COMPARTMENT SYNDROME

Cindy Fehr Malaspina University-College BSN Nursing Program Nursing 335 Fall 2005
Diagram Source: Nursing 1999, June, p. 33

Definition
Area of body where muscles, blood vessels, nerves may be compressed within tissue like fascia or bone Occurs when extremely high pressures build in confined space Caused by anything at s compartment size (external or internal compression forces) Can occur anywhere in body but most often in lower leg or forearm

Categories of Etiologies
1. Decreased Compartment Size
Caused by restrictive dressings, splints or casts, excessive traction, premature closure of fascia

2. Increased Compartment Content

Bleeding or swelling within compartment Can also result from interstitial IV into compartment

3. Externally Applied Pressure

Constrictive dressing, prolonged compression from lying on limb

Compartments of the lower leg; Source: Emergency Nurse (2004) 12(2), 33

Pathophysiology
elevation of interstitial pressure in closed fascial compartment (limited space) that results in microvascular compromise Capillary blood perfusion which prevents adequate circulation & compromises tissue viability metabolic demands not met ischemia & anaerobic metabolism histamine release by affected muscles edema & perfusion as duration & magnitude of interstitial pressure increases, myoneural function is impaired & necrosis of soft tissues eventually develops Left untreated nerve & muscle function loss, infection, myoglobinuria, renal failure, amputation

Compartment Syndrome/Edema-Ischemia Cycle

Source: Orthopaedic Nursing, 2001, 20(3), 17.

Types
Acute
Most severe Often requires immediate surgical intervention Symptoms present usually within 6-8 hrs of injury but can take as long as 2 days Caused by external or internal forces secondary to trauma of muscle compartment External pressure s compartment size while internal pressure s compartment contents which results in tissue necrosis Associated with ing pain disproportionate to type of injury Deep, unrelenting pain; throbbing & localized Pain with passive stretch Numbness & tingling or paresthesias in affected limb

Types cont.
Chronic or Exertional
With exercise & overuse of muscle groups inflammation & swelling which intracompartmental pressures aching pain, tight squeezing sensation but usually relieved by rest Most frequently in young, active individuals c/o aching, tightness, cramping in affected limb, localized to affected compartment & often bilaterally Symptoms often disappear with rest

Types cont.
Crush Syndrome
From prolonged compression of skeletal muscle or severe soft tissue crush trauma bleeding, edema, fluid shifts contribute to injury Multi-compartmental involvement results in systemic effect of severe muscle ischemia muscle necrosis and/or infarction Leads to muscle infarction, myoglobinemia, rhabdomyolysis

Assessment & Interventions

Always compare injured limb in comparison to uninjured limb Early recognition imperative Assessing 6 Ps Pain

with passive motion, stretching of compartment Usually first sign, but can be impaired by analgesics with elevation of extremity Often narcotics ineffective in relieving pain

Paresthesias

One of first signs sensory deficit in affected compartment area Subtle tingling or burning sensation leading to numbness (hypoesthesia) Loss of differentiation between sharp & dull (loss of two-point discrimination)

Assessment & Interventions

Pressure
Limb (over compartment affected) will feel tense, skin tight and shiny

Paralysis
Late sign Sometimes unable to move limb distal to injury d/t compression of nerves can start as weakness in active movement of joint distal to injury

Pallor
Late sign Color pale & dusky, limb cool to touch & cap refill > 3 sec

Pulselessness
Very late sign

Assessment & Interventions cont.

Diagnostic Evaluation
Variety of compartment pressure monitors
Needle inserted into affected compartment & pressure measured in milimeters of mercury (mmHg) Normal compartment pressure = 0-8 mm Hg; pressure 30-40 mm Hg = damage to blood vessels & nerves in compartment; pressure > 65 mm Hg = tissue ischemia & necrosis in compartment pressure affects nerves more severely than muscle Compartment ischemia > 4-12 hrs can cause permanent muscle damage

MRI to assess chronic muscle density changes Lab findings

WBC & ESR d/t severe inflammatory response urine myoglobin muscle necrosis and protein loss serum K+ cell damage Serum pH acidosis

Assessment & Interventions cont.

Treatment
Relieve source of pressure & restore perfusion; loosen external devices, debride eschar, fasciotomy (incision thru skin into fascia of muscle compartment allow tissue expansion, restore blood flow) Extremity elevated to level of heart higher than heart restricts blood flow further Absolutely NO ICE vasoconstrict and ischemia Adequate hydration maintain mean arterial pressure for tissue perfusion Manage pain to minimize vasoconstriction d/t effects of SNS

Fasciotomy

Source: Orthopaedic Nursing, 2001, 20(3), 20.

Source: Orthopaedic Nursing, 2001, 20(3), 17.