From the Guidelines
To rule out compartment syndrome, a thorough clinical assessment combined with pressure measurements is essential, with a focus on evaluating the patient for pain out of proportion to injury, paresthesia, and other clinical signs, as well as measuring compartment pressures, which should be below 30 mmHg or within 30 mmHg of the diastolic blood pressure to exclude the condition 1. When evaluating a patient for compartment syndrome, it is crucial to consider the clinical signs and symptoms, including pain, paresthesia, pallor, paralysis, poikilothermia, and pulselessness, although pulses may remain present until late stages 1.
- The clinical signs of compartment syndrome have a low sensitivity for diagnosis, but a high negative predictive value, making it essential to rely on a combination of clinical assessment and pressure measurements 1.
- Direct measurement of compartment pressures using a needle manometer or electronic transducer provides the most definitive assessment, with normal compartment pressures below 10-12 mmHg and pressures above 30 mmHg or within 30 mmHg of the diastolic blood pressure strongly suggesting compartment syndrome 1.
- Serial measurements are more valuable than single readings, particularly in unconscious patients or those with altered sensation, and continuous monitoring may be necessary in high-risk situations 1. The use of scoring charts, such as the one provided by the UK's Royal College of Nursing, can help maintain a heightened sense of awareness of compartment syndrome among healthcare workers caring for at-risk patients 1. In patients with severe limb trauma, the presence of risk factors such as fracture, crush injury, or hypotension should prompt repetitive investigation for clinical signs of compartment syndrome, every 30 minutes to 1 hour, during the first 24 hours 1. Early diagnosis is critical, as muscle and nerve damage becomes irreversible after 6-8 hours of ischemia, and surgical consultation for potential fasciotomy should not be delayed if compartment syndrome cannot be ruled out and clinical suspicion remains high 1.
From the Research
Ruling Out Compartment Syndrome
To rule out compartment syndrome, the following steps can be taken:
- Clinical evaluation: The diagnosis of compartment syndrome is largely clinical, with the classical description of 'pain out of proportion to the injury' 2, 3.
- Compartment pressure monitors: Can be a helpful adjunct where the diagnosis is in doubt 2, 4.
- Measurement of intracompartmental pressures: Using a pressure monitor is the most reliable test 3.
- Physical examination: Findings may include paresthesias, pain with passive stretch, tenseness or firmness of the compartment, focal motor or sensory deficits, or decreased pulse or capillary refill time 3.
- Supplemental methods: Such as infrared spectroscopy, and ultrasound can provide additional information that support decision-making 5.
Initial Treatment
If compartment syndrome is suspected, initial treatment involves:
- Removal of any constricting dressings or casts 2.
- Avoiding hypotension and optimizing tissue perfusion by keeping the limb at heart level 2.
- Surgical consultation for emergent fasciotomy, as well as resuscitation and management of complications 3.