Tuesday Advanced Cases

Critical Cases – Compartment Syndrome!

by Carlos Cevallos M.D.


A 60 year old male with a PMH of DM, HTN, HLD, MI presents to the ED after being found down with waxing and waning mentation. The patient complains of abdominal pain and diffuse myalgias.

BP 76/56, HR 92, Temp 98.4F, RR 22. 

Physical exam

Pressure wounds of the right rib cage, right side of his forehead

Right calf tenderness with a firm anterior compartment, cool/pale right lower extremity, dorsalis pedis and posterior tibial pulses were unable to be palpated.


ECG interpretation: Peaked T waves, widened QRS concerning for hyperkalemia

Clinical course:

1L bolus of LR

IV calcium gluconate for possible hyperkalemia

Surgery was immediately consulted due to concern for compartment syndrome

Labs were notable for a potassium of 7.2, creatinine of 3.49, creatinine kinase of 188,760, a lactate of 4.0, and ALT/AST in the 3,000s/5,000s

Given intermittent hemodynamic instability a dialysis line was placed for definitive hyperkalemia management

Patient underwent emergent lower extremity fasciotomy with surgery

Compartment syndrome learning points:

·       Diagnosis is both clinical and by compartment pressure measurements

·       Compartment pressure >30mmHg or a delta pressure <30mmHg (diastolic BP – compartment pressure) is diagnostic

·       Clinical findings: 6Ps. Pain is the earliest and often only symptom, the rest are late findings.

o   Pain out of proportion to the exam (most common finding)

o   Pallor

o   Paresthesia

o   Paresis/paralysis

o   Pulselessness

o   Poikilothermia

·       Management: Immediate surgical consult for fasciotomy

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