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