Compartment Syndrome

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Cue Scene:

  • 20yoM w/ no pmh who hurt his leg while playing basketball.  He tried to walk it off but the pain keeps getting worse.  He arrives via EMS, screaming in pain and clutching his leg.  You get an x-ray which shows a fibula fracture.
Remember your Ps:
1.  Pain out of proportion
2.  Pallor
3.  Paresthesias
4.  Paralysis- late finding!
5.  Pulseless- late finding!
 
Compartment syndrome is most commonly seen in legs and forearms.  Often seen in crush injuries, circumferential burns, constrictive dressings (e.g. casts that aren't bivalved), or ischemia-reperfusion injuries.  In Tibial Fractures the most common is the deep posterior compartment followed by the anterior compartment.
 
 
Here's a cool video for you to watch:  https://www.youtube.com/watch?v=ewMD0OUlpqg
 
Treatment:  Fasciotomy is indicated if the difference between patient's diastolic pressure and the compartment pressure is less than 30mmHg or if the compartment pressure itself alone is over 30mmHg.  Get ortho involved ASAP if available.  Otherwise you have to perform the fasciotomy.
 
Now let's review with a little Board question:
  • 24M presents as a trauma code shortly after a motorcycle accident. Pt was thrown from his motorcycle when a car suddenly braked in front of him, and his leg was caught under the wheel of the vehicle. Airway is intact, he is complaining of severe leg pain, and his blood pressure is stable. He was helmeted, and his injuries appear to be isolated to the left lower extremity. When you move to the secondary survey, you note severe left lower extremity edema, and the patient screams and writhes in pain upon palpation of the distal pulses. You observe diffuse road rash but no open lacerations. His peripheral pulses are palpable and strong. Radiograph of his left lower extremity is shown in Figure A. What is the next best step in management?
  • Next best step?
    • A.  Admission for observation and pain control
    • B.  Closed reduction and splinting
    • C.  Percutaneous pinning and casting
    • D.  Multi-compartment fasciotomy
    • E.  Physical and occupational therapy
 
 
 
 
 
 
 
 
 
 
 
 
Answer:  D
 
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POTD Tuesday. Tricky TrickY Tuesday

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FIRST AND FOREMOST, GO BRONCOS!

Today's POTD is a shoutout to Dr. John "Fearless Leader" Marshall, as brought up at last weeks CQI.

ABDOMINAL EXAMS AND A COMMON PITFALL

There was a recent case of a PERFORATED VISCOUS (of course he presented with SOB, but that's another story). The XR was extremely clear. Of course it was missed. The patient had no abdominal TTP, no rebound/guarding/rigidity. Completely non surgical. The free air was missed because they weren't looking for it. (Even the radiologist only read this obvious free air as "possible free air")

 

HOW THE HELL WAS HE NON-TENDER!?!?!?!?!?!? THESE PATIENTS ABDOMEN'S SHOULD BE A BOARD THEY'RE SO RIGID

 

 

 

CHRONIC STEROIDS (*ominous sounds*)

  • Patients on long term steroids (for asthma, auto-immune dz, etc...) can mask a surgical abdominal exam. They may have no tenderness, nothing.
  • Again, patients on long term steroids may have a completely normal abdominal exam, even with having surgical pathology.

Don't believe me? While there may be no true RCT, or even a retrospective trial, there are case studies and anecdotal cases (such as the one above). The best one I found is linked right below.

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3391396/

 

From Medscape: "Remember that the presentation and the findings on clinical examination may be entirely inconclusive or unreliable in patients with significant immunosuppression (eg, severe diabetes, steroid use, posttransplant status, HIV infection)"

 

So Be DILIGENT. Have a HIGH-LEVEL OF SUSPICION.

And as Dr. Marshall would say, "Anoscope, Anoscope, Anoscope"

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POTD MONDAY: ZEUS EM TWICE DAWG!!!

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DUAL SEQUENTIAL DEFIBRILATION (aka the return of the CAPS AND COLORS!!!!) Also, thank you for participating, Antony "Not the guy from the 2nd Triumvirate" Mathew, week 1 of fantasy football is in the books! (Just jinxed myself)

 

 

Back to the topic at hand, What the hell is it?

  • Placing 2 sets of defib pads on a patient
  • Charging them both fully
  • Hitting the Shock button at the same time. ZAP GOES THE WEASEL

HOW TO PLACE THE PADS

 

There are a few ways to place the pads, but the general idea is you want to blanket the chest with electricity

 

Image result for double sequential defibrillation 

 

Consideration, Evidence, and when to Use (the meat of the article)

  • Studies showed that the higher the amount of body fat, the lower the amount of electricity gets to the heart (in pigs)
  • However, initial ROSC with VF arrest and single defib is fairly high (studies show various numbers, but it's decent)
  • Series of case studies showing that after multiple rounds of CPR, multiple single shocks, and appropriate meds given, Dual Defib can increase the chances of ROSC.
  • One study in an EP lab showed increased success of dual defib, but in a more controlled setting.
  • Certain EMS systems, and hospitals are now including it in their ACLS protocol, either after FOUR OR FIVE normal shocks.

 

WHAT WILL I BE DOING????

  • By the time you're considering doing this, the patient is pretty dead. They can't get dead-er. I've tried this a few times (never worked) but I think I'll keep using it. There are case studies out there with it working, and some pretty smart people swear to it anecdotally.
  • As Einstein put it (probably about defibbing a patient 10 times during a code)
    • "The definition of INSANITY is doing the same thing over and over again, butexpecting different results"
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