# Is this compartment syndrome?



## adamjh3 (Oct 12, 2011)

Gonna be quick with this one;

70 YO female fell down when getting out of bed, witnessed, no LOC yadda yadda. She broke her fall with her left forearm on a nice shag rug. End result was what looked like a giant hematoma that engulfed her forearm from wrist to elbow, all the way around, with a small laceration just distal to the elbow on the dorsal side. left forearm was about double the size of her right, red all the way around. When the arm was palpated at the wrist (about 6 inches distal from the laceration) blood would ooze from the lac. The patient was on Coumadin. 

I don't see much trauma working BLS IFT, thus I've never actually seen compartment syndrome. I asked my partner and he said compartment syndrome only occurs with crush injuries.


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## truetiger (Oct 12, 2011)

Sounds like the coumadin...


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## Shishkabob (Oct 12, 2011)

It COULD result from the edema causing a restriction in blood flow distal to the wound, but no, that in itself does not sound like compartment syndrome.



And no, compartment syndrome doesn't only occur with crush injuries.  Tell him to look up eschar and escharotomies.


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## ArcticKat (Oct 12, 2011)

If she had a distal pulse it wouldn't have been compartment syndrome.


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## adamjh3 (Oct 13, 2011)

The coumadin is definitely responsible for the amount of blood outside the vessels.

I looked up eschar, and if I understand correctly compartment syndrome associated with eschar can occur any time there's full circumferential  escharotic tissue, yes?




ArcticKat said:


> If she had a distal pulse it wouldn't have been compartment syndrome.


Ah, I see, so compartment is whenever there's a cut off of distal circulation?


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## foxfire (Oct 13, 2011)

Think of a full tuppaware container with a closed lid when it comes to compartment syndrome. nothing is getting out and not much is getting past the injured zone. Circumference burns is a good example of  developing compartment syndrome. if a upper arm has second and third degree burns completely around, I would be concerned about compartment syndrome developing. Hope that makes sense.^_^


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## adamjh3 (Oct 13, 2011)

foxfire said:


> Hope that makes sense.^_^




Yes, it does, thanks. 


So... what would the type of injury I described be called? Just a hematoma?


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## Akulahawk (Oct 13, 2011)

Compartment syndrome doesn't always set in fast. When you see an injury like that, you need to serial distal CSM exams. As pressure builds within the compartment, paresthesias and decreasing pulses will be felt distal to the compartment. Remember, the compartment could be damaged and be filling with fluid but is early on in the process that you'd see good distal CSM but if you were able to see venous flow, there wouldn't be any...

perhaps a better analogy would be a slowly inflating BP cuff. At first, only a little blood flow is restricted, then venous flow gets shut off. Then as pressure builds, arterial flow begins to be restricted and you feel the pulse become thready. The patient begins experiencing paresthesias and numbness. Eventually pressure builds and cuts off all flow and then the fun _really_ begins.

While it's possible that there was _some_ outlet for pressure via the lac, if the swelling was distal to the lac, compartment syndrome could still set in if the lac doesn't actually extend into the compartment. When you suspect compartment syndrome, get the patient to a surgeon. If it's an extremity, figure there's a 6 hour clock from the time blood flow stopped.


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## BandageBrigade (Oct 13, 2011)

adamjh3 said:


> Yes, it does, thanks.
> 
> 
> So... what would the type of injury I described be called? Just a hematoma?



From what you described, most likely yes. A large hematoma. Its rare, but this injury could result in compartment syndrome if the pressure becomes great enough from the hematoma. For further reading, look up fasciotomy.


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## ArcticKat (Oct 13, 2011)

*Akulahawk has the best...*

Explanation yet.  That's a very accurate description of the processes behind compartment syndrome.

I agree, it was a significant hematoma and likely more superficial than deep.  Compartments are seperated by the fascia, if the pressure builds within the fascia, then the syndrome can occur.


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## mycrofft (Oct 13, 2011)

*2cents:*

Lots of blood under the skin with coumadin in a little old guy or lady is purpura. It will stop at joints for the same reason compartment syndrome does, things get closed off at joints or our insides would squish between lower and upper parts of extremities like toothpaste, sort of. Purpura is not a sign of compartmentalization per se; in fact, compartmentalization can (occasionally) occur very deeply so it is not really visible.

I would suspect that an anti coagulated person would be more at risk for a bleeding compartmental syndrome situation, but you need some pretty good trauma to get that much bleeding. Unfortunately, we skinny older folks get significant trauma more easily than beefy padded types.  

Anything which prevents return or reabsorption of free blood or other fluid (serum, lymph) from a defined segment of an extremity is compartmentalization. It can be palpable, but before that the pt will c/o pain, then tingling numbness due to nerve compression.

Review your protocols, know what you can do for it (nothing as a field person, except maybe very localized pressure to STOP that bleeder if you can find it), and keep on learning! 

Wonder if an intracranial bleed technically counts as some sort of "compartmentalization"?:unsure:


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## AlphaButch (Oct 13, 2011)

mycrofft said:


> Wonder if an intracranial bleed technically counts as some sort of "compartmentalization"?:unsure:



To the OP - it can lead to compartment syndrome if the pressure continues to increase.

To Mycrofft - Sneaky question <_< (since I'm 85% sure he already knew the answer and is testing us)

Answer is yes, it's seen in the intracranial cavity after severe brain injury. (Cite; Geisler FH, Greenberg J, et al: Management of the acute head injury patient. In: Neurologic Emergencies. Second Edition. Salcman M (Ed). New York, Raven Press, 1990, pp 125–165)

I consider it a trick question since intracranial bleeds are actually classified based on their compartments (ICH, SAH)

Compartment syndrome is caused by either an increase in content or a decrease in size of a compartment. So compartment syndrome can be caused by bleed (due to a rise in pressure/content), a mass or structural change causing decrease in container size; or a combination of those. 

In the OP's example the forearm is seperated into ventral and dorsal compartments; In Mycrofft's question; the cranial compartments are divided by the dura and arachnoid membranes.


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## mycrofft (Oct 13, 2011)

*I think IC bleed is philosophically compartmentalization...*

...but "compartmental syndrome" is defined as hydraulic pressure confined by the unyielding fascia around muscles which is sort of closed off at joints; hence, extremities. 

Anyone else know a good field tx except trying to stop the bleed into the space?


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## adamjh3 (Oct 13, 2011)

mycrofft said:


> ...but "compartmental syndrome" is defined as hydraulic pressure confined by the unyielding fascia around muscles which is sort of closed off at joints; hence, extremities.
> 
> Anyone else know a good field tx except trying to stop the bleed into the space?



I was thinking a TQ, but once true compartmentalization sets in the effects will be the same as a TQ, no?


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## mycrofft (Oct 13, 2011)

*You could sort - of make CS  with a TK (TQ)*

Grade school demonstrator: Take a tough nylon plastic film tube. Run three rubber tubes through it , then seal each end of the nylon to the tubes at either end.One tube is leaky (injured artery). One tube intact (intact vein) and the third is thinner latex (nerve). Start pumping water into the broken "artery", watch the nerve, then the "vein", collapse.

If you put the TK on hard enough to close veins but not arteries, the blood backing up would congest the distal limb, but the extra-compartmental pressures might equal the intra-compartmental pressure; that would mean the skin would define the "compartment" (i.e., the whole forearm or whatever). Phlebotomists do this all the time to a much lesser degree. That's why you need to put on the TK hard enough or it can speed bleeding.


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## AlphaButch (Oct 13, 2011)

In this particular case, treatment would be quick transport. Establish an IV, and monitor (due to age and protocols here). If the skin is getting stretched tight, parasthesia sets in or there is a loss of perfusion, then I'd go into our CS/CI protocols.


As for intracranial compartment syndrome;

"A compartment syndrome exists when the increased pressure in a closed anatomic space threatens the viability of enclosed and surrounding tissue" 

Intracranial compartmental syndrome occurs when ICP>25 mmHg, primarily due to tumor or hematoma. Treated by opening the compartment for decompression (burr holes, flaps).

Citations

Malbrain M.L., Cheatham M.L., Kirkpatrick A., et al:  Results from the International Conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. I. Definitions.  Intensive Care Med 32. 1722-1732.2006

Malbrain M.L., De Laet I., and De Waele J: The Polycompartment Syndrome: What's all the Fuss About. Intensive Care Medicine:Annual Update 464-484.2010


Edit; Mycrofft, mind if I use/incorporate that experiment into our tourniquet program?


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## usafmedic45 (Oct 13, 2011)

adamjh3 said:


> I was thinking a TQ, but once true compartmentalization sets in the effects will be the same as a TQ, no?


Not exactly.  With a tourniquet you have several hours (or even a day or more) depending upon several factors- concomitant tissue damage, temperature of the tissue, the type of tissue, etc- before any serious injury occurs.  With compartment syndrome, which is not what you were describing BTW, often the interval is much shorter to permanent injury due to an increased severity of tissue damage associated with the triggering event (think comminuted tib/fib fracture vs. a gunshot wound to the thigh that doesn't strike bone but still produces a vascular injury) and a lower incidence of associated hypothermia.  

BTW, mycrofft, you might want to rethink the suggestion that venous drainage is the last thing to go since it is much easier for there to be occlusion on that side because of lower pressures and thinner vessel walls.  Also the analogy of the nerve as a thin walled tube is misleading and potentially confusing to those not welled versed in anatomy. Most early loss of motor and sensory function in a person with compromised circulation (think laying on one's arm while asleep or in anticipation of masturbation) is due to lactic acid buildup and not nerve impairment.  There have been studies done with this (what is called "Saturday night palsy", which can lead to compartment syndrome or crush syndrome in severely prolonged cases) looking at nerve conduction and they find that most of the time during early stages there is minimal impairment of nerve function even with full loss of circulation.

The most important lesson that can be learned here is simply to watch out for the five "Ps" of vascular injury of the extremities:
-Pain
-Parathesia  (inappropriate or abnormal sensations,decreased sensation or the absence of pain where it should be)
-Pallor (or mottled tissues)
-Pulselessness/decreased blood pressure in the extremity
-Poikilothermia (cold temperature)


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## mycrofft (Oct 13, 2011)

*I bow to the usafmedic*

Lactic buildup, dang! 
Good points, goes past what I learned from Professor Pterodactyl.

An old correspondent, Mr V, suggests that since intravascular pressure exceeds (or at least cannot be exceeded by) pressure in the compartment, that  throughput of blood will continue. However, if there is clotting occurring, that could affect the picture. I suggested back that perhaps while major vascular pressure is that high, the vascular compromise associated with CS might be due to compression of the smallest, then smaller, then small vessels. Maybe.
 Alphabutch, use USAF's data, not mine.:blush:


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## AlphaButch (Oct 14, 2011)

Our CS/CI protocol covers the 5 p's and addresses the issue of hyperkalemia and rhabdomyolysis.

 I just like mycrofft's setup to train the guys the importance of correctly tightening a tq. It can be difficult to visualize how tight it actually should be when applied to a dummy or a demonstrator.


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