Trauma ICU Rounds – Extremity Compartment Syndrome

Originally posted on Trauma ICU Rounds on October 10, 2020 – Visit to listen to accompanying podcast. Follow Trauma ICU Rounds (@traumaicurounds) and Dr. Kim (@dennisyongkim) to learn more on simplifying trauma critical care together.


What are the 5 or 6 Ps? If you answered Pain, Pain, Pain, Pain, Pain, and Pain, you can go right ahead and skip this episode. Extremity compartment syndrome is an acute surgical emergency and requires a HIGH index of suspicion in order to make the diagnosis. Therapy consists of fasciotomy. If left untreated, numerous complications and sequelae may develop including AKI and even death.

Learning Objectives

By the end of rounds you should be able to:

1. Describe the pathophysiology of acute extremity compartment syndrome

2. Recognize risk factors and key clinical features of compartment syndrome, namely the 6Ps

3. Understand how to measure and interpret compartment pressures

4. Discuss management considerations and pitfalls re: fasciotomy

Take Home Points

  • Extremity compartment syndrome is an acute surgical emergency that required a HIGH INDEX OF SUSPICION

  • Although commonly associated with fractures (especially, tib-fib and distal forearm), up to 1/3 of patients have NO LONG BONE FRACTURE

  • Pain out of proportion or on passive stretching of a muscle group and paresthesias are the first signs of extremity compartment syndrome

  • Physical exam, specifically, feeling for the tenseness of a compartment is UNRELIABLE

  • In the leg, the ANTERIOR and DEEP POSTERIOR compartments are the most frequently missed!

  • If you suspect it, DO SOMETHING = either a compartment pressure check OR fasciotomy

Time Stamps

  • 00:12 Introduction

  • 02:45 Learning Objectives

  • 03:32 Pathophysiology of Extremity Compartment Syndrome

  • 06:19 Starling’s Hypothesis

  • 09:32 Risk Factors for Extremity Compartment Syndrome both Direct & Indirect

  • 13:41 6Ps (Pain out of proportion and/or with passive motion, Paresthesias, Pallor, Poikilothermia, Paralysis, Pulselessness)

  • 15:46 The Physical Exam for Diagnosing Extremity Compartment Syndrome SUCKS!

  • 17:47 A Prospective Study to Support the Statement Above

  • 19:18 Performing an Intracompartmental Pressure Check

  • 21:42 Use the Differential Pressure NOT Absolute Compartment Pressures

    • (P diastolic – P compartment < 30mmHG = ABNORMAL)

  • 22:46 Performing Fasciotomies (with a focus on the leg)

  • 25:29 Prophylactic versus Therapeutic Fasciotomy: Who, When, Why?

  • 27:53 Wound Care & Postoperative Considerations

  • 28:28 Rhabdomyolysis

  • 29:48 Take Home Points

  • 30:59 Outro & Call to Action

Core Concepts, Equations, and Other Stuff

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Recommended Reading

Articles

Brown CV, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference? J Trauma. 2004 Jun;56(6):1191-6. doi: 10.1097/01.ta.0000130761.78627.10. PMID: 15211124.

Schellenberg M, Chong V, Cone J, Keeley J, Inaba K. Extremity compartment syndrome. Curr Probl Surg. 2018 Jul;55(7):256-273. doi: 10.1067/j.cpsurg.2018.08.002. Epub 2018 Aug 23. PMID: 30470346.

Shuler FD, Dietz MJ. Physicians’ ability to manually detect isolated elevations in leg intracompartmental pressure. J Bone Joint Surg Am. 2010 Feb;92(2):361-7. doi: 10.2106/JBJS.I.00411. PMID: 20124063.

von Keudell AG, Weaver MJ, Appleton PT, Bae DS, Dyer GSM, Heng M, Jupiter JB, Vrahas MS. Diagnosis and treatment of acute extremity compartment syndrome. Lancet. 2015 Sep 26;386(10000):1299-1310. doi: 10.1016/S0140-6736(15)00277-9. Erratum in: Lancet. 2015 Nov 7;386(10006):1824. Appelton, Paul T [corrected to Appleton, Paul T]. Erratum in: Lancet. 2015 Nov 7;386(10006):1824. PMID: 26460664.

Websites

Starling’s Hypothesis: https://www.anaesthesiamcq.com/FluidBook/fl4_2.php

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