Compartment Syndrome for Certified Emergency Nursing (CEN)

Compartment Syndrome:

Definition/Etiology:

Compartment syndrome is the buildup of pressure within a closed body space, usually one of the extremities, but can also occur in the abdomen.

This is usually the result of bleeding or edema secondary to a traumatic event, most commonly seen in crush injuries.

Pathophysiology:

The compartments that house the muscle, bone and serve of the extremities are surrounded by a nonelastic fascia. I’ll say it again…non-elastic. As pressure from bleeding or edema increases, microcirculation is compromised, causing more edema. Eventually, the pressure within the compartment starts to cause collapse of the small vessels which leads to ischemia and necrosis.

The process can be triggered by a fracture, soft tissue injury (envenomation, crush), vascular injury, burns, or external compression like when a cast has been applied too tightly or when someone falls asleep on their arm or leg, or some who has “FDGB” (fallen down and gone boom, like an elderly person for example, or someone under the influence of ETOH or drugs)

Clinical Presentation:

The most reliable indicator of progressing compartment syndrome is pain out of proportion to the injury. This is important… Disproportionate pain is a key finding in compartment syndrome.

• No relief from pain medications.

Can follow a “5 Ps” progression:

• Pain
• Pallor
• Paresthesias
• Paralysis
• Pulse

This is how this may progress. Starts with that disproportionate pain, then the discoloration or pallor to the area. As the nerves become compressed, they develop paresthesias which progress to paralysis and finally the compression of the vasculature will cause a loss of pulses! Keep that in mind, loss of pulse is a very late sign in compartment syndrome and would require immediate action.

Collaborative Management:

• We need to remove any restrictive items, like tape or ace wraps or anything that could be constricting to the limb.
• Maintain the limb AT THE LEVEL OF THE HEART. Not above. Not below. Hang it low and you increase the pressure. Raise it up and you inhibit arterial perfusion.
• We would want to measure intracompartmental pressure. Check with your facility as to what device you have for this. A very common one, like this one, is the stryker needle. You basically insert the needle into the compartment and get a reading. 10mmhg or less is good. 30-40 and were talking possible fasciotomy.
• Labs…UA, myoglobin, MB, CPK, CBC, Coags

Evaluation | Patient Monitoring | Education:

• Continued monitoring of compartment pressures. If pressures recede and pain is reduced, then we can surmise that the compartment pressures are reducing. 
• Cardiac monitoring is a must. 
• As with any trauma, don’t lose focus of the whole patient. While the limb is concerning, make sure any other injuries are also being addressed.

Linchpins: (Key Points)

• 5 Ps
• Stryker Needle
• Disproportionate pain