Transcript COMPARTMENT SYNDROME- an overview By Suvarna Maharaj

Compartment Syndrome- an
overview
By Suvarna Maharaj
Intro
• Compartment syndrome is a limb and life
threatening condition that occurs when perfusion
pressure falls below tissue pressure in a closed
anatomical compartment .
• If left untreated -tissue necrosis and sequele
• Ultimately death
• It is found wherever a compartment is present.
Causes
• Simple cause: THE PRESSURE IS TOO HIGH.
• Either –decreased compartment size or increased
fluid content.
• Increased fluid contentintensive muscle use
burns
intra-arterial injection
infiltrated infusion
haemorrhage
envenomation
Causes
• Decreased compartment pressure
Burns
Casts
Military aftershock trousers
Pathophysiology
• This follows the path of ischemic injury. When
fluid is introduced into a fixed volume or when
volume decreases, pressure rises.
• In the case of CS, compartments have a
relatively fixed volume. An introduction of excess
fluid or extraneous constriction increases
pressure and decreases tissue perfusion until no
O2 is available for cellular metabolism.
Pathophysiology cont.
• Elevated perfusion pressure is the physiological
response to rising intracompartmental pressure (IP).
When IP rises, autoregulatory mechanisms are
overwhelmed and a cascade of injury develops.
• Tissue perfusion pressure is measured by
subtracting the interstitial fluid pressure from the
capillary perfusion pressure. When this pressure
falls below a critical level, injury results.
Pathophysiology cont.
• When intracompartmentalpresssure rises,
venous pressure rises. When venous pressure
exceeds CPP, capillaries collapse. Generally, an
intracompartmental pressure greater than
30mmHg requires intervention.
• At this point, blood flow stops, resulting in
decreased O2 delivery. Hypoxic injury causes
cells to release vasoactive substances which
increases endothelial permeability.
Pathophysiology cont.
• Capillaries allow continued fluid loss which
increases tissue pressures and advances injury.
• Nerve conduction slows,tissue ph falls due to
anaerobic metabolism,surrounding tissue suffers
further damage, and muscle tissue suffers
necrosis releasing myoglobin.
• The end is loss of the extremity and possibly, the
loss of life.
Clinical- History
• Suspect CS whenever significant pain
occurs in an extremity
• Mechanism of injury- long bone fracture,
high energy trauma, penetrating injuries,
crush injuries
• Remember to ask about anticoagulationincreases risk of CS
Signs
• 5 P’s parasthesia, pallor,pulselessness,
pain, poikilothermia are not diagnostic of
CS. Except for pain and parasthesia , the
other traditional signs are not reliable.
• Severe pain at rest or with any movement
especially passive stretching of the
muscles should raise suspicion
Less common sites of CS
• FOOT
• -Classic signs What are they?
expected with foot fractures and injury so
tense tissue bulging maybe the most
reliable sign.
-associated with CS of deep posterior
compartment of leg.
CS of the hand
Symptoms from compression causes pain,
loss of sensation and decreased hand
function due to pressure on blood vessels
and the median nerve within the wrist
compartment .
CS of the gluteal region
The large gluteal muscle mass is confined in
fascia hence area prone to CS. How?
Signs include pain especially on passive
flexion at the hip and tense swelling of the
buttock. Late signs include foot drop with a
loss of sensation along distribution of
sciatic nerve and no active movements of
the ankle.
Workup
• LAB STUDIES
- Often normal and not helpful in diagnosing
or excluding CS
- Definitive diagnosis is compartment
pressure measurement using a tonometer
if available.
- Remember PITFALLS
Measurement Methods
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Simple needle
Wick Catheter
Slit catheter
Side Port catheter
Transducer –Tipped Catheter
Technique
• STRYKER TECHNIQUE
• MERCURY MANOMETER
Technique
Demonstration
• Go to
www.emprocedures.com/compartment
ED care
• Stabilize the patient
• Ischemic injury is basis for CS. Additional
O2 should be given.
• IV hydration is essential. Hypovolemia
worsens ischemia.
• Do not elevate the affected limb-decreases
arterial pressure
• Fasciotomy is definitive treatment so early
referral is warranted.
Fasciotomies
• Two Incision Technique
• Used to adequately decompress all four
compartments
• Medial Incision made longitudinally just posterior
to tibia
• Lateral incision made posterior to fibula from
level of head to lat malleolus
• Closure
• Post-op
Complications
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Permanent nerve damage
Infection
Loss of limb
Death
Cosmetic deformity from fasciotomy
References
• Emedicine Compartment Syndrome by Richard
Paula MD Director of Research, Assistant
Professor of Emergency Medicine,University of
South Florida
• Mutimedia Procedure Manual- Compartment
pressure Measurement
• Gluteal Compartment Syndrome following Joint
Arthroplasty Under Epidural Anaesthesia,Journal
of Orthopaedics Surgery
References
• April 2007 By Kumar V Saeed, A
Panagopoulos, PJ Parker
• Wheeless’ Textbook of OrthopaedicsCompartment syndrome of the Foot.
• Acute Compartment Syndrome Update on
Diagnosis and treatment by TE Whitesides
and MM Heckman Academy of
Orthopaedic Surgery July 1996
The end
Thank you