Management of Acute Compartment Syndrome

Diagnosis and Recognition

The American Society of Anesthesiologists recommends monitoring for the "four P's": pain, pain with passive stretch, paresthesia, and paresis in patients with suspected acute compartment syndrome 1
Clinical signs have low sensitivity but high negative predictive value, and avoiding waiting for pulselessness and pallor is crucial as these are late signs indicating irreversible damage 1
Acute compartment syndrome is defined as compartment pressure >30 mmHg OR differential pressure (diastolic BP - compartment pressure) <30 mmHg, and measure compartment pressures every 30 minutes to 1 hour during the first 24 hours in high-risk patients 1

High-risk scenarios requiring vigilant monitoring include fractures, especially tibial fractures, crush injuries, hemorrhagic injuries or reperfusion of ischemic lesions, and hypotension 1

The American Society of Regional Anesthesia and Pain Medicine recommends using motor-sparing regional anesthesia with low-concentration local anesthetics if regional anesthesia is employed, and avoiding dense blocks that eliminate all sensory function 2
Monitor motor function using straight-leg raising ability as a screening tool 2

The American College of Surgeons recommends early surgical stabilization involving wide incision of skin, subcutaneous tissue, and fascia, and decompressing all involved compartments as incomplete fasciotomy leads to continued ischemia 1
Indications for fasciotomy include compartment pressure >30 mmHg with clinical signs of acute compartment syndrome, and differential pressure (diastolic BP - compartment pressure) <30 mmHg 1

The Society of Critical Care Medicine recommends measuring plasma creatine phosphokinase, myoglobin, and potassium levels serially, and monitoring hourly urine output via bladder catheterization 1
Administer >6L of fluid in patients with severe rhabdomyolysis to prevent acute kidney injury, and maintain urine pH ≥6.5 1

The Pediatric Orthopedic Society recommends using the "three As" for diagnosis in young children who cannot articulate symptoms: anxiety, agitation, and analgesic requirement, and normal compartment pressures are higher in children compared to adults 3