Acute Compartment Syndrome: Four First Steps to Diagnosis and Management

Acute compartment syndrome is an important complication of peripheral intervention and one that requires quick diagnosis and treatment, said Eric Scott, MD, at the start of his AMP 2020 Virtual talk entitled, “When Faced with Compartment Syndrome, The 1st 4 Things to Protect the Patient While Waiting for Help.”

“I am a vascular surgeon and I have to admit this complication makes even me uncomfortable and it should, this is a surgical emergency,” said Dr. Scott, medical director of the Outpatient Endovascular Center at the Iowa Clinic in West Des Moines, Iowa.

“It's not something any of us [expect] on a given day in the catheter lab, but it can happen if we do enough cases below-the-knee, in particular—there’ll come a time when you're likely to see compartment syndrome and how you recognize it and how quickly you respond will determine your patient's outcome.”

There are four compartments in the calf, but only two of which contain tibioperoneal vasculature relevant to peripheral intervention.

The anterior compartment contains the anterior tibial artery and vein, as well as the deep peroneal nerve. “So, a bleed in this compartment can injure the deep peroneal nerve and give your patient a foot drop, which is probably the one of the most feared complications of compartment syndrome,” said Dr. Scott.

In the deep posterior compartment lies the posterior tibial artery and vein, the tibial nerve, and the peroneal artery and vein. “This compartment is a little bit more difficult to assess,” he said. “A bleeding can occur just as frequently in this compartment as the anterior, it's just a little bit more difficult to clinically recognize.”

From a frequency perspective, the most common form of compartment syndrome is an ischemia reperfusion injury. “When it comes to our work in the catheter lab, compartment syndrome is usually from acute hemorrhage, and it's only going to involve one of the compartments of the calf, so it can be a little bit more difficult to diagnose,” he added.

Given this, the first step in Dr. Scott’s Four Keys is to recognize that you, indeed, are dealing with compartment syndrome. This is easier said than done, but since the complication represents a surgical emergency, recognition can mean the difference between saving a limb and losing one.

“A delay in diagnosis can cause lifelong disability and, quite frankly, it's often easier to treat this than to diagnose it,” said Dr. Scott. Diagnosis and treatment delays are among the most common complaints listed in medical malpractice claims.

The early signs of compartment syndrome include pain or parasthesias, particularly when it’s unexpected. “Angioplasty can hurt,” said Scott, but when there’s nothing happening that should be causing pain, if the patient is reporting pain, this is a cause for concern.

Later signs include pallor, pulselessness, or paralysis. “But, honestly, you don't want to be in this zone,” said Dr. Scott, particularly since most patients undergoing lower limb intervention likely have some pallor or pulselessness to begin with.

Of course, if there is any bleeding, the calf should be examined immediately. “These patients are usually exquisitely tender. If a bleed has resulted in a compartment syndrome, you may be able to palpate fullness of the anterior compartment,” said Dr. Scott. There may also be pain with ankle flexion, or dorsiflexion, and less common is ecchymosis over the overlying skin.

“If you suspect a compartment syndrome, the key thing is to notify the surgeon on call immediately,” said Scott.

The next step is to stop the bleeding, which is typically caused by guidewires, he noted. Other offenders are atherectomy devices and angioplasty balloons. “The guidewires, I think, are the most versatile offenders here. Guidewires, particularly when you shape them, can perforate main arteries, or can particularly perforate branch arteries.”

Bleeding can be controlled by balloon occlusion, a blood pressure cuff inflated at the site, or even placement of a covered stent or embolization of a small branch vessel. “Whatever you can do to quickly control the bleeding, it can be helpful,” said Dr. Scott.

“The third thing to do is to help prepare the patient for the operating room, because that's where a compartment syndrome is going to be successfully treated.” This includes calling the OR and notifying them that you have a patient with compartment syndrome so that they might prep for a fasciotomy.

Other things to do include getting consent for a fasciotomy and type and screen the patient if you suspect they might need blood.

“Elevate the limb, don't compress it because that can increase the compartment pressures, but elevation can help,” said Dr. Scott.

And, finally, consider the access site. “So, in my mind, the default path here is to maintain my access site, to not give it up or close it. If I have an up and over sheath, you can replace this with a short sheath in the contralateral groin, connected to a heparin-saline infusion, and that can allow you then to reverse heparinization, if you feel like that's important,” Dr. Scott said.

But, he added, make sure to keep the sheath in place so it's not dislodged on the way to the operating room. “Nothing's worse than having two bleeding complications in two legs,” he told listeners.