[Musculoskeletal] Compartment Syndrome

1. Acute compartment syndrome (ACS) -> medical emergency!

2. Cause

i) Increased internal pressure within an enclosed fascial space (ie. compartment) - bleeding, edema

ii) decreased compartment size by external pressure - restrictive dressing, casts.(too tight)

iii) incresed swelling ->compression of arteries and nerves -> ischemia and impaired nerve function

 

3. Risk Factors

-Burns (eschar)

-Musculoskeletal injury (eg, fracture, muscle destruction)

-Casts, splints

-Surgery (revascularization)

-Snake bites

-Massive IV

 

4. High-priority symptoms that may indicate ACS include:

i) Pain: unresponsive to analgesics. Unrelieved by medication

ii) Immobility of digits

iii) Paresthesia-tingling, numbness (indicating early nerve ischemia), burning

iv) Pulselessness, poikilothermia,  in distal extremity (not reliable for early ACS; absence of pulses indicates advanced/severe ACS)

v) Pallor = pale distal extremity

vi) Pressure: Taut skin, cast fits too tightly

 

5. can lead to Valkmann contracture, Limb amputation, irreversible nerve damage, Long-term and persistent weakness in the affected limb or complete loss of limb fuction

 

6. NRS Action

i) Limb at the level of the heart(심장보다 높아도 문제고 낮아도 문제여서 ㅠ)

ii) Remove the cast or tight dressing

iii) Possible emergency fasciotomy

iv) Signs of infection at exposed surgical site

-Check the return of perfusion time: Capillary refill < 2 seconds

-Check bilateral pulses

-Check Range-of-motion exercises

 

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"Throbbing"은 맥박이 뛰는 듯한, 규칙적이고 강렬한 고통이나 불편감을 묘사하는 단어입니다. 보통 두통이나 치통, 또는 염증이 있는 부위에서 느낄 수 있는 감각입니다. 맥박이 뛰는 것처럼 주기적으로 반복되는 고통을 의미합니다.

"Throbbing on dependent positioning"은 특정 신체 부위가 아래쪽으로 향할 때 맥박이 뛰는 듯한 통증이 발생하는 상황을 의미합니다. "Dependent positioning"이란, 신체의 특정 부위가 중력에 의해 아래로 내려가 있는 위치를 말합니다. 예를 들어, 다리를 아래로 내리거나, 팔을 아래로 내린 상태를 가리킵니다.

 

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1. Pathophysiology

i) Limb-threathening condition caused by 

-Increased internal pressure within an enclosed fascial space (ie, compartment) : Bleeding, edema

-Decreased compartment size by external pressure : Restrictive dressings, casts.

어쨌든지, Increased swelling -> compression of arteries and nerves -> ischemia nad impaired nerve function.

 

results from compression of vascular structures by either external compression (restrictive dressing/casts) or increased pressure within a compartment (bleeding, inflammation, and edema).

After an injury or trauma (eg. surgery), the vessels surrounding the injury site are compressed by swelling muscle and connective tissues. Muscle is encapsulated by a fibrous layer of fascia, which does not yield to swelling. Eventually, compression of tussues within the compartment restricts blood flow to the extremity. 

 

2. Risk Factors

i) Burns (eschar)

ii) Musculoskeletal injury (eg. fracture, muscle destruction)

iii) casts, splints

iv) surgery (revascularization)

v) Snake bites

vi) massive IV infiltration

 

 

3. 7 Ps

Paresthesia: Tingling, numbness, burning

Pain: unrelieved by medi

Pallor

Pressure: taut skin, cast fits too tightly

Pulselessness

Poikilothermia(cold to touch)

Paralysis

 

4. Complications

Limb amputation

Volmann contracture: upper extremities

Irreversible nerve damage

Long-term, persistent weakness in the affected limb or complete loss of limb function

 

5. NRS Action

Limb at the level of the heart

Remove the cast or tight dressing

possible emergency fasciotomy

signs of infection at exposed surgical site: 

-return of perfusion (capillary refill < 2sec, check bilateral pulses), range of motion exercises

 

Conclusion: a client with signs of compartment syndrome (eg. pain, pallor, pulselessness) after a fracture or orthopedic surgery should be evaluated by the health care provider (HCP) immediately. After notifying the HCP, the nurse should position the affected extremity at heart level and loosen any restrictive bandaging/casting material.

 

 

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ICU Case #1

The client underwent a right popliteal artery repair 5 hours ago and reports persistent pain  rated as 10 despite IV morphine. The pain worsens with passive ankle movement. The right lower leg is swollen, tense, and tender on palpation. The right foot is numb, pale, and cool to the touch. Pedal pulses are palpable bilaterally.

혈관 수술했다고 해서 DVT 걸린 줄 알았는데 아니었음, DVT 였으면 일단 환부에 피가 몰려있어서 따뜻한데 얘는 cool하다니까 아닌 것임. 

 

-> CS (Compartment syndrome) is a limb-threatening condition caused by increased pressure within an enclosed fascial space, typically from edema after direct injury (eg. fracture, dislocation, burn), medical device placement (eg. cast, splint), or revascularization precedures. CS limits perfusion of muscle and nerve tissues, resulting in severe pain that is classically out of proportion to the injury, paresthesia (eg. tingling, numbness), motor weakness, diminished pulse, and limb pallor and coolness.

 

-> DVT is a blood clot formed in large veins, generally of the lower extremities. Typical manifestations include unilateral edema, localized pain (eg. calf pain) or tenderness to touch, warmth, and erythema. 

Severe pain and sensory deficits are more consistent with CS. IF DVT is suspected, the nurse should prepare the client for Doppler ultrasound of the lower extremity to confirm the diagnosis. Doppler ultrasound is unnecessary with CS.

 

-> Cellulitis is inflammation of the subcutaneous tissues that is typically caused by bacterial infection. Manifestations include redness, edema, pain, and fever; pallor and sensory or motor deficits are not characteristic. Management includes elevating the affected extremity and applying ice packs to reduce pain and swelling. ( NOT CS )