Rosen & Barkin's 5-Minute Emergency Medicine Consult (167 page)

Radiographs should be performed if fracture is suspected.

• Measurement of compartment pressures with a system such as the Stryker IC pressure monitor system (Stryker Surgical, 2825 Airview Boulevard, Kalamazoo, MI 49002.
  www.stryker.com
  ), using an 18G needle or continuous pressure monitoring with the attachment for an indwelling catheter
  
• Technique is as follows:
  
  • Prep overlying skin with antiseptic solution.
    
  • Local anesthetic can be infiltrated into the
    SC tissue only,
    taking care not to inject intramuscularly.
    
  • The needle used for pressure measurements is advanced through the skin until a popping sensation is felt when the fascia is pierced.
    
  • 0.2 mL of saline is injected to clear the lumen of the needle, and the intracompartmental pressure measurement is then read.
    
  • To ascertain correct placement of the needle within the compartment, external pressure may be applied over the muscle compartment, or the muscles can be passively stretched to increase the intracompartmental pressure transiently; once these maneuvers are discontinued, the pressure should drop to baseline and stabilize.
    

• Chronic compartment syndrome
  
• Fascial hernia
  
• Stress fracture
  
• Arterial occlusion
  
• Neurapraxia
  
• Deep venous thrombosis
  
• Cellulitis
  
• Osteomyelitis
  
• Tenosynovitis
  
• Synovitis
  

TREATMENT

• Acutely injured extremities that are casted should have the cast univalved and spread and underlying cast padding should be cut.
  
• Keep the extremity at the level of the heart.
  

• Acute compartment syndrome is a surgical emergency.
  
• Mainstay of treatment is fasciotomy, particularly for compartment pressures >30–40 mm Hg.
  

• Medications are not helpful, including steroids or vasodilators, in the treatment of compartment syndrome.
  
• Pain medication is essential after diagnosis is made or consultant evaluation is begun.
  

IV narcotic analgesics may provide some relief, although the pain is frequently so severe that only decompression in the OR can provide relief.

Oral narcotic analgesics and nonsteroidal agents are of very little benefit acutely.

FOLLOW-UP

• Emergent orthopedic or surgical consultation for compartment pressures >30 mm Hg
  
• For compartment pressures >20 mm Hg but <30 mm Hg, surgical consultation should be sought and the patient admitted.
  
• For compartment pressures between 15 and 20 mm Hg, serial measurement of pressures should be taken; if the patient cannot be relied on to return for repeat measurements, the patient should be admitted.
  

Compartment pressure <10–15 mm Hg: Patients should be given symptomatic treatment and instructed to return for increased pain, swelling, development of paresthesia.

If the clinician suspects chronic compartment syndrome, then prompt referral to orthopedic surgeon is necessary. Direct communication is best to express your concerns.

• Must measure compartment pressures or arrange transfer to higher level of care if capability is lacking.
  
• Care must be taken when measuring compartment pressures to avoid injury to tendons, nerves, and blood vessels.
  
• Must consider concomitant rhabdomyolysis in crush-type injuries.
  

• Farr D, Selesnick H. Chronic exertional compartment syndrome in a collegiate soccer player: A case report and literature review.
  Am J Orthop
  . 2008;37(7):374–377.
  
• Mabee JR. Compartment syndrome: A complication of acute extremity trauma.
  J Emerg Med
  . 1994;12(5):651–656.
  
• Reis ND, Better OS. Mechanical muscle-crush injury and acute muscle-crush compartment syndrome.
  J Bone Joint Surg Br
  . 2005;87(4):450–453.
  
• Sahni V, Garg D, Garg S, et al. Unusual complications of heroin abuse: transverse myelitis, rhabdomyolysis, compartment syndrome, and ARF.
  Clin Toxicol (Phila)
  . 2008;46:153.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Acute Compartment Syndrome
  http://emedicine.medscape.com/article/307668-overview
  
• Compartment Syndromes of Extremities
  https://online.epocrates.com/u/2911502/Compartment+syndrome+of+extremities/Summary/Highlights?ICID = EMN0909
  

CODES

• 958.90 Compartment syndrome, unspecified
  
• 958.91 Traumatic compartment syndrome of upper extremity
  
• 958.92 Traumatic compartment syndrome of lower extremity
  

BASICS

Abnormality in the cardiocirculatory system that is present at birth but does not cause mixing of deoxygenated and oxygenated blood:

• L→R shunting lesions:
  
  • Ventricular septal defect (VSD)
    
  • Atrial septal defect (ASD)
    
  • Patent ductus arteriosus (PDA)
    
  • Endocardial cushion defects (AV canal)
    
• Ventricular outflow obstructions:
  
  • Coarctation of aorta (LV)
    
  • Aortic stenosis (LV)
    
  • Pulmonic stenosis (RV)
    
  • Hypoplastic left-heart syndrome (HLHS)
    
• Ductal dependent: Symptoms as DA closes:
  
  • Coarctation of aorta
    
  • Critical aortic stenosis
    
  • Critical pulmonic stenosis
    
  • HLHS
    

For most forms, cause is unknown:

• Genetic: Down (AV canal), Turner (coarct)
  
• Environmental: Congenital rubella (PDA, AS)
  

DIAGNOSIS

• Many asymptomatic
  
• Lethargy, poor feeding, and failure to thrive
  
• Dyspnea on exertion
  
• Recurrent respiratory infections
  

• VSD and AV canal:
  
  • Dusky color, hepatomegaly
    
  • Holosystolic and diastolic murmurs + thrill
    
  • Hyperdynamic precordium, displaced PMI
    
• ASD:
  
  • Fixed, split S2
    
  • Systolic ejection and diastolic murmurs
    
• PDA:
  
  • “Machine-like” murmur and bounding pulses
    
• Coarctation:
  
  • Differential cyanosis (pink only upper 1/2)
    
  • BP upper extremities > BP lower extremities
    
  • ↓ or absent lower-extremity pulses
    
• AS:
  
  • Harsh systolic murmur, thrill, aortic click
    
• PS:
  
  • Systolic ejection murmur, thrill, pulmonic click
    
  • Widely split S2
    
  • Jugular venous A-waves
    
• HLHS:
  
  • Dusky, listless, tachypneic, ↓ pulses
    
  • Single heart sound, systolic ejection murmur