Compartment Syndrome

Question 1

Six P’s (Signs and Symptoms of Compartment Syndrome)

Answer 1

Pain
Pressure
Pulselessness
Paresthesia
Pallor
Paralysis

Question 2

Pain - Signs & Symptoms (S&S)

Answer 2

Pain: primary symptom in awake patient

Question 3

Pain - Key Points

Pain is NOT a reliable symptom in patients who are unconscious, insensate, or patients with a nerve block

Answer 3

Pain out of proportion:

• Increases with passive motion (stretch test)
• Unrelieved by analgesics, loosening of cast, dressing, splint
• In late stage, pain may not be present if ACS already established, as receptors and nerve fibers may face ischemic necrosis and death

Question 4

Pain - Assessment

Answer 4

• Passive stretch test: extension/hyper-extension of toes, fingers
• Use validated pain scales for individual type of patient

Question 5

Pain - Interventions

Answer 5

• Relieve the pressure with positioning
• Loosen cast, bandage, splint, tourniquet, compression stockings
• Position extremity at heart level (do not elevate)
• Communicate findings to provider, surgeon
• Treat pain
• When not improving, ICP (Intracompartmental Pressure) measurement warranted

Question 6

Pressure - Key Points

Answer 6

• Massive swelling

- Tense feeling of muscle(s) on palpation

Question 7

Pressure - Assessment

Answer 7

-Results can be variable secondary to severe pain and/or peripheral nerve block

Question 8

Pressure - Interventions

Answer 8

• Communicate findings to provider, surgeon

- ICP (Intracompartmental Pressure) measurement warranted

Question 9

Pulselessness - Key Points

Answer 9

-Very late sign signaling potential for tissue necrosis

Question 10

Pulselessness - Assessment

Answer 10

-Palpate all pulses distal to injury
(Doppler ultrasound may be useful)
-Assess for capillary refill delay greater than three seconds

Question 11

Pulselessness - Interventions

Answer 11

• Urgently notify provider, surgeon of finding
• ICP measurement
• Fasciotomy (a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle)

Question 12

Paresthesia - S&S

Answer 12

Burning or prickling sensation

Question 13

Paresthesia - Key Points

Answer 13

• First sign of nerve ischemia

- May be compounded by nerve block

Question 14

Paresthesia - Assessment

Answer 14

-Presence of burning, numbness or tingling

Question 15

Paresthesia - Interventions

Answer 15

• Notify provider, orthopedic surgeon immediately

- ICP measurement

Question 16

Palor - Assessment

Answer 16

-Skin color changes compared to unaffected extremity

Question 17

Palor - Intervention

Answer 17

-Notify provider, surgeon, orthopedic surgeon

Question 18

Paralysis - Key Points

Answer 18

-Neurovascular deficits can cause muscles in the affected compartment to become weak/paralyzed

Question 19

Paralysis - Assessment

Answer 19

-Establish ability to move affected extremity

Question 20

Paralysis - Interventions

Answer 20

Notify provider, surgeon, orthopedic surgeon immediately

Question 21

Normal intracompartmental extremity measurement

Answer 21

ranges from 0 to 4 mmHg

Question 22

Methods of diagnosing ACS

Answer 22

• infrared spectroscopy monitoring and noninvasive ultrasound techniques to measure tissue perfusion
• Magnetic resonance imaging can also play a role in the diagnosis of ACS.
• Continuous pressure monitoring can be useful when diagnosing patients who are unable to communicate, or patients who have received a regional nerve block for postoperative analgesia.
• pressure measurement value considered necessary for diagnosing extremity ACS is equivocal depending on the anatomic location and the measurement location in relation to the injury site.
• There is currently no consensus on the threshold compartment pressure at which a fasciotomy is needed, yet traditional recommendations for decompression have suggested pressure above 30 mmHg.
• Another method to determine the need for fasciotomy is based on the delta between compartment pressure and blood pressure. The delta pressure is obtained by subtracting the compartment pressure from the diastolic pressure.
• The use of delta pressures less than or equal to 30 mmHg has been shown to be an effective method in diagnosing compartment syndrome in a timely and accurate manner.