![]() ![]() 7,9,15 Also, different compartments have different pressure thresholds. 16,17,59,77,82-84 The problem with using an absolute pressure is that patients can vary widely concerning intracompartmental pressures. 77-81 Previous recommendations used an absolute intracompartmental pressure of 30-40 mm Hg as a threshold for fasciotomy. What’s this about using intracompartmental pressure alone versus differential pressure (ΔP)? 7,9,16,17.42 The normal resting pressure within muscle is close to 8-10 mm Hg in adults and 10-15 mm Hg in children. 50,73-76 If the patient is hypotensive, resuscitation is needed to restore circulating volume. 16,17,42 Analgesia is needed, but regional blocks are not recommended (they can make monitoring based on symptoms challenging). 16,17,71,72 Reducing a displaced fracture will decrease edema. 7,9,14 Removing external compressive devices alone can reduce pressures by 65-85%. Once you suspect ACS, consult orthopedic or general surgery, remove any constrictive dressings, and avoid a dependent position of the extremity (try your best to keep the extremity at the level of the heart). The most important point is to consider ACS. What are the keys to diagnosis and management? 70 Neither of these is ready for the sick trauma patient. 7,67-69 Ultrasound can assess the arterial pulse waveform in the setting of increased intracompartmental pressure, with a sensitivity of 77% and specificity of 93% for correlation with intracompartmental pressures in healthy patients. Near-infrared spectroscopy assesses the oxygen saturation of tissues, which shows promise in healthy volunteers and correlates with intracompartmental pressures. There are several noninvasive techniques, but they need further study. 42,63,65 If the first pressure is normal, but concern for ACS is present, a compartment recheck is needed, with another pressure assessment. 7,66 Failure to place the transducer at the same height of the catheter tip will cause a falsely high or low, depending upon the position. If placed within the fracture, levels will be falsely high. 42,63-65 Make sure to keep the catheter tip outside of the actual fracture site. When obtaining intracompartmental pressures, place the catheter within 5 cm of the fracture level, with the transducer secured at the level of the measured compartment. 38,60,61 However, the literature for use of STC monitors in trauma patients is limited. The Stryker monitor TM is accurate, with a sensitivity of 94% and specificity of 98%. 7,9,16,17 For more, see this video from EM:RAP on using the Stryker monitor TM and this EPMonthly article for a step-by-step guide. 7,16,17,59 The most common method is an STC device such as the Stryker monitor TM, or using an arterial line transducer system. 7,9,16,59 There are a variety of invasive methods for measuring pressures, including needle manometry, the wick catheter, the Whitesides method, and the solid-state transducer intracompartmental catheter (STC) device (Table 3). Once ACS is suspected, definitive diagnosis involves obtaining the intracompartmental pressure, which is most commonly assessed with direct, invasive monitoring. 7,9,15,56 X-rays of the affected extremity are usually obtained to look for fractures and other potential underlying causes. 56-58 Renal injury can occur, usually due to rhabdomyolysis. 7,9,15,56 Rhabdomyolysis is present in > 40% of traumatic ACS cases. 5 The RisksĪCS is most common in patients 1000 units/mL or myoglobinuria suggest ACS, and CK levels will continue to increase during the course of ACS. 4 In fact, 23% of medicolegal cases are due to misdiagnosis, and 32% of cases are due to delay to definitive treatment. 2 Failure to treat ACS can cause long-term neurovascular deficits, and ACS is associated with significant medicolegal risk. 1-3 Incidence varies but is close to 0.7-7.3 cases per 100,000 people. ![]() What could be going on? The Dreaded Compartment Syndrome…Ī surgical emergency, acute compartment syndrome (ACS) is the result of excessive pressure within a fascial compartment, leading to decreased perfusion. His right leg pain continues to increase despite multiple doses of hydromorphone IV and what appears to be a great reduction based on post-splinting films. ![]() He was recently splinted after evaluation by orthopedics, and the results of several CT’s are still pending. He suffered right comminuted tibia and fibula fractures, but fortunately, his only other injuries were some extremity abrasions and road rash. Authors: Brit Long, MD Attending Emergency Physician, San Antonio, TX) and Michael Gottlieb, MD, RDMS (Attending Emergency Physician and Ultrasound Director, Rush Medical Center, Chicago, IL) // Edited by: Alex Koyfman, MD Attending Emergency Physician, UTSW, Dallas, TX) CaseĪ 24-year-old male presents with severe right lower leg pain after a motorcycle accident. ![]()
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