Compartment Syndrome - Pathophysiology PDF

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Compartment Syndrome Condition in which swelling and increased pressure within a limited space (compartment) press on and compromise the function of blood vessels, nerves, and tendons that run through that compartment.  Causes for capillary perfusion be reduced below a level necessary for tissue viability May be caused by a restrictive cast/splint/dressing, excessive traction, or premature closure of fascia, or edema, excessive bleeding, intravenous infiltration, or chemical response Most commonly involving the leg; but can occur in the arm, shoulder, pelvis, or buttock. Prompt, accurate diagnosis of compartment syndrome is critical. Prevention and early recognition is key.  Regular neuro-vascular assessments should be performed and documented on all patients with fractures. Remember the “six P’s”. May occur after dislocation Risk Factors Associated with trauma, fractures, extensive soft tissue injury, and crush injury  Fractures of the distal humerus and proximal tibia are the most common fractures associated with compartment syndrome  Compartment injury can also occur following knee or leg surgery  Prolonged pressure on a muscle compartment may occur when someone is trapped under a heavy object or persons limits trapped beneath the body because of an obtunded state such as drug and alcohol overdose  In the upper extremity, this condition is referred to us volkmann ischemic contracture, and in the lower extremity, it is known as anterior tibial compartment syndrome, although the underlying pathophysiological mechanism is similar

Clinical Manifestations Ischemia can occur within 4 to 8 hours after the onset of compartment syndrome The 6P's are a neuro vascular assessment mnemonic that can be used to assess for impending compartment syndrome 1. Pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment 2. Increasing pressure in the compartment 3. Paresthesia 4. Pallor, coolness, and loss of normal colours of the extremity 5. Paralysis or loss of function 6. Pulselessness or diminished or absent peripheral pulses

Compartment Syndrome

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Compartment Syndrome Layers (fascia) separate groups of muscles in the arms and legs Inside each layer of fascia is a confined space, called a compartment that includes the muscle tissue, nerves, and blood vessels Unlike a balloon, fascia do not expand, so any swelling in a compartment will lead to increasing pressure in that compartment, which will compress the muscles, blood vessels, and nerves. If this pressure is high enough, blood flow to the compartment will be blocked Decreased blood flow leads to further edema Ischemia (no blood flow) to the extremity can result Nerve and muscle cells are destroyed, and fibrotic tissue replaces healthy tissue

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Causes Decreased compartment size: Restrictive splints, casts, bandages, excessive traction Increased compartment contents: Bleeding, Edema, Surgical manipulation, Traumatic injury Complications Irreversible muscle and nerve ischemia Loss (amputation) of the limb 

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Post Op Complications of Fasciotomy Wound is left OPEN for several days to ensure adequate decompression, therefore: o VERY high risk for infection o Wound care very important o Watch for signs of infection o May die or have severe complications from infection/sepsis o High risk for thromboembolic complications o Vigilant post-operative care o Wound healing and closure will be delayed o Consider psychological issues (altered body image) Nursing Management Leave extremity flat (never above heart level) o Increased elevation may worsen swelling Do not ice or cool extremity o May further vasoconstrict Remove or split cast/Loosen bandage Reduce or discontinue traction Analgesia/sedation/comfort Surgical decompression (fasciotomy) may be required Possible amputation

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Collaborative Care Regular neuro vascular assessment should be performed and documented on all patients with fractures but especially those of injury of the distal humerus or proximal tibia or soft tissue disruption in these areas Carefully assess the location, quality, and intensity of the pain  Evaluate the pain on a scale of 0 to 10  Pain unrelieved by drugs and out of proportion to the level of entry and pain on passive muscle stretch appeared to be the most effective clinical observations and some of the first indications of impending compartment syndrome  Pulselessness and paralysis a later signs of compartment syndrome  Health care physician notified immediately of a patient's changing condition Because of the possibility of muscle damage, urine output should be assessed  Myoglobin released from damaged muscle cells precipitates as a gel like substance and causes obstruction renal tubules  This condition results in acute tubular necrosis and acute kidney injury  Common signs are dark, reddishBrown urine and clinical manifestations associated with acute kidney injury Elevation of the extremity may lower venous pressure and slower to real profusion; Thus, the extremities should not be elevated above heart level  Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome  It may also be necessary to remove or loosen the bandage and bivalve or split the cast in half  A reduction traction weight may also decrease external circumferentially pressures Surgical decompression of the involved compartment may be necessary o Fasciotomy site is left open for several days to ensure adequate soft tissue decompression o Infection resulted from delayed wound closure as a potential problem following a fasciotomy o In several cases of compartment syndrome, an amputation may be required...