List I - Act Core Conditions Flashcards
1
Q
What is compartment syndrome?
A
- Particular complication that may occur following fractures (or following ischaemia reperfusion injury in vascular patients)
- Characterised by raised pressure within a closed fascial compartment causing local tissue ischaemia and hypoxia
- Raised pressure compartment will eventually compromise tissue perfusion resulting in necrosis
- Two main fractures carrying this complication include supra-condylar fractures and tibial shaft fractures
2
Q
What are the features of compartment syndrome?
A
- Pain, especially on movement (even passive) - disproportionate
- Parasthesiae
- Pallor may be present
- Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
- Paralysis of the muscle group may occur
(Presence of a pulse does not rule out compartment syndrome)
3
Q
How is diagnosis of compartment syndrome made?
A
- Unequivocal positive clinical findings
- Measurement of intra-compartmental pressure measurements
- Pressures in excess of 20 mmHg are abnormal and >40 mmHg is diagnostic
- Compartment syndrome will typically not show any pathology on an x-ray
4
Q
What are the recommendations for patients at risk of developing compartment syndrome?
A
- Assessment should be part of routine evaluation of patients with significant limb injuries, after surgery for limb injuries and after any prolonged surgical procedure which may result in hypoperfusion of a limb
- Clear documentation should include: time and mechanism of injury, time of evaluation, level of pain, level of cosnciousness, response to analgesia and whether a regional analgesia has been given
- Patients documented to be at risk of compartment syndrome should have routine nursing limb observations for these early signs and they should be recorded
- Observations should be performed hourly whilst the patient is deemed still to be at risk
- If pain scores are not reducing senior review is mandated
- In high risk patients, regional anaesthesia should be avoided as it can mask the symptoms - when evaluating these patients, the rate and dose of opiates and other analgesics must be take into consideration and recorded in the medical records
5
Q
What are the key clinical findings of compartment syndrome?
A
- Pain out of proportion to the associated injury and pain on passive movement of the muscles of the involved compartments
(limb neurology and perfusion including capillary refill and distal pulses, should be clearly documented but do not contribute to early diagnosis of the condition
6
Q
How should patients with symptoms or signs of compartment syndrome be initially managed?
A
- All circumferential dressings to be released to skin and the limb elevated to heart level
- Measures should be taken to maintain a normal blood pressure
- Patient should be re-evaluated within 30 minutes
- If symptoms persist the urgent surgical decompression should be performed
- Alternatively, in situations where the clinician is not completely convinced by the clinical signs, compartment pressure measurements should be undertaken
- All actions should be recorded in the medical records
7
Q
When should surgery take place if a patient has a confirmed compartment syndrome?
A
- Compartment syndrome is a surgical emergency and surgery should take place within an hour of the decision to operate
8
Q
What can cause diagnostic uncertainty in a patient with compartment syndrome?
A
- Where clinical assessment is not possible (e.g. patients with reduced level of consciousness)
- Poly trauma victim
- Inconclusive findings
9
Q
How should patients with diagnostic uncertainty be assessed for compartment syndrome?
A
- Intra-compartmental monitoring
- Pressure sensor should be placed into the compartment(s) suspected of being abnormal or at risk
- Difference between diastolic BP and the compartment pressure (delta pressure) of less than 30 mmHg suggests an increased risk of compartment syndrome
- Recommended these should either proceed to surgical decompression or continue to be monitored depending on the consultant decision
- If the absolute compartment pressure is greater than 40 mmHg with clinical symptoms, urgent surgical decompression should be considered unless there are other life threatening conditions that take priority
10
Q
What is the definitive surgical management of compartment syndrome?
A
- Fasciotomy - immediate open decompression of all involved compartments, taking into account possible reconstructive options
- Necrotic muscle should be excised
- Compartments decompressed must be documented in the operation record
- All patients should undergo re-exploration at approximately 48 hours or earlier if clinically indicated
- Early involvement by a plastic surgeon may be required to achieve appropriate soft tissue coverage
11
Q
What is recommended in the method of performing a lower leg fasciotomy?
A
- Perform a two-incision four compartment decompression
12
Q
What are the recommendations for the management of a late presentation or diagnosis of compartment syndrome (greater than 12 hours)?
A
- High risk of complications with surgery
- Decision making is difficult and should involve two consultants
- Non-operative management is an option
13
Q
How can compartment pressures be measured?
A
- Commercial device such as the Stryker STIC Device
- Angiocath connected to a blood pressure transducer (e.g. arterial line set up)
- Other options include needle technique, wick catheter and the slit catheter
14
Q
What are the possible causes of compartment syndrome?
A
- Fractures (75%)
- Especially tibia, humeral shaft, combined radius and ulna fractures, and supra-condylar fractures in children
- May be open or closed
- Soft tissue injuries due to:
- Crush injury
- Snake bite
- Excessive exertion
- Prolonged immobilisation
- Constrictive dressings and plaster casts
- Soft tissue infection
- Seizures
- Extravasation of IV fluids and medications
- Burns
- Tourniquets
15
Q
Which compartment in the arm is most commonly affected in compartment syndrome?
A
- Forearm (volar) compartment
