“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 DAMAGE

Muscle • 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

• Hyperkalemia

• Cardiac

Arrythmias

Lactic Acid

• Decreased pH

• Acidosis

Phosphorus

• Calcifications in

vasculature

• Small clots

RHABDOMYOLYSIS!

EPIDEMIOLOGY

EPIDEMIOLOGY

Decreased 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 SYMPTOMS

Classic 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 GOALS

Decrease 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 AND EVALUATION LINK

• 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

• https://msu.co1.qualtrics.com/jfe/form/SV_eKwSTTh4KlqjbEN

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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.