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December 2006 - Volume 3 - Issue 6
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ACS: A Curable Situation

The nurse comes up to you and says, " I just put a patient in Room 6 who was here yesterday for a leg fracture and the hydrocodone isnít working". Translation: "We have a drug seeker, be tough". Before you politely toss him out of the ED because of this obvious case of pain out of proportion to the injury, you better stick an 18 gauge needle into him. No not an IV to give toradol, but rather a needle that enters the soft tissue in the area of greatest pain. Now this is not to be cruel nor is it the art of acupuncture. This is the art of ACS, that is A Curable Situation or Acute Compartment Syndrome, which I will make Ridiculously Simple for Dummies.

To break down ACS and make it simple, you must be able to accomplish 2 goals. They are:

1) Recognize and consider the possibility of ACS
2) Check the intracompartmental pressure.

To accomplish goal number 2, you must have available 2 things. They are:

1) A reliable intracompartmental pressure monitoring device (Stryker Quick Pressure Monitor)
2) A reference book to aid in positioning the needle into the compartment in question ( I recommend Clinical Procedures in Emergency Medicine by Roberts and Hedges).1 Clinical Procedures has great pictures and descriptions of placing the needle into the compartment in question.

What is ACS?

Simply, it occurs when the tissue pressure of a closed compartment space is increased such that it reduces the capillary pressure and decreased perfusion of the tissues takes place. The tissues most affected are the nerves and muscles in that space. The condition is reversible and it is a surgical emergency where time is of the essence. The treatment is acute fasciotomy by a specialist, usually an orthopedist. The onset of symptoms ranges from 2 hours to 6 days.2 Complete loss of perfusion to an extremity is reversible up to 4 hours and irreversible changes occur with total ischemia of 8 hours.3

What is the cause of ACS?

Any condition that either reduces the compartment size or increases the compartment volume can lead to ACS. The list of etiologies is large, the most common causes are acute fractures. The most common location is the anterior compartment of the lower extremity due to an acute tibial fracture. Other common causes include: supracondylar fractures, humeral shaft fractures, forearm fractures, crush injuries, constrictive dressings or casts, hemorrhage, infiltrated IV injections, prolonged compression or immobilization and snake bites.4 The complications of ACS include: permanent neurologic and muscular dysfunction, extremity deformity (contractures), myonecrosis and possible resulting acute renal failure, loss of limb, and occasionally death, as well as threatened law suits, depositions, hospital peer review and higher malpractice rates.5,6

How does ACS present?

Pain out of proportion to apparent injury is the hallmark of ACS. Disproportionate pain is the earliest sign. Loss of sensation, loss of 2 point discrimination, loss of vibratory sense and pain with passive movement are all early and reliable signs of ACS. Remember the pneumonic of the 5 Pís: Pain, Paresthesias, Paresis, Pulseless, and Pressure.

What is an abnormal intracompartmental pressure?

Normal tissue pressures ranges from 0 to 16 mmHg. Pressures above 30 are typically considered critical, prompt consultation and acute fasciotomy are indicated.7 Patients should be admitted with orthopedic consultation and carefully observed with serial neuromuscular examinations if the pressure is above 20 and below 30, without signs of impairment. If signs of neuromuscular impairment are present and acute ACS is obvious, fasciotomy is indicated regardless of the pressure measured.

What is the treatment for ACS?

First, remove any external pressure. A cast that is bivalved will decrease the compartment pressure by as much as 55%. If the cast is completely removed the pressure will decrease by up to 85%. Elevate the affected extremity to the level of the heart (not higher). Coagulopathies should be corrected if bleeding and hemorrhage are involved. Rhabdomyolysis and myoglobinuria should be treated with adequate hydration to maintain urinary output. As stated above, acute fasciotomy is the treatment for ACS.

Finally, patients with extremity injuries that are being discharged, especially if there is a crush injury or fractured tibia, or have any potential for ACS, they must receive directions for when to return to the ED. They include increased pain, any numbness, tingling, significant swelling or discoloration suggesting decreased blood flow. Letís turn ACS from A Critical Situation, due to A Crushing Scenario and into A Cured Solution by keeping a high index of suspicion, being familiar and comfortable with checking the intracompartmental pressure and to consult timely.

Mark Lieberman, MD, FACEP, is with Phoenix Physicians and is the Assistant Medical Director of Emergency Services at Coral Springs Medical Center CSMC). He can be reached at (954) 293-2701 or markliebermanmd@yahoo.com. Phoenix Physicians manages the delivery of quality healthcare in hospital emergency departments by streamlining patient throughput, improving patient satisfaction and providing each physician and practice with the most personalized service in the industry. For more information, visit Phoenix online at www.phoenixphysicians.com.

References

1. Frankel NR, Villarin LA Jr: Compartment syndrome evaluation. Clinical Procedures in Emergency Medicine 4th Edition, 2003.
2. Matsen FA, Clawson OK: The deep posterior compartmental syndrome of the leg. J Bone Joint Surg AM 57:34, 1975.
3. Heckman MM, Whitesides TE, Grewe SR, et al: Histiologic determination of the ischemic threshold of muscle in the canine compartment syndrome model. J Orthop Trauma 7:199, 1993.
4. Matsen FA: Compartment Syndromes. New York, Grune and Stratton, 1980.
5. Dalismer D: Case of delayed onset compartment syndrome. Am J Emerg Med 12, 1994.
6. Reis D, Michaelson R: Crush injury to the lower limb. J Bone Joint Surg AM 68-A:414, 1986
7. Hargens AR, Schmidt DA, Evans KL, et al: Quantitation of skeletal muscle necrosis in a model compartment syndrome. J Bone Joint Surg AM 63-A:631, 1981.

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