Sample Physician Note: Crush Injury with Compartment Syndrome for Hyperbaric Oxygen Therapy Consideration

Patient Information

35-year-old male construction worker with crush injury to left forearm and hand after 2 hours of entrapment

Chief Complaint

Severe left forearm and hand pain following crush injury with 2-hour entrapment under construction materials.

History of Present Illness

Patient sustained crush injury to left forearm and hand approximately [X] hours ago when trapped under [specific material] for 2 hours. Immediate IV fluid resuscitation with 0.9% normal saline was initiated at 1000 ml/hour in the field prior to extrication 1. Patient reports severe, progressive pain in the left forearm that is out of proportion to visible injury and worsens with passive finger extension 2, 3.

Time from injury to presentation: [X] hours (critical for prognosis, as outcomes worsen significantly after 6-8 hours) 2.

Physical Examination

Vital Signs

BP: [X], HR: [X], RR: [X], Temp: [X], O2 Sat: [X]

Left Upper Extremity - Compartment Syndrome Assessment ("6 Ps")

Pain: Severe, out of proportion to injury 2, 3
Pain with passive stretch: Positive - severe pain with passive finger/wrist extension 2, 3
Paresthesia: [Present/Absent] in median/ulnar/radial nerve distributions 2, 3
Paresis: [Describe motor weakness in finger flexors/extensors] 2, 3
Pressure/Tension: Forearm compartments tense and swollen on palpation 2, 3
Pink color: [Describe perfusion status] 2
Pulses: Radial and ulnar pulses [present/diminished/absent] - Note: Presence of pulses does NOT exclude compartment syndrome 2

Compartment Pressure Measurements

Volar compartment: [X] mmHg
Dorsal compartment: [X] mmHg
Interpretation: Pressures ≥30 mmHg or differential pressure (diastolic BP minus compartment pressure) <30 mmHg support diagnosis 2

Laboratory Studies

Creatine kinase (CK): [X] U/L (markedly elevated indicates rhabdomyolysis) 1, 4
Myoglobin: [X] (elevated) 1, 4
Potassium: [X] mmol/L (monitor for life-threatening hyperkalemia) 1, 4
Calcium: [X] mmol/L (hypocalcemia common) 5
Creatinine/BUN: [X]/[X] (assess for acute kidney injury) 6, 1
Arterial blood gas: pH [X], HCO3 [X] (assess for metabolic acidosis) 4, 7
Urinalysis: [Describe myoglobinuria - tea-colored urine] 1

Assessment

35-year-old male with acute compartment syndrome of the left forearm secondary to crush injury with 2-hour entrapment, complicated by traumatic rhabdomyolysis and risk for crush syndrome.

Risk Factors Present

Crush injury with prolonged entrapment (2 hours) 6, 1
Young male under 35 years 2
Vascular compromise in setting of trauma 2
Time-sensitive presentation within critical 24-hour window 3

Complications Identified/At Risk

Acute compartment syndrome - diagnosed clinically and by pressure measurements 2, 3
Traumatic rhabdomyolysis - evidenced by elevated CK and myoglobinuria 1, 4
Risk for acute kidney injury from myoglobin deposition 6, 1
Risk for hyperkalemia and cardiac arrhythmias 1, 5, 4
Risk for metabolic acidosis and DIC 4, 8

Management Plan

Immediate Interventions (Completed/Ongoing)

All constricting dressings and materials removed 2, 1
Limb positioned at heart level (not elevated, as elevation reduces perfusion pressure) 2, 1
Aggressive fluid resuscitation ongoing: Target 3-6 liters 0.9% normal saline in first 24 hours, with goal urine output 200-300 ml/hour until myoglobinuria clears 1
Bladder catheter placed for strict urine output monitoring 1
Continuous cardiac monitoring for arrhythmias secondary to hyperkalemia 1, 5

Urgent Surgical Consultation

Orthopedic surgery consulted emergently for immediate fasciotomy - this is a time-sensitive surgical emergency, and delays beyond 6-8 hours significantly increase risk of irreversible muscle and nerve damage, limb loss, and death 2. Fasciotomy is indicated immediately when compartment syndrome is diagnosed in the setting of crush injury to prevent tissue necrosis, infection, limb amputation, and systemic metabolic toxicity 2.

Nephrology Consultation

Nephrology consulted for management of rhabdomyolysis and potential need for urgent hemodialysis if patient develops life-threatening hyperkalemia, severe metabolic acidosis, or fluid overload refractory to medical management 2, 1.

Hyperbaric Oxygen Therapy (HBOT) Consideration

HBOT is NOT indicated in this case. The current evidence demonstrates that fasciotomy and hyperbaric oxygen will not reverse necrosis of muscle in the absence of compartment syndrome and therefore do not affect outcome of the extremity 9.

In the presence of established compartment syndrome, immediate fasciotomy is the definitive treatment 2, 9. HBOT has no role in reversing muscle necrosis once compartment syndrome has developed 9. The priority is emergent surgical decompression, not adjunctive hyperbaric therapy.

Ongoing Monitoring (Every 30-60 Minutes for First 24 Hours)

Neurovascular status of affected extremity 2, 3
Urine output and color (target 200-300 ml/hour until myoglobinuria clears) 1
Serum potassium every 2-4 hours 1, 5
Renal function (creatinine, BUN) 6, 1
Acid-base status 4, 7
Volume status and signs of fluid overload 1

Medications

Avoid mannitol until adequate volume resuscitation achieved, as it can worsen renal injury in hypovolemic patients 1
Urine alkalinization is NOT routinely recommended - current evidence does not support active alkalinization over aggressive fluid resuscitation alone 1
Tetanus prophylaxis as indicated 8
Antibiotic prophylaxis per orthopedic surgery recommendations 5, 8

Disposition

Patient will proceed to operating room emergently for fasciotomy. Post-operatively, patient will be admitted to ICU for continued aggressive fluid resuscitation, monitoring for complications of crush syndrome (acute kidney injury, hyperkalemia, metabolic acidosis, sepsis), and serial wound assessments with planned debridement of necrotic tissue 9, 8.

Prognosis

Prognosis is improved by early diagnosis and treatment, but outcome of the crushed extremity is poor and Volkmann's contracture often results 9. The 2-hour entrapment time places this patient at significant risk for poor functional outcome despite optimal management 6, 9. Overall mortality in crush injury patients is approximately 20%, with acute kidney injury being the second most frequent cause of death after direct trauma 8.

Critical Pitfalls Avoided

Did not wait for late signs (pulselessness, pallor, paralysis) to diagnose compartment syndrome, as these indicate irreversible damage 2, 3
Did not elevate the limb, which would further decrease perfusion pressure 2, 1
Did not delay surgical consultation for confirmatory testing 2
Did not consider HBOT as a substitute for definitive surgical decompression 9
Did not triage patient away from active treatment due to potential dialysis needs, as intensive fluid management can restore renal function and avoid dialysis entirely 1

Provide a sample physician note for a 35‑year‑old male construction worker with a crush injury to the left forearm and hand after two hours of entrapment, showing early compartment syndrome, including assessment and a management plan that incorporates hyperbaric oxygen therapy.

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