Скачать или смотреть Bedside Fasciotomy for Compartment Syndrome Indications and Technique

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The diagnosis of compartment syndrome may be difficult
In general, a high index of suspicion is necessary for the diagnosis of compartment syndrome. If a patient has pain that is disproportionate to what is expected from surgery or injury, or if there is an increased requirement for narcotics, accompanied by intense swelling and pain that increases with passive stretch of the compartment muscles, this is an indication that the patient may be suffering from compartment syndrome. You should see these patients and treat them during the impending stage, not the well-established stage. The goal is to diagnose compartment syndrome early, before muscle necrosis and weakness occurs.

Diagnosis and treatment of compartment syndrome should be done early.

Tight dressings should be removed. If there is a cast, you should split and remove the cast and examine the extremity. Examine the extremity for pain, swelling, and pain with passive stretch.

Do not wait for the classic old teaching of the five Ps to appear. These findings are considered late signs.

Do not wait for paresthesia, pulselessness, pallor, and paralysis. These are bad signs. They are late findings that indicate irreversible damage to muscles and nerves. The patient may have normal pulses even in the presence of compartment syndrome.

A combination of pain, swelling, and pain with passive stretch indicates compartment syndrome. If you suspect compartment syndrome and are not certain of the diagnosis, measure the compartment pressures.

Indication for fasciotomy based on compartment pressure:
A pressure greater than 30 millimeters of mercury or within 30 millimeters of mercury of the diastolic pressure indicates that the patient is likely developing compartment syndrome and needs Immediate fasciotomy.

Compartment syndrome can occur in the upper or lower extremity.

The most commonly involved anatomical part in the lower leg is the anterior compartment.

The anterior compartment of the leg contains the deep peroneal nerve.

The deep peroneal nerve provides sensation to the first web space. When you examine the patient for compartment syndrome, check for numbness in the first web space.

Elevated pressure affects the microcirculation and tissue perfusion.

The muscle compartment should be released within six hours. Irreversible damage can occur after eight hours.

Formal compartment release in the operating room under general anesthesia remains the procedure of choice.

However, this may not always be possible. You may be called to see a patient in the intensive care unit, emergency room, or hospital floor, and there may not be time to perform the procedure in the operating room due to patient condition or operating room availability.

Indications for bedside fasciotomy include:

Delayed presentation of compartment syndrome

Anticipated delay in surgery

Contraindications to general anesthesia

Bedside fasciotomy under conscious sedation and local anesthesia was developed to avoid delay in fasciotomy.

Time is critical. Fasciotomy should be performed early.

If fasciotomy is done within three to four hours, the damage is reversible. At six hours, variable muscle damage will occur.

Why can fasciotomy be delayed? Delay can occur due to medical comorbidities requiring clearance for general anesthesia, the need to reverse anticoagulation, polytrauma requiring resuscitation, or recent oral intake of food or fluids.

It is difficult to determine exactly when the elevated compartment pressure began. Bedside fasciotomy is a good option in cases of delayed presentation or anticipated delay. The procedure can be done in the ICU, ER, or hospital floor.

The patient can receive conscious sedation. Dose appropriately, as standard doses for a healthy adult may not be suitable for patients with sleep apnea or other comorbidities. One percent lidocaine without epinephrine can be used to infiltrate the marked skin or subcutaneous tissue at the incision line.

Bedside fasciotomy can be done for the arm, forearm, hand, thigh, lower leg, and foot.

It is important to train a diverse group of healthcare professionals in bedside fasciotomy.

How is leg fasciotomy is done?

There are four compartments in the leg. The anterior, lateral, superficial posterior, and deep posterior compartments are usually released through two incisions: one medial and one lateral.

One percent lidocaine without epinephrine is used at the marked skin incision.

For two incisions: the lateral incision is made halfway between the tibia and fibula to release the anterior and lateral compartments.

When releasing the lateral compartment, avoid injuring the superficial peroneal nerve. The medial incision is made about two centimeters posterior to the tibia.
This releases the superficial and deep posterior compartments.
The procedure can also be done through one lateral incision.