Acute Compartment Syndrome is a condition that occurs with an increase in pressure in a confined space or compartment that results in decreased blood flow to tissues (Lewis et al., 2017; Papachristos & Giannoudis, 2018; Walls, 2017)

1. Decreased compartment size (Lewis et al., 2014)
   1. Restrictive dressings
      1. can cause increased pressure on the compartments
   2. Splints
   3. Casts
   4. Excessive Traction
   5. Premature closure of fascia
2. Increased compatment contents (Lewis et al., 2014; Wall, 2017)
   1. Fractures (Wall, 2017)
      1. Closed
      2. Open
      3. Complete
      4. Incomplete
      5. Long bone fractures including the humerus and tibia
   2. Soft Tissue injuries
      1. More common in older ages
      2. Subluxation, Dislocation, Strains & Sprains causing edema and blood to increase within the compartments
   3. Intravenous Infiltartion
      1. Resulting in an increase in pressure from fluid build up
   4. Bleeding
   5. Edema
   6. Chemical response to snake bite
      1. Resulting in an increase in pressure from inflammation and the immune response
   7. Trauma
      1. Volkmann's ischemic is compartment syndrome in the upper limb
      2. Anterior tibial compartment syndrome occurs in the lower limbs
   8. Crush injuries
      1. Blood and swelling cause an increased pressure with in the compartment

1. Age
   1. Under 35 years old
      1. This s because younger people tend to have more muscle in a compartment compared to older adults
   2. Adolescents
      1. Have the biggest rate of tibial fractures
2. Male gendered

   Annotations:

   • (Papachristos & Giannoudis, 2018)
   1. 7.3 per 1000, 000 in men compared with 0.7 per 100,000 in wom

1. Muscles are made of compartments, which house the nerves and blood vessels.
   1. When the pressure of the compartments increase the fascia does not stretch which results in impaired tissue perfusion. This leads to ischemia, capaillary bed damage causing plasma to leak out resulting in edema and nerve damage
      1. Necrosis of tissue occurs with compartment pressures over 30 mm Hg, this happens in about 4-8 hours (Lewis et al., 2014)
      2. Lack of oxygenated blood leads to tissue hypoxia which causes an increase in waste product accumulation and muscle tissue damage
         1. Cellular destruction results in myoglobin being realesed into the bloodstream, also there is a release of creatine kinase which, in high amounts, can lead to rhabdomyolysis. Both are life threatening conditions that can cause acute renal failure (Papachristos & Giannoudis, 2018; Walls, 2017)
         2. Hyperkalemia and acid is released into the blood which can cause dysrhythmias, organ failure and death
   2. The outer covering that encloses and separates muscle from other organs is called the fascia, it does not stretch. The normal compartment pressure range is 0-8 mm Hg.

1. The 6 P's (Lewis et al., 2017; Papachristos & Giannoudis, 2018; Walls, 2017)
   1. Pain which is described as intense, deep and difficult to localize. Pain increases with passive stretch and as the pressure increases
   2. Paresthesia or pins and needles is a sign of impaired circulation
   3. Pallor is seen distal to the injury, cyanosis and mottling may also be present. The affected area can also look shiny, tense and swollen. This is caused by impaired circulation and increased capillary pressure
   4. Paralysis is considered a late sign and is more common with crush injuries. Motor function is lost if the limb is ischemic (Wall, 2017)
   5. Pulselessness at or just below the injury due to impaired circulation, this is also seen as a late finding
   6. Pressure is from decreased compartment size or increase in compartment contents. 30 mm Hg or higher indicates compartment syndrome (Lewis et al., 2014)

Annotations:

• (Papachristos & Giannoudis, 2018)

1. Specific clinical signs- The 6 P's of compartment syndrome
2. Intra compartmental pressure (ICP) messurements are essential, peak pressure is 5 cm distal and proximal to fracture site. ICP of 30 mm Hg indicates compartment syndrome
3. Infrared spectroscopy is a new non-invasive tool that messures tissue oxygenation with a probe that goes on the skin
4. pH monitoring- due to anerobic cellular activity acidosis can occur, intra-compartment pH of <6.4 indicates compartment syndrome
5. MRI to detect intra-compartmental swelling however this finding is non-specific

1. Complications are directly corrolated with timing of treatment
2. Myoglobin may be realsed from damaged muscle causing kidney damage and acute renal failure
3. The ischaemic muscle becomes necrotic and replaced by fibrous tissue causing weakness, disfiguration and nerve damage
   1. Ectensive tissue necrosis may require amputation, widespread damage may result in death
   2. Nerve damage leads to lack o sensation, muscle paralysis and neurogenic pain
   3. Infection, locally or systematically
      1. (Rangel, Hernandez-Castro, Arenas, Dominguez-Cherit, Vick, Diaz, Rodriguez-Cruz, 2010)
4. Further complications are dependent on the compartment that is affected

1. Fasciotomy is an incision into the skin and fascia allowing for the affected muscle to swell, releasing tension and pressure (Schmidt, 2017)
   1. Emergency surgical procedure
      1. General anaesthesia is used, offering the highest level of patient sedation. The patient loses all sensation, total loss of consciousness and inability to self maintain functional airway.
      2. Aseptic technique to minimize risk of infection
   2. Complications
      1. Must be done immediately or irreversible tissue necrosis occurs
      2. Additional surgery for delayed wound closure, skin grafts, cosmetic issues, pain and nerve injury
      3. Permanent muscle weakness
      4. Chronic venous insufficiency
   3. Wound closure (Bengezi & Vo, 2013)
      1. Alleviating edema by strictly elevating the affected limb
         1. Wound cloure time was three to five days with elevation
         2. Practical in settings with limited resources
      2. Split-thickness skin grafting, which involves removal of the epidermis and a portion of the dermis
         1. Six to eight days to restore full circulation to the skin graph
            1. (Reynolds, Christophersen, Mulcahey, 2017)
         2. Ten to twelve days for the donor site to heal

1. Drug therapy is individualized (Ersek & Polomano, 2014)
   1. Non-opioids/Nonsteroidal anti-inflammatory drugs (NSAIDs). Used for mild to moderate pain, promotes blood clotting and encourages normal function of the kidneys. They work by limiting the production of prostaglandins that promotes inflammation, pain and fever.
   2. Opioids are used for moderate to severe acute pain. They work by attaching to opioid receptors in your brain, and those cells release signals that muffle the perception of pain
      1. Adjuvant analgesic therapy are drugs used in conjunction with opioid and nonopioid analgesics.
2. Therapeutic Relationships: Composed of significant knowing and meaningful connecting with patients (Mirhaghi, Sharafi, Bazzi & Hasanzadeh, 2017)
   1. Barriers
      1. Staff shortages
      2. Time restraints
      3. Sterotyping
   2. To be effective the nurse needs to be self-conscious, self-aware, have a philosophy about life, death and the overall human situation
   3. Features
      1. Mutual targeted experience
      2. Meeting nursing needs of the individual and family
      3. Coordination and cooperation
      4. Being near the patients bedside
      5. Honesty and empathy
3. Patient education is put into place to help patients and their caregivers focus on optimizing their health and to enable them to cope with health problems (Goodridge, 2014)
   1. Clinical patient education: planned, systematic, sequential and logical process of teaching and learning
   2. Health education: focuses mostly on wellness, prevention and health promotion
4. Use a pressure monitor/catheter to measure intra-compartmental tissue pressure to ensure it does not exceed 30mmHg (Harvey, 2006).