Project: Ghana Emergency Medicine Collaborative
Document Title: Compartment Syndrome
Author(s): Chris DeFlitch (Penn State...
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{ Content the ...
Compartment Syndrome
Chris DeFlitch, MD, FACEP
Director & Vice-Chair
Department of Emergency Medicine
Penn State Hershey M...
Case Presentation
n 

n 

23yo deaf male with Left lower extremity
injury after motocross event
Questions?

4
History that’s Important
n 

Mechanism of Injury

n 

Associated Complaints

n 

Associated Injury

n 

PQRST

5
Physical Findings ?
n 

ABC’s
n 

Vital Signs

n 

Associated Injury

n 

Local Examination

n 

Joint Above & Below
...
What’s the Differential Dx?
n 

Life threatening

n 

Most Common

n 

Bizzare Stuff

n 

Things to Impress
your Atten...
What YOUR Assessment & Plan ?
1. 
2. 
3. 
4. 
5. 

Anti-inflammatory medications ?
Narcotics ?
Imaging ?
Consultation ?
As...
n 

n 

Your
Interpretation
Want
another
view ?

Source undetermined

9
n 

Diagnosis ?

n 

YEP…ITS NORMAL

Source undetermined

10
What’s the ED Disposition ?
1. 
2. 
3. 
4. 

Admission
Observation
Discharge
Consultation for Specific Procedure

3. DISCH...
Guess What…….
n 

The patient came back with…..

n 

Increasing PAIN, especially with Passive range of
motion
Paresthesi...
Objectives
n 

Define Compartment Syndrome

n 

Understand the Pathophysiology

n 

Consider Anatomic Factors

n 

Ide...
Compartment Syndrome
n 
n 

n 
n 

TRUE EMERGENCY
Increase Pressure in Closed space
(compartments)
Most Common with Le...
Mechanism Associated
n 
n 
n 
n 
n 
n 
n 

Crush Injury
Fractures (closed)
Burns
Prolonged Procedures/Pressure
Spon...
Pathophysiology
n 

Increased Pressure in a CLOSED
compartment
n 
n 
n 

Increased Compartment Contents
Decreased Comp...
Cellular Physiology
n 

Compartment Pressure > Diastolic
Venous vascular congestion
n  Tissue Ischemia
n  Release of Hi...
Anatomic Considerations
n 

n 

CAN affect ANY
CLOSED COMPARTMENT
Leg
n 
n 
n 
n 

Anterior – MOST FREQUENT
Lateral
...
Other Extremities
n 

Thigh
n 

n 

Quadriceps

Forearm
n 
n 

n 

Hand & Foot
n 

Interosseous

n 

Dorsal
Volar
...
CLASSIC “5 P’s”
n 
n 
n 
n 
n 

n 

Pain
Paralysis
Paresthesia
Pallor
Pulselessness
Said together, but if they’re al...
Clinical Presentation
n 

Pain
n 
n 
n 

n 

Out of Proportion to exam
Deep, burning,
Unrelenting

Frequent Revisit f...
Physical Exam

n 

Pain with PASSIVE stretching
Pain with Active Flexing
Paralysis (secondary to pain)

n 

Tense or “fu...
The other 3 P’s
n 

n 
n 

Paresthesia – earlier sign
PALLOR
Pulselessness
n 

LATE, OMINOUS SIGNS

23
Diagnosis
n 
n 
n 
n 
n 
n 

High Index of Suspicion
GOOD H&P
Insure neurovascularity Intact
Consider extremity XR
E...
Pressure Measurement
n 

Stryker Machine (needle with transducer)
n 

Baseline machine to atmosphere pressure
n 

n 
n...
Tissue Pressure Gradient

n 

0 mmHg
NORMAL
10-30 mmHg Variable
30 mmHg
Microcirculation Impaired

n 

Within 30 mmHg of...
Complications
n 

Tissue Necrosis & Loss
n 
n 
n 
n 

n 
n 
n 

Nerve damage
Contractures
Amputation
Cosmetic Defi...
Fasciotomy
n 

Definitive Treatment
n 

n 

OPEN the Closed Compartment

Indication For Fasciotomy
Pressures >30
n  Pr...
Back to the Patient
n 

Had Clinical findings of Compartment
syndrome
n 
n 
n 
n 

LATE Findings
Flown to Tertiary Ca...
The OUTCOME
n 

n 

He still has his Leg
BUT with a
Significant Cosmetic
& Functional Defect

30
QUESTIONS ?
THANK YOU !!!!!

31
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GEMC- Compartment Syndrome- Resident Training

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This is a lecture by Dr. Chris DeFlitch from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC- Compartment Syndrome- Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Compartment Syndrome Author(s): Chris DeFlitch (Penn State Hershey Medical Center), MD, FACEP 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. 2
  3. 3. Compartment Syndrome Chris DeFlitch, MD, FACEP Director & Vice-Chair Department of Emergency Medicine Penn State Hershey Medical Center 3
  4. 4. Case Presentation n  n  23yo deaf male with Left lower extremity injury after motocross event Questions? 4
  5. 5. History that’s Important n  Mechanism of Injury n  Associated Complaints n  Associated Injury n  PQRST 5
  6. 6. Physical Findings ? n  ABC’s n  Vital Signs n  Associated Injury n  Local Examination n  Joint Above & Below n  Neurovascular Status 6
  7. 7. What’s the Differential Dx? n  Life threatening n  Most Common n  Bizzare Stuff n  Things to Impress your Attending 7
  8. 8. What YOUR Assessment & Plan ? 1.  2.  3.  4.  5.  Anti-inflammatory medications ? Narcotics ? Imaging ? Consultation ? Ask the Attending ? 8
  9. 9. n  n  Your Interpretation Want another view ? Source undetermined 9
  10. 10. n  Diagnosis ? n  YEP…ITS NORMAL Source undetermined 10
  11. 11. What’s the ED Disposition ? 1.  2.  3.  4.  Admission Observation Discharge Consultation for Specific Procedure 3. DISCHARGE 11
  12. 12. Guess What……. n  The patient came back with….. n  Increasing PAIN, especially with Passive range of motion Paresthesia Pallor Pulselessness Paralysis n  And had COMPARTMENT SYNDROME n  n  n  n  12
  13. 13. Objectives n  Define Compartment Syndrome n  Understand the Pathophysiology n  Consider Anatomic Factors n  Identify Signs & Symptoms n  Define Diagnostic & Treatment Options 13
  14. 14. Compartment Syndrome n  n  n  n  TRUE EMERGENCY Increase Pressure in Closed space (compartments) Most Common with Leg Injury/Fracture Can occur with thigh, forearm, arm, hand, or foot injury 14
  15. 15. Mechanism Associated n  n  n  n  n  n  n  Crush Injury Fractures (closed) Burns Prolonged Procedures/Pressure Spontaneous Hemorrhage External Pressure (cast, MAST) Overuse Syndromes 15
  16. 16. Pathophysiology n  Increased Pressure in a CLOSED compartment n  n  n  Increased Compartment Contents Decreased Compartment Space/volume Increased External Pressure 16
  17. 17. Cellular Physiology n  Compartment Pressure > Diastolic Venous vascular congestion n  Tissue Ischemia n  Release of Histamine increasing membrane permeability n  Increasing Compartment Pressure n  n  Arterial Vasospasm plays a minimal Role 17
  18. 18. Anatomic Considerations n  n  CAN affect ANY CLOSED COMPARTMENT Leg n  n  n  n  Anterior – MOST FREQUENT Lateral Deep Posterior Superficial Posterior 18
  19. 19. Other Extremities n  Thigh n  n  Quadriceps Forearm n  n  n  Hand & Foot n  Interosseous n  Dorsal Volar Arm n  n  Biceps Deltoid 19
  20. 20. CLASSIC “5 P’s” n  n  n  n  n  n  Pain Paralysis Paresthesia Pallor Pulselessness Said together, but if they’re all there …the 6th P…….PATIENT is in trouble 20
  21. 21. Clinical Presentation n  Pain n  n  n  n  Out of Proportion to exam Deep, burning, Unrelenting Frequent Revisit for MORE PAIN MEDS n  THEY AIN’T DRUG SEEKERS !!!! 21
  22. 22. Physical Exam n  Pain with PASSIVE stretching Pain with Active Flexing Paralysis (secondary to pain) n  Tense or “full” compartment n  n  n  Be Careful….some you can’t palpate 22
  23. 23. The other 3 P’s n  n  n  Paresthesia – earlier sign PALLOR Pulselessness n  LATE, OMINOUS SIGNS 23
  24. 24. Diagnosis n  n  n  n  n  n  High Index of Suspicion GOOD H&P Insure neurovascularity Intact Consider extremity XR Early Orthopedic Consultation Compartment Pressure Measurement n  >30 mmHg 24
  25. 25. Pressure Measurement n  Stryker Machine (needle with transducer) n  Baseline machine to atmosphere pressure n  n  n  Prep Area 18 G Needle into Compartment n  n  n  Should Read ZERO Sometime hard with SMALL compartment Inject small amount of Saline Measure Plateau Pressure At Least 2 times 25
  26. 26. Tissue Pressure Gradient n  0 mmHg NORMAL 10-30 mmHg Variable 30 mmHg Microcirculation Impaired n  Within 30 mmHg of diastolic BP n  n  n  Tissue Ischemia 26
  27. 27. Complications n  Tissue Necrosis & Loss n  n  n  n  n  n  n  Nerve damage Contractures Amputation Cosmetic Deficit Rhabdomyolysis---Renal Failure Hyperkalemia Myoglobinuria 27
  28. 28. Fasciotomy n  Definitive Treatment n  n  OPEN the Closed Compartment Indication For Fasciotomy Pressures >30 n  Pressures within 30mmHg of Mean Arterial Pressure n  28
  29. 29. Back to the Patient n  Had Clinical findings of Compartment syndrome n  n  n  n  LATE Findings Flown to Tertiary Care Medical Center Fasciotomy Prolonged Course 29
  30. 30. The OUTCOME n  n  He still has his Leg BUT with a Significant Cosmetic & Functional Defect 30
  31. 31. QUESTIONS ? THANK YOU !!!!! 31

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