Compartment Syndrome

1. Compartment Syndrome Kyle Miller

2. Compartment Syndrome • Definition • Compartment Syndrome involves the compression of nerves and blood vessels within an enclosed space. This leads to impaired blood flow and muscle and nerve damage.

3. Causes: • Thick layers of tissue called fascia separate groups if muscles in the arms and legs from each other. Inside each layer of fascia is a confined space, called a compartment. This includes muscle tissue, nerves and blood vessels. This is much like wires surrounded by insulation.

4. Unlike a balloon, fascia do not expand, so any swelling in a compartment will lead to increasing pressure in that compartment. This will compress the muscles, blood vessels and nerves. If this pressure is high enough, blood flow to the compartment will be blocked. This can lead to permanent injury to the muscle and nerves. If it lasts long enough, the limb may die and need amputation.

5. Swelling leading to compartment syndrome is associated with high-energy trauma, such as a car accident or even surgery. It may also occur from tight bandages or from a cast. Pressure will build up and cause compartment syndrome. Chronic compartment syndrome can be caused by repetitive activities like running or cycling that increase pressure only during those activities. • Compartment syndrome is most common in the lower leg and forearm, but can also occur in the foot, thigh and upper arm.

6. SYMPTOMS • The main symptom of compartment syndrome is severe pain that does not respond to elevation or medication. In a more advanced case, there may be decreased sensation, weakness and paleness of the skin.

7. Overuse • Local Tissue Swelling • Tight Compartment • Decreased Blood Supply • More Tissue Swelling • Cycle repeats itself

8. Diagnosis • Pressure testing of the muscle. • Insertion of small plastic catheter into the skin of the affected muscle to measure pressure. • Patient engages in the pain inducing activity while recording of compartment pressure is recorded. • Reproduction of symptoms associated with pressures above the certain value confirms the diagnosis.

9. TREATMENT • Correction of biomechanical abnormalities. • Soft tissue therapy. • Usually surgery. Long incisions are made in the fascia to release the pressure. • Incisions generally left open to prevent pressure rebuilding. • Skin grafts may be required to close the wound.

10. Prognosis • If pressure release is accomplished promptly, the outlook is very good for muscle and nerve recovery. • The overall outlook is determined by the injury that lead to the syndrome. • If diagnosis is delayed, there may be permanent nerve and muscle damage and loss of muscle function. This is more common when a person has been heavily sedated and incapable of complaining. Permanent nerve injury can occur after only 12-24 hours of compression.

11. Complications • Dramatic function impairment. • In more severe cases, limbs may have to be removed because the muscles in the compartment have died from lack of oxygen.

12. PREVENTION • Always be aware of this condition so early diagnosis can prevent complications. • If placed in a cast, be aware of the risk of increased swelling so they contact a health care provider immediately if they have increased pain under the cast, despite elevation and pain medication.

13. Abdominal Compartment Syndrome • Pressure inside the abdominal compartment can increase as a result of the build up of blood, fluid or edema in the critically ill, trauma, and post operative patients. • Accumulation of fluid can be the result of traumatic injury, bowel ischemia or infarction or gastrointestinal hemorrhage. • The build up can result in abdominal bleeding, cirrhosis, profound hypothermia, pancreatitis and fluid resuscitation in severe sepsis are other possible causes. • When pressure inside the abdominal compartment overcomes the pressure inside the capillaries perfusing the organs of the abdomen, ischemia and infarction of these organs can occur.

14. Adverse Effects of Increased Abdominal Pressure • Oliguria (urine output) due to renal ischemia. • Increased peak airway pressures due to restriction and elevation of the diaphragm. • Hypotension and decreases CO as a result of decreased venous return, increased ventricular wall tension and intra-abdominal volume loss.

15. GI bleeding due to ischemia of the bowel. • Impaired distal extremity circulation secondary to pressure on the aorta. • With concurrent head injury, the ICP can be elevated, along with decreased cerebral perfusion pressure. • When a patient develops a distended and taunt abdomen, the measurement of abdominal compartment pressure can help with early recognition of organ dysfunction.

16. Sources • http://ccforum.com/content/4/1/23 • Merck Manual eighteenth edition,2006 • Paramedic Care, Bledsoe Porter and Cherry, 2006 • www.med.umich.edu/ccmu/acs.htm • www.rice.edu • www.nlm.nih.gov