumferential cast may also lead to compartment syndrome.
References
1.Rorabeck, C. H. “The Treatment of Compartment Syndromes of the Leg.” Journal of Bone & Joint Surgery, British Volume 66-B, no. 1 (January 1, 1984): 93–97.
2.McQueen, M. M., P. Gaston, and C. M. Court-Brown. “Acute Compartment Syndrome WHO IS AT RISK?” Journal of Bone & Joint Surgery, British Volume 82-B, no. 2 (March 1, 2000): 200–203.
3.Whitesides, T. E., and M. M. Heckman. “Acute Compartment Syndrome: Update on Diagnosis and Treatment.” Journal of the American Academy of Orthopaedic Surgeons 4, no. 4 (July 1, 1996): 209–218.
4.Gw, Sheridan, and Matsen FA 3rd. “Fasciotomy in the Treatment of the Acute Compartment Syndrome.” The Journal of Bone and Joint Surgery. American Volume 58, no. 1 (January 1976): 112–115.
