A 24-year-old woman is admitted to the hospital after a motor vehicle accident resulted in a right humerus fracture, multiple rib fractures, and a contusion over her right leg. The patient receives multiple packed red blood cell transfusions. Chest and abdominal evaluation show a right-sided hemothorax. A chest tube is inserted. Pain is controlled with intravenous morphine. The next morning, she has a crawling and burning sensation and worsening pain in her right leg despite repeated doses of morphine. Temperature is 37.2 C (99 F), blood pressure is 140/82 mm Hg, heart rate is 96/min, and respirations are 18/min. The right leg is swollen and tense. Pulses are palpable in both lower extremities. Laboratory results this morning are as follows:
Which of the following is the best next step in management of this patient?

Question

A 24-year-old woman is admitted to the hospital after a motor vehicle accident resulted in a right humerus fracture, multiple rib fractures, and a contusion over her right leg.  The patient receives multiple packed red blood cell transfusions.  Chest and abdominal evaluation show a right-sided hemothorax.  A chest tube is inserted.  Pain is controlled with intravenous morphine.  The next morning, she has a crawling and burning sensation and worsening pain in her right leg despite repeated doses of morphine.  Temperature is 37.2 C (99 F), blood pressure is 140/82 mm Hg, heart rate is 96/min, and respirations are 18/min.  The right leg is swollen and tense.  Pulses are palpable in both lower extremities. Laboratory results this morning are as follows:
 Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Rapidly worsening limb pain and swelling with paresthesias in a crush injury (evidenced by leg hematoma) is highly concerning for acute compartment syndrome (CS). Measurement of tissue pressures is diagnostic: Pressure >30 mm Hg or delta pressure (diastolic blood pressure − compartment pressure) <20-30 mm Hg indicates significant CS. Serial measurements should be performed even if initial pressures are within normal limits. If compartment pressures are improving, patients may be observed closely. Patients with elevated compartment pressures not improving rapidly require fasciotomy to avoid permanent loss of function from nerve and muscle injury. (Choice A) Blood cultures would be indicated in complicated lower-extremity cellulitis that may also present with pain and swelling. However, unlike CS, the leg is usually warm and erythematous and neurologic symptoms are absent. (Choice B) Creatine kinase (CK) levels may be elevated in patients with crush injury with or without CS and may be helpful for predicting possible renal injury. However, waiting for CK level results may unnecessarily delay the more important diagnosis of CS. (Choice D) Red blood cell transfusion would be indicated when hemoglobin (Hgb) is <7 g/dL. When Hgb is 8-10 g/dL, transfusion may be indicated in symptomatic patients or due to ongoing bleeding. This patient has stable hemodynamics and is unlikely to have ongoing bleeding. Red blood cell transfusion (Choice E) Deep venous thrombosis (DVT) may also present with increasing pain and swelling, but symptoms are more insidious in onset and less severe. The presence of neurologic symptoms makes CS more likely due to nerve ischemia. Full therapeutic dose anticoagulation would be indicated if Doppler ultrasonography reveals venous thrombosis; otherwise, a DVT prophylaxis dose would be sufficient. Educational objective: Direct measurement of compartment or tissue pressure is the diagnostic procedure of choice in patients with suspected acute compartment syndrome. Serial measurements should be performed even if initial pressure is within normal limits. References: The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/23595064)

A 24-Year-Old Woman Is Admitted to the Hospital After a Motor