“UNDER PRESSURE”
A REVIEW OF COMPARTMENT SYNDROMEAllison Biliti, BS, CC Paramedic I/C

OBJECTIVES

• Understand the definition • Identify the Anatomy • Identify the Pathophysiology • Identify the Epidemiology • Identify the Signs and Symptoms • Identify the Pre-Hospital Treatment • Identify complications

CRUSH INJURY Injury caused as a result of direct physical crushing of the

muscles

CRUSH INJURY 


Compartment Syndrome • Complication of crush injury • Any condition in which a structure

has been constricted within an osteofascial space • Localized rapid rise of tension in a

muscle compartment • Inevitably leads to rhabdomyolysis

Crush Syndrome • Complication of crush injury • AKA Rhabdomyolysis • Series of metabolic changes

produced due to an injury of skeletal muscle of such severity to produce systemic complications

ANATOMY

ANATOMY• 36 compartments in the

extremities

• Comprised of muscles, blood vessels, and nerves

• Surrounded by Fascia • Band of connective tissue • Attaches, stabilizes, and

encloses muscles • Limited ability to expand

TYPES OF COMPARTMENT SYNDROME

Acute Compartment Syndrome

• Time sensitive surgical emergency

• Caused by severe injury

• Can lead to death

Chronic Compartment Syndrome

• Exertional, recurrent, or subacute

• Exercise induced

• Isolated to lower limbs

• Young athletes

PATHOPHYSIOLOGY

PATHOPHYSIOLOGYVolkmann’s Ischemia

• Increased compartment pressure • Increased venous pressure • Narrowed arterio-venous gradient • Decreased arterial pressure

• Decreased perfusion pressure • O2 deprivation • Tissue necrosis • Muscle and nerve ischemia

Increased pressure causes swelling to concentrate inward toward internal structures

TISSUE DAMAGEMuscle • 3-4 hours - reversible

changes

• 6-8 hours - variable damage

• 10 hours – irreversible damage (myonecrosis)

Nerve• 2 hours – loose nerve

conduction

• 4 hours – neuropraxia

• 8 hours - irreversible

SYSTEMIC PATHOPHYSIOLOGY

SYSTEMIC PATHOPHYSIOLOGY• Skeletal Muscle

• Cell membrane called sarcolemma • Structure • Function • Pumps potassium and calcium inside • Pumps sodium outside • Fueled by ATP (energy source)

• Myoglobin • Found inside skeletal muscle cell • Has high affinity for O2 (draws it into cell for metabolism)

• Enzymes inside the cell • Normally not harmful to the cell (except when calcium levels are

high)

SYSTEMIC PATHOPHYSIOLOGY

Cell membrane increased permeability

Calcium and Sodium rush into the cell (hypercalcemia)

Myoglobin, Potassium, Uric acid, Phosphorus leak out

SYSTEMIC PATHOPHYSIOLOGY

Myoglobin • Lodges in

kidneys • Renal

failure (myoglobinuria)

Potassium • Hyperkale

mia • Cardiac

Arrythmias

Lactic Acid • Decreased

pH • Acidosis

Phosphorus • Calcificatio

ns in vasculature

• Small clots

RHABDOMYOLYSIS!

EPIDEMIOLOGY

EPIDEMIOLOGYDecreased Compartment Size

• Tight dressings • Splints, tourniquets, casts • Burn eschar • Lying on limb for

extended periods • Automatic blood pressure

cuffs

Increased Compartment Contents

• Fractures • Open Fx does NOT rule

this out!! • Hemorrhage • Muscle edema • Burns • Fluid infiltration (IV/Med

Admin/Drug Addicts)

SIGNS AND SYMPTOMS

SIGNS AND SYMPTOMSClassic 5,6, or 7 P’s• Pain • Pallor • Paralysis • Paresthesia • Pressure • Pulselessness • Poikilothermia

SIGNS AND SYMPTOMSDifficult diagnosis

• Classic s/s (P’s) are NOT RELIABLE • These are signs of an ESTABLISHED compartment syndrome where

ischemic injury has already taken place • These signs may be present in the absence of compartment syndrome

• Sensory changes and paralysis do not occur until ischemia has been present for 1 hour or more

• Pulses and capillary refill are normal and deviation is a VERY late finding

• Challenging in children and patients with neurological compromise

SIGNS AND SYMPTOMS• Most reliable indicators of

IMPENDING compartment syndrome are

• Pain disproportionate to injury

• Pain increases on passive stretching

• Pain increases with elevation

What else can we do for early

diagnosis?

INTRA-COMPARTMENTAL PRESSURE MONITOR

SYSTEM

PRESSURE MONITORING• Normal tissue pressure • 0-4 mmHg • 8-10 mmHg with exertion

• Compartment pressure > 30 mmHg strongly suggests compartment syndrome

• Delta pressure • Difference between diastolic pressure and compartment pressure • < 30 mmHg strongly suggests compartment syndrome

INTRA-COMPARTMENTAL PRESSURE MONITOR

TREATMENT

TREATMENT GOALSDecrease tissue pressure

Increase blood flow

Minimize tissue damage/functional loss

TREATMENT• Note the time of occurrence and mechanism

• Relieve any external causes (splints, bandages, casts, etc)

• High flow O2

• IV fluids to maintain kidney output (maintain MAP)

• Pain management (immobilization will NOT reduce pain)

• Mannitol-free radical scavenger and decreases edema

TREATMENT Fasciotomy

• Goal is first 4 hours after injury

• 2/3 patients regained normal function 
when performed within 12 hours

• HBOT as an adjunct to fasciotomy

• May require debridement of muscle tissue

TREATMENT (TO AVOID)•Do NOT ice - vasoconstriction

•Do NOT elevate – decrease arterial bloodflow

•Do NOT give Lasix – obstructions occur before the Loop of Henle

COMPLICATIONS• Myonecrosis • Myoglobinuria • Rhabdomyolysis • Nerve damage • Infection • Blood clot • Volkmann’s contracture (claw hand) • Loss of extremity • DEATH

QUESTIONS??

QUIZ & EVALUATION

• The quiz & evaluation must be completed within 2 weeks with a score of 80% or higher to receive your continuing education credit.

• Attendance is verified. • CE’s are delivered via email to the address provided • Quiz & evaluation link: https://msu.co1.qualtrics.com/jfe/form/

SV_5w00y4kLnklxhn7

https://msu.co1.qualtrics.com/jfe/form/SV_5w00y4kLnklxhn7

REFERENCESAmerican College of Surgeons, Committee on Trauma. (2007). Advanced Trauma Life Support Course: Student Manual. Chicago: American College of Surgeons.

Bledsoe BE, Porter RS, Cherry RA. (2001). Trauma Emergencies Paramedic Care: Principles and Practice. 5th ed. Upper Saddle River, NJ: Prentice-Hill.

Daniels M, Reichmar J, Brezis M. (2008). Mannitol treatment for acute compartment syndrome. Nephron 79(4):492-3.

Emergency Nurses Association, TNCC Revision Task Force. (2000). Trauma Nursing Core Course. 5th ed. Des Plaines, IL: Emergency Nurse Association.

McPhee SJ, Vishwanath RL, et al. (2000). Pathophysiology of Disease: An introduction to clinical medicine. 3rd ed. New York: Lang/McGraw-Hill.

Sippel R. (2014). Compartment syndrome of the extremities. EMSworld.