Compartment Syndrome…oh the Pressure!

Compartment syndrome, in the clinical setting, is considered an emergent situation that requires immediate treatment. Note we’ll be talking about acute compartment syndrome here, and not the chronic variety which is usually caused by muscular exertion. What we’re talking about here is a limb-threatening condition that, if left untreated, could result in loss of the affected body part, kidney failure and even death.

What is compartment syndrome?

To understand compartment syndrome, you must first understand what is meant by the “compartment.” Your muscles and blood vessels are surrounded by fascia, a thin but very strong connective tissue layer that helps keep everything, including your organs, in place. Think of it as the scaffolding for the inside of your body. Each of these groupings of muscle or organ is therefore inside a “compartment” created by the fascia.

When bleeding, edema or muscle swelling occur due to injury, it puts pressure on this fascia. When the pressure goes beyond the ability of the fascia to stretch, then pressure builds up INSIDE the “compartment”, causing blood vessels to be compressed. As the blood vessels compress, blood flow is restricted which leads to a lack of oxygen in the tissues and, eventually, tissue death.

The most common locations for compartment syndrome are the arms, legs and abdomen. When the abdomen is involved it’s a result of intra-abdominal hypertension and it’s scary stuff. For the purposes of this post, we’re just focusing on the arms and legs today, but if you want to read about the belly, check out my post Introduction to Intra-Abdominal Hypertension.

What causes compartment syndrome of the limbs?

One of the most common causes of compartment syndrome are crush injuries or a limb being compressed for an extended period of time. Other causes include surgery to the vessel (leading to bleeding into the compartment), overly tight bandages, blood clots or even very very very strenuous exercise. I do indoor rock climbing occasionally, and every time I do it I swear I’m getting compartment syndrome in my forearms!

How do you assess for compartment syndrome?

As the super rockstar nurse that you are, you’re going to be ever vigilant on your head-to-toe assessment, which is where you may get your first inkling that something is wrong. When checking pulses, ESPECIALLY in those who are at risk, you’ll  check them very thoroughly (you’ll be surprised how often this gets overlooked or just plain flubbed). If those pedal pulses are hard to palpate, it could just be that they’re hard to palpate…but it could also mean there’s some funny business going on. Now if the foot is still warm,  you won’t go into Major Freak Out Mode just yet…but you definitely want to assess further. Let’s start from the beginning, shall we?

0700: You’re doing your head-to-toe and your patient is grumbling about her lower leg hurting. Well, she had vascular surgery on her leg yesterday, so you’re not super concerned. You check pedal pulses and notice that the pulses distal to the surgical site aren’t palpable. But, she also has a fair amount of swelling so you don’t stress just yet. After all, the foot is still warm and pink…she can wiggle her toes, though it does make her grumble a little louder. Maybe she’s just a grumbler, who knows?

0705: Because you’re so thorough, you’re not just going to chart that the pulses were “weak” (which is what a lot of people do, sadly), but instead you’re going to do a little detective work. First, you check the chart. How were her pulses after surgery? You look at the chart and see that pulses were present and palpable after the procedure. Hmmm…the plot thickens.

0715:  So off you go in search of the doppler (which in most nursing units is squirreled away in a top secret location to prevent it growing legs and walking off). You locate the doppler (along with the bladder scanner, manual BP cuff and binder of take-out menus..haha), and do a fully thorough assessment of the missing pulses. You give it a few tries, checking both posterior tibial and dorsalis pedis…nada, nothing, zilch. So, you do what any smart nurse does. You ask a buddy to come give it a whirl. Sometimes dopplers are finicky and you have to have it at EXACTLY the right angle in order to get anything. Your friend is not able to find the pulse either and so now you’re thinking “Oh &##&%…this isn’t good.” You’re right…it isn’t.

0720: Oh look, there’s the surgeon, Dr. Bob, waltzing into the unit for morning rounds with his cup of free doctors-lounge coffee. If he hadn’t waltzed in just then, you’d be on the phone calling him anyway. But since Dr. Bob rounds before his surgeries begin for the day, you’re breathing a nice sigh of relief now. You tell Dr. Bob of your findings and he goes to see the patient, no doubt thinking you are a stellar nurse (and making a mental note to bring you a cup of free doctor-coffee sometime soon).

0730: Dr. Bob discusses with you what he found on his assessment…basically the same thing you did, so he wants to keep a close eye on things. You’re going to be checking for signs of compartment syndrome like a hawk for the rest of your shift. He tells you to give him a call if things worsen. He gives you his pager number, saving you 15 frustrating minutes later on as you try to track it down, and goes on his way, leaving his free coffee behind. You’re starting to think he respects you (as he should…because you’re AMAZING, right???).

0735:  You check Dr. Bob’s orders and he’d like you to assess the patient’s neurovascular status every hour for 24-hours and call if any of the present are noted: pallor,  increased pain, poikilothermia, paralysis, parasthesia. Since you already have pulselessness then your 6 Ps of compartment syndrome are covered! You wished you had asked Dr. Bob why he’s not freaking out yet, but one of your more experienced nurse friends lets you in on a little tip. If the patient has been having chronic vascular problems, they likely have developed collateral circulation. So even though you can’t feel the distal pulses in the big vessels, perhaps they’re still getting some flow through collaterals. Since the foot is still warm, you think this sounds like a pretty good answer. So, you take a deep breath and try to relax. Maybe you patient doesn’t have compartment syndrome after all? Maybe she’s just got some edema that’s making the pulses challenging to assess. You feel pretty good about this line of reasoning…that is, until you go check your patient an hour later.

0830:  The doppler still shows no audible signs of turbulence in the vessel, and you think, but aren’t 100% sure, that the foot is cooler than before. You compare right foot vs left foot and yes…the right foot is definitely cooler. You ask the patient how she is feeling and she states that the pain is increased. The color looks a bit pale, but nothing horrifying. The patient can still move her foot, can still feel when you touch and just wants you to leave her alone so she can go back to watching Housewives reruns.

0835:  You page Dr. Bob.

0845:  Dr. Bob’s circulating nurse calls you back from the OR. Dr. Bob is deep into a AAA repair and can’t come see the patient until this case is done. He increases the frequency of monitoring to every 30 minutes for the next 2 hours and says to call again if things get scary.

0900:  You go in for your assessment. No change for the worse. Whew!

0930: The other patient in bed B goes into respiratory distress right as you were about to start the assessment on your patient. You end up assisting with an emergent intubation that takes fifteen minutes, so you’re late getting to your assessment. It happens.

0945:  Now your patient is moaning and complaining of intense pain. You do your assessment. Still no pulse. The foot is now obviously cool to the touch and pale. The patient can barely wiggle her toes and has difficulty discerning touch. You get on the phone and page Dr. Bob again.

1000: While your friendly and helpful charge nurse gets your patient some pain medication, you talk to Dr. Bob’s circulating nurse again. You tell her of the findings and she puts you on speaker phone so you can talk to Dr. Bob as he works on his AAA case. Seeing as how he’s almost done, he leaves it to his assistant to close-up and says he’ll be right up to see your patient.

1015: Dr. Bob arrives on the scene, gets a quick update from you (nothing has changed since you went into “Threat Level Midnight” mode) and goes in to see the patient who is now in unbearable pain. Being the smart nurse that you are, you’ve already prepped the patient for emergency surgery (just in case!). But Dr. Bob can’t wait for an OR…he asks for a sterile drape, scalpel and a few other doctor-ish things. Wait a minute, is he thinking what you think he’s thinking? When he orders 2 mg Versed and 200 mcg Fentanyl, you know he’s thinking what you think he’s thinking. Your day just got real interesting real fast!

10:20: As you scamper around gathering the supplies Dr. Bob is going to need you realize he’s definitely planning to do it. Yes. IT. An emergency fasciotomy. At the bedside. Bam! Things just got real. In true ICU-nurse fashion, all your buddies suddenly become even more helpful than they usually are. Nurses love a good bedside surgery almost as much as they love when the charge nurse springs for pizza in the middle of an intense shift. As you head back to the room you review what you know about fasciotomy…basically you know that it’s an emergent procedure that will relieve pressure in the compartment. It is considered a limb-saving therapy when the compartment syndrome pressures are severely impeding blood flow.

1030:  You’ve got your supplies and your patient gets a nice dose of happy drugs. You watch in fascination (and horror?) as Dr. Bob skillfully cuts into the patient’s leg and through the fascia in one long strip. The skin splits apart,  releasing the pressure on the compartment. It also leads to (hopefully) return of blood flow and, not to mention a whole other type of pain for your patient (namely the pain of having a scalpel applied to your body in such an unrelenting fashion). The wound will be left open and repaired with skin grafts as the swelling subsides.

1115: You clean up the chaos in the room, ensure your patient has adequate pain management and finally take your morning break. Good job, you!

So that’s basically what a fasciotomy is…a surgical incision through the fascia to release pressure. As you can see from this photo, it isn’t pretty, but it is effective.

What are the complications of compartment syndrome?

The obvious complication is tissue death leading to irreparable injury aka amputation. Dying tissues also release toxins into the bloodstream leading to sepsis, which is no walk in the park, either.

Other bad things that can happen include permanent nerve damage due to the severe compression, severe muscle scarring or contracture leading to loss of mobility, and even acute kidney failure due to rhabdomyolysis (muscle breakdown). So, as you can see, compartment syndrome is not to be taken lightly, but your awesome nursing skills not only saved this patient’s limb but possibly also her life.

Hopefully that gives you a little inside peek at compartment syndrome, how a condition can change, and how the nurse responds.

P.S. Get this on audio in episode 119 of the Straight A Nursing Podcast.

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