Management of Compartment Syndrome

Initial Emergency Management

The American College of Surgeons recommends removing all constricting dressings, casts, or splints immediately when compartment syndrome is suspected, and positioning the limb at heart level to prevent further injury 1, 2
Arrange urgent surgical consultation for fasciotomy without delay to prevent irreversible tissue damage 1, 2
Measure compartment pressures if diagnosis remains in doubt, particularly in obtunded or uncooperative patients who cannot reliably report pain 1
Do not wait for late signs (pulselessness, pallor, paralysis) as these indicate irreversible tissue damage has already occurred 1, 2

Perform immediate fasciotomy of all involved compartments when compartment syndrome is diagnosed to prevent irreversible tissue damage 1
Monitor for myoglobinuria and maintain urine output >2 ml/kg/h if myoglobinuria develops 1
Provide diligent wound care to mitigate complications and facilitate closure 1
Consider negative pressure wound therapy to reduce discomfort and facilitate closure in patients not candidates for delayed primary closure 1
Monitor for compartment syndrome recurrence, particularly in severe cases 1

For intra-abdominal hypertension (IAP ≥ 12 mmHg), measure IAP at least every 4-6 hours or continuously, and titrate therapy to maintain IAP < 15 mmHg 3, 4, 5
Implement a medical management stepwise approach, including evacuating intraluminal contents, evacuating intra-abdominal lesions, improving abdominal wall compliance, and optimizing fluid administration 4, 5
Surgical decompression is indicated when IAP ≥ 20 mmHg with new organ dysfunction/failure, or when the patient's IAH/ACS is refractory to medical management 4, 5

Never wait for late signs (pallor, pulselessness, paralysis) as these indicate significant irreversible tissue damage 1, 2
Never rely solely on palpation for diagnosis, as it is unreliable (sensitivity 54%, specificity 76% in children) 1
Never elevate the limb excessively, as this further decreases perfusion pressure and worsens compartment syndrome 1, 2
Never delay diagnosis in obtunded patients—measure compartment pressures earlier in these populations 1
Never miss compartment syndrome in patients without fractures, as it can occur with soft tissue injuries alone 1
Consider prophylactic fasciotomy in acute limb ischemia with threatened but salvageable limb, particularly with prolonged or severe tissue ischemia 1