Acute Compartment Syndrome

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Acute compartment syndrome is when the pressure in a muscle compartment increases, compromising circulation and function. This occurs because the compartment is surrounded by a fascial membrane that restricts further expansion. It typically occurs after trauma, crush injury, or burns. Signs include severe pain (earliest sign), pallor, paresthesia, paresis, and pulse deficit. To measure compartments, you take your measurement device and insert it into the compartment of interest. 

How to set up your measurement device: 

  • Your materials include a sterile 3cc saline syringe, chamber, and needle. The needle has a side port (hole) for measuring pressure.

  • Connect the syringe, chamber, and needle

  • Flush the chamber and needle with saline to get rid of the air; do this by holding the entire device at a 45-degree angle.

  • Load into the monitoring unit and press zero, you should see 00

  • Insert the needle into the compartment of choice and hold it for reading

There are two ways to assess for compartment syndrome. You can use the absolute or delta pressure (normal: 0-8). Suspect compartment syndrome if:

  • the absolute pressure is > 30 mmHg

                                   OR

  • The delta pressure is < 30 mmHg

    • Delta pressure = diastolic pressure - compartment pressure. This means that the pressure in your compartment is so high that it is close to your diastolic blood pressure

Tip: remember the number 30 

These patients require a fasciotomy so call ortho ASAP. Meanwhile, you should level their affected limb and support BP if hypotensive to help maintain perfusion. 

Thanks for reading!

-Ariella

References: 

https://www.emrap.org/episode/trauma1/compartment

https://www.emrap.org/episode/measuring/measuring

EMS Protocol of the Week - Smoke Inhalation

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Hello all, 

This week's EMS Protocol is brought to you by my obsession with the HBO smash hit House of the Dragon. 

Picture this -- Two Westerosi men walk into a King's Landing bar. They see Princess Rhaenyra and strike up a heated conversation to delight her. After exhausting all the advances in their arson-al, they realize they're no match. Syrax, fuming at this show of smoke and mirrors, suggests they use Tinder and burns them to the ground. EMS arrives at the scene and then has to deal with the rest of the patrons...

Enter the REMAC protocol for smoke inhalation!

-In general, always start with ABC's -- airway is critical.

-Place patients on NRB for O2.

-EMTs can measure carbon monoxide (SpCO) with a pulse co-oximeter.

              -Keep in mind SpCO measured by an external pulse co-ox is less reliable compared to that calculated from blood co-oximetry.

              -Consider transfer to a facility with hyperbaric capabilities (like Jacobi) if you suspect CO poisoning.

-Medics perform advanced airway management.

              -Have a low threshold to use DL/VL.

              -Intubate early for soot/edema in airway, neck burns, progressive hoarseness, AMS.

-Treat cyanide poisoning early (stay tuned for more info).

Don't forget to check out www.nycremsco.org and the protocol binder for more and reach out for questions!

Remember: Winter is coming. And with winter, comes more electric/gas heating fires and potential for burn/smoke injures.

 

Best,

Chris Kuhner, MD

PGY-2 Emergency Medicine

EMS Protocol of the Week - Traumatic Cardiac Arrest (Adult and Pediatric)

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For the large number of “medical” cardiac arrest calls we field on the OLMC phone, we rarely (if ever) get calls from crews asking for orders in traumatic cardiac arrest. Why? Well for one, as you can see in this week’s protocol, the only real Medical Control Option available in traumatic cardiac arrest is for additional crystalloid fluid resuscitation, which I think we can all agree is probably not the lifesaving intervention here. But more to the point, as you read through the protocol from the top down, you’ll see how high a priority it is for crews to simply transport the patient, starting at the EMT level. Remember, this is in line with most trauma jobs, which are usually managed by EMTs who can more rapidly bring these patients to a trauma center for definitive care rather than spend extra time securing vascular access or an airway in the street. So don’t be caught off guard if BLS rolls in a traumatic arrest rolls with chest compressions, a BVM and nothing else; the EMTs are doing what they were trained to do!

 

Look at us, gang, we’ve made it through another year of these emails! I really appreciate you all taking the time to read through these and provide feedback, and I’m glad to hear that it’s helped some of you have more informed interactions with our EMTs and paramedics. But look at me, prattling on…such a bleeding heart.

 

www.nycremsco.org and the protocol binder for all you go-getters out there!

Dave