Compartment syndrome is to be considered to be life-threatening as well as limb-threatening. Its occurrence is linked to increased tissue pressure relative to the perfusion pressure within compartment muscles. The prevalence of this condition has been linked to severe damages to muscles. This particular condition was discovered by Hippocrates, back in 400 BC (Sippel, 2014). While it has multiple causative factors, this paper focuses on compartment Syndrome that comes about due to deep vein thrombosis (DVT). A muscle compartment is essentially the tough membrane by the name fascia which covers the muscle groups. Under normal body conditions, this particular membrane is vital for the effective and efficient functioning of muscles. The occurrence of trauma and injuries within the muscles, however, often result in swelling. The fascia, in this case, becomes an inhibitor to the extent to which a muscle can swell. The resultant effect is the restriction of the flow of blood.
The impact of the fascia restriction significantly affects the venous blood and lymph flow. It is also important to highlight the fact that there is a likelihood of impaired functioning of sensory nerves passing through the affected area. In this case, therefore there an individual is likely to experience numbness as well as a tingling sensation, before the onset of pain. Further swelling of the muscle is likely to impact the flow of blood within the arteries; the pain will also increase with motor functions linked to the limb being impaired. DVT defines a condition in which a blood clot emerges in the vein that is deep inside the body. The result is a swollen vein in the event of a massive blood clot, a smaller clot, on the other hand, is likely to break free and result in pulmonary embolism if it reaches the lungs. DVT has numerous causes and risk factors including slow blood flow, thicker blood or damages within the inner lining of a vein.
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Medical attention is essential in alleviating the impact of this condition. Even more crucial is the pre-hospital attention that an individual suffering from this condition receives. The first goal should be to help minimize the pressure within the affected region, and as such paramedics should focus more on pain reduction and pressure release (Torlincasi and Waseem, 2017). A paramedic is thus expected to focus on reducing the patient's mobility before initiating limb elevation and cooling. It is vital for paramedics to be aware of the various mechanism of injury that results in this particular condition. While traumatic causes such as severe thermal injuries and penetrating trauma are the most common with the compartment syndrome, other non-traumatic causes have also been identified. Bleeding disorders, ischemia-reperfusion injury, and thrombosis are some of the non-traumatic causes of the condition.
Appearance of Compartment Syndrome due to DVT
The compartment syndrome has to be analyzed relative to its area of occurrence. In this case, therefore, a total of thirty-six compartments are to be found in all extremities. Any increases of pressure within the compartment result in a subsequent decline in capillary perfusion causing restriction of blood flow into nerves and muscles. Compartment muscles are most vulnerable to this problem, and they include, muscles in the forearm, the thigh, buttock, foot or upper arm. The most important thing with compartment syndrome is realizing that its diagnosis is highly sensitive. In other words, the decision of the paramedic influences the speed and type of remediation that will be utilized for the patient. The gravity of this particular role is to be seen in the possible loss of a limb or life for an individual with the condition (Torlincasi and Waseem, 2017). A compartment syndrome comes about when the membrane surrounding muscles has an impaired expansion capacity, this, therefore, increases pressure as a result of decrease space. In the case of compartment syndrome as a result of DVT, the blood clot creates an obstacle in the vein which significantly reduces the space available for blood flow.
As the pressure within the vein continues to rise, it results in a subsequent drop in perfusion pressure. The limited flow of blood in such a vein limits access to muscles and nerves resulting in ischemia in these regions. The time difference between the onset of a DVT and the significant destruction of the muscles and nerves tends to vary with the amount of pressure that the clot inflicts within the vein. Functional impairment of muscles due to ischemia has been capped at a total of two to four hours. A total functional loss is estimated to take between four and twelve hours. However, after two to three days a scar is formed by the muscle tissue. As a paramedic, the appearance of compartment syndrome will be based on measuring pressure within the muscle compartment (Sippel, 2014). One way of doing this is by measuring the intra-compartmental pressure with the help of a manometer. A manometer comes in handy in determining the amount of pressure within the compartment muscle by assessing the degree of resistance that is experienced when a saline solution is injected into the affected compartment. The normal compartmental pressure ranges between 0 mmHg to 8 mmHg. In the event of compartment syndrome, the pressure is likely to rise to the upwards of 20 mmHg to 30 mmHg.
How to Assess Compartment Syndrome due DVT
As earlier stated in the paper the management and treatment of compartment syndrome is highly dependent on the emergency care and diagnosis. In other words, the paramedic has to help both patient and doctor in the management of the condition to avoid possible death or limb removal. Diagnosis of the condition will focus on various physical signs that are pertinent to the condition. Primarily, one can focus on the extremity of pain at the affected area. It is also possible that there extreme swelling and tenseness will be present. So far, six critical signs have been singled out to help medical practitioners to make a timely diagnosis (Torlincasi and Waseem, 2017). First of is the aspect of pain, which has been identified as a universal symptom of the condition. The crucial element in regards to pain is to consider the mechanism of injury and the proportion of pain as described by the patient. Ideally, the pain that is associated with the compartment syndrome tends to be deep aching and dull, and more importantly difficult to localize.
The second sign is that of paresthesia. Paresthesia is described the pin-and-needle sensation that is felt due to the absence of air circulation over a given period. While numbness is not necessarily an indication of compartment syndrome, its presence after an injury is a possible indication of nerve damage which reflects the presence of progressing compartment syndrome. Pallor is another vital sign that can help in the diagnosis of the compartment syndrome. It is described as the paleness of the skin distal to the injury. Paralysis is another sign that can help a paramedic quickly arrive at a diagnosis. It represents to total inability to move a limb distal to an injury. This comes about when the muscle and nerves have been significantly disrupted. The absence of a pulse within the affected is another possible indication of the presence of the compartment syndrome. This particular syndrome is linked to any injury mechanism that results in a tourniquet type effect (Schmidt et al. 2017).
The absence of a pulse within an intact limb could mean that there is a delayed capillary refill indicating a decreased circulation and as such, it becomes a possible sign of the compartment syndrome. The sixth sign that has been noted in relation to the compartment syndrome is that of poikilothermia. Ideally, poikilothermia concerning compartment syndrome is the existence of differing temperatures between an injured and an uninjured limb. This particular difference can be noted by taking temperatures at the site of the injury as well as on the opposite limb. If an injured limb has a lower temperature as compared to the unaffected one, then it is evident that the thermoregulation has been impaired in the affected area (Schmidt et al. 2017). It is important to note that the most conspicuous symptom of the compartment syndrome is the severity of pain in the affected compartment relative to the apparent injury.
The presence of blisters is another vital sign of the compartment syndrome. Blisters often occur when the compartment syndrome is highly advanced. If the affected area is within the forearm, the paramedic can ask about any pain that comes with passive stretching of fingers. The key aspect of pre-hospital assessment is to analyze the mechanism of injury as well as the time of its occurrence. It is also essential to consider the position of the body during and after the injury. Secondly, one has to take into account if the pain is localized, deep, if it has been gradually increasing or if any motion results in greater intensity. The symptoms and complications associated with DVT can also come in handy in identifying compartment syndrome (Newman and Deo, 2014). By blocking normal blood flow in the pulmonary artery, the supply of oxygen becomes limited, and in most cases, this has a direct impact on the respiration. The respiratory distress accruing from pulmonary embolism often reduces the available surface area that is available for gaseous exchange. In this case, therefore, tiredness and general body weakness can be used to identify the presence of pulmonary embolism.
Problems Associated With Compartment Syndrome due to DVT
Various complications can be noted in relation to the compartment syndrome. First of there is the risk of limb amputation due to extreme damage to the muscle resulting in a functional loss in the affected limb. Immobility is another challenge which comes about as a result of extreme damage in the affected muscle. Compartment syndrome due to DVT can also result in pulmonary embolism which can cause death. While pulmonary embolism is hard to detect, it is essential for a paramedic to take note of incidences such as shortness of breath as well as pain during deep breathing. There is also the aspect of chest pains, which can be described by patients as a feeling of heaviness in the entire chest (Newman and Deo, 2014). Maintaining a heightened sense of suspicion becomes vital for paramedics. For instance, the use of vasodilators to alleviate compartment pressure can exacerbate the occurrence of pulmonary embolism.
Increasing the size of the veins can result in the blood clot breaking loose and traveling to the lung where it causes blockage in the pulmonary artery. For a paramedic, the identification of pulmonary embolism should be followed by an immediate administration of anticoagulants such as heparin to help minimize the clot before delivering the patient to the emergency room upon arriving at the hospital. Anticoagulants are vital in thinning the blood to minimize the size of the existing clot as well as impede its expansion within the vein. In case that the patient is conscious, the patient should be provided with a high flow of oxygen. Tissue necrosis is another complication associated with delayed or ignored reduction of pressure within compartment muscles. Tissue necrosis comes about as result of oxygen deprivation within tissues in the affected muscle. If left unattended, tissue necrosis can result in total muscle breakdown; a condition referred to as rhabdomyolysis. Muscle breakdown not only results in possible limb amputation, but it can also cause considerable damage to the kidney and renal failure.
How to Treat In a Prehospital Emergency Care for Compartment Syndrome due to DVT
For a paramedic, the focus is on making a timely diagnosis as well as minimizing pain. This, therefore, means one has to focus on decreasing tissue pressure, reinstating the flow of blood and minimizing the functional loss. Ideally, compartment syndrome is treated through the surgical removal of the blood clot in the case of DVT. For a paramedic, however, the primary goal should be to relive the external causes for the compartment pressure. The pertinent procedures include the removal of external devices that increase or sustain the pressure, including casts and splints, constricting bandages as well as any occlusive dressings. Secondly, it is important to ensure that the injured limb is raised to the level of the heart. The idea is to ensure that the arterial-venous pressure gradient is sustained. Placing the limb above the heart often translates to a decreased arterial blood flow thus compromising perfusion.
The paramedic must also ensure that arterial pressure is maintained through hydration. Hydration is also essential in preventing hypotension which is has a significant impact on perfusion pressure. A number of medical treatments are available for the management of this condition. Vasodilators, antispasmodics, and mannitol are examples of medical options available for paramedics (Sippel, 2014). Hyperbaric oxygen has also been highlighted as a major treatment approach for compartment syndrome, more so in cases where immediate surgical treatment is not possible. Vasodilators are crucial in helping ease the pressure and allow for blood flow. The use of mannitol accrues from the fact that it is an edema reducer as well as a free-radical scavenger. The challenge of compartment syndrome as a result of DVT is that it can result in pulmonary embolism. In this case, therefore, pre-hospital attention should be directed at ensuring oxygenation and cardiac output are enhanced. In such a case, therefore, supplemental oxygen can be administered to help maintain the peripheral capillary oxygen saturation above 94% (Newman and Deo, 2014).
Conclusively, it is important to keep in mind that diagnosis of compartment syndrome is primarily tied to the presence of a swelling as well as severe pain relative to the injury. It is also worth noting that the pain tends to increase with passive stretching and limb elevation. The paramedic has one of the greatest responsibility when it comes to proper management of compartment syndrome. Timely diagnosis allows for the employment of appropriate preventive measures that reduce any further damage or ischemia. It is important to acknowledge the complexity that comes with identifying the existence of compartment syndrome, more so when it is caused by deep vein thrombosis. A paramedic has the mandate to cultivate a sense of keen awareness of every external and internal symptom at their disposal. Amputations and other severe outcomes can easily be eliminated by the decisions and actions of paramedics.
References
Sippel, R. E. (2014). EMS Recap: Compartment syndrome of the extremities. EMS World . Retrieved on 2 February 2018, from https://www.emsworld.com/article/12016910/compartment-syndrome-of-the-extremities.
Newman, P. A., & Deo, S. (2014). Non-traumatic compartment syndrome secondary to deep vein thrombosis and anticoagulation. BMJ case reports , 2014 , bcr2013201689.
Schmidt, A. H., Bosse, M. J., Frey, K. P., O'Toole, R. V., Stinner, D. J., Scharfstein, D. O., ... & MacKenzie, E. J. (2017). Predicting acute compartment syndrome (PACS): The role of continuous monitoring. Journal of orthopaedic trauma , 31 , S40-S47.
Torlincasi, A. M., & Waseem, M. (2017). Compartment syndrome, extremity . StatPearls [Internet].
