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Acute Compartment Syndrome - Overview

Discussion in 'Emergency Medicine' started by Ghada Ali youssef, Jan 12, 2017.

  1. Ghada Ali youssef

    Ghada Ali youssef Golden Member

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    What is it?
    Compartment syndrome is defined as increased pressure within a compartment of the body, commonly in the arm or leg. Acute compartment syndrome is caused by trauma.
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    Common causes
    • Major trauma e.g. car crash
    • Lower leg or radial/ulnar fractures
    • Crush injuries
    • Plaster of Paris casts – causing restriction
    • Burns

    Pathophysiology

    Muscular compartments are enclosed by fascia, which defines the borders of each compartment. Fascia doesn’t stretch, therefore even small amounts of bleeding and/or tissue oedema within a given compartment can result in significant increases in pressure. The increase in pressure reduces the incoming blood supply of the compartment, which can result in tissues being deprived of oxygen.

    In addition venous and lymphatic drainage from the compartment is also compromised, adding to the problem by increasing compartment pressure even further, leading to a vicious cycle of continually increasing pressure. As a result, if this is left untreated tissue can become hypoxic and be permanently damaged, potentially resulting in loss of function or loss of a limb completely.

    If Compartment Syndrome is not treated quickly and effectively, skeletal muscle can begin to rapidly break down, this is known as rhabdomyolysis. One of the breakdown products is myoglobin, which can damage the kidneys leading to acute renal failure.

    History and Examination
    Symptoms & signs of limb ischaemia are best remembered by the 6 Ps!
    • Painful
    • Pale
    • Pulseless
    • Paraesthesia
    • Paralysis
    • Perishingly cold
    Pain is often out of proportion to the clinical situation. An example may be a post-op Orthopaedic patient who despite large amounts of both IV & hourly oral morphine continues to have severe pain in the associated limb.

    Diagnosis
    Compartment Syndrome is primarily a clinical diagnosis but pressure gauges can be used if the diagnosis is not clear.

    Treatment
    The only treatment is fasciotomy, a surgical procedure which releases the pressure in the affected compartment, in addition to releasing the pressure in all other surrounding compartments. This may need to be done multiple times in some cases.
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    How to approach compartment syndrome as a junior doctor
    • History and examination
    • Observations
    • Pain control (do not forget this!)
    • If affected limb is in a cast –> Split the cast!!!
    • Ensure patient is nil by mouth – in case they need an emergency fasciotomy
    • Make seniors aware and request urgent review – ensure you communicate your concern
    And that is it! Compartment Syndrome is something all juniors live in fear of, but actually it’s pretty simple! The bottom line is, if you’re worried or it is playing in the back of your mind, ask your registrar to come take a look.

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