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surgery.compartment-syndrome.core.v1PRODUCTION
surgery.compartment-syndrome.core.v1

Acute Extremity Compartment Syndrome

emergencyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm extremity compartment syndrome scope; differentiate from DVT, arterial occlusion, cellulitis (AAOS 2019)

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ACS in differential

Patient inputs (12)

Pediatric ACS presents with 3-A sign — anxiety + agitation + increasing analgesic requirement; alters threshold (AAOS 2019)

Fracture / crush / reperfusion / burn / cast / IV infiltrate -> different risk profiles (AAOS 2019)

Rhabdomyolysis monitoring; CK >5000 -> aggressive volume + bicarb for AKI prevention (AAOS 2019)

AKI risk from rhabdo; baseline for trending (AAOS 2019)

Hyperkalemia from muscle necrosis (AAOS 2019)

DBP enters delta-P calculation; hypotension lowers DBP and raises ACS risk at lower compartment pressures (McQueen 1996 PMID 8898137)

Delta-P = DBP minus compartment pressure; <30 mmHg = fasciotomy (McQueen 1996 PMID 8898137)

Anticoagulation raises bleeding into compartment risk (AAOS 2019)

Cannot self-report pain — REQUIRES pressure measurement (AAOS 2019)

Distal SpO2 + pulse — present early in ACS, absent late (do not rely on for diagnosis) (AAOS 2019)

Myoglobinuria: positive blood on dipstick without RBCs (AAOS 2019)

Ischemic muscle marker (AAOS 2019)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningdelta_p_below_30_emergent_fasciotomy
    Delta-P (DBP minus compartment pressure) <30 mmHg in awake or sedated patient — fasciotomy within 6 hours (McQueen 1996 PMID 8898137)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninglate_p_signs_pallor_paresthesia_paralysis
    Pallor + paresthesia + paralysis + pulselessness — late ACS with poor recovery expected (AAOS 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererhabdomyolysis_post_compartment
    CK >5000 + myoglobinuria + rising creatinine — rhabdomyolysis-induced AKI (AAOS 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_3a_sign
    Pediatric patient with anxiety + agitation + escalating analgesic requirement (3-A sign) — high-suspicion ACS even without classic Ps (AAOS 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresedated_obtunded_at_risk_limb
    Intubated / sedated / obtunded patient with high-risk mechanism (tibia fracture, crush, reperfusion) — REQUIRES compartment pressure measurement (cannot self-report pain) (AAOS 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acute compartment syndrome — fasciotomy + rhabdo / AKI prevention (AAOS 2019; McQueen 1996)
axis: compartment_syndrome_pathwaystep 1 - Step 1 — Emergent decompression (NOT a drug step — included for completeness)
Selected step "Step 1 — Emergent decompression (NOT a drug step — included for completeness)" — Delta-P <30 mmHg OR clinical ACS with appropriate risk factors
  • fasciotomy_all_compartments
    first line
    surgical_decompression
    OR within hours; all 4 leg compartments (anterior / lateral / superficial posterior / deep posterior) or 3 forearm (volar / dorsal / mobile wad) • surgical • one-time
    triggers: delta_P_below_30, late_signs_pallor_paresthesia_paralysis, rising_CK_with_tense_compartment
    DEFINITIVE — pharmacotherapy does not treat ACS; only decompression. <6h = ~100% recovery; >12h = poor outcome (AAOS 2019; McQueen 1996 PMID 8898137)
  • remove_circumferential_compression
    first line
    mechanical_decompression
    Bivalve cast / cut bandage / escharotomy for circumferential burn • procedure • one-time
    triggers: tight_cast_or_bandage, circumferential_burn_eschar
    Often resolves ACS without fasciotomy if cast / bandage is sole cause (AAOS 2019)

ed playbook — drug actions (4)

  1. 1. IV crystalloid
    LR or NS 1.5 L/h if rhabdo signs, titrate UOP 200-300 mL/h adult • IV • continuous
    trigger: CK >5000 / myoglobinuria (AAOS 2019)
    Primary rhabdo / AKI prevention
  2. 2. fentanyl
    25-50 mcg IV q15min PRN • IV • q15min PRN
    trigger: Severe pain awaiting OR (AAOS 2019)
    Note: escalating opioid requirement IS a red flag for ACS — communicate to surgeon
  3. 3. sodium bicarbonate
    150 mEq / 1L D5W @ 150-200 mL/h titrate urine pH >6.5 • IV • continuous
    trigger: Established rhabdo + acidemia (AAOS 2019)
    Urinary alkalinization (observational evidence)
  4. 4. NPO + anesthesia prep
    NPO; bivalve cast / remove circumferential dressing • mechanical • pre-op
    trigger: Fasciotomy planned (AAOS 2019)
    Pre-op + remove reversible cause

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Pain out of proportion to injury (EARLIEST sign) (AAOS 2019); Pain with passive stretch of compartment muscles (EARLY) (AAOS 2019); Tense, woody compartment on palpation (AAOS 2019).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Extremity Compartment Syndrome** (surgery.compartment-syndrome.core.v1).
Phenotype framing: ACS vs phlegmasia cerulea dolens (DVT) vs acute limb ischemia (arterial) vs cellulitis vs DVT vs nerve injury (AAOS 2019)
Scope: Confirm extremity compartment syndrome scope; differentiate from DVT, arterial occlusion, cellulitis (AAOS 2019)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute compartment syndrome — fasciotomy + rhabdo / AKI prevention (AAOS 2019; McQueen 1996)** — step "Step 1 — Emergent decompression (NOT a drug step — included for completeness)".
1. fasciotomy_all_compartments OR within hours; all 4 leg compartments (anterior / lateral / superficial posterior / deep posterior) or 3 forearm (volar / dorsal / mobile wad) surgical one-time (surgical_decompression, first line) — DEFINITIVE — pharmacotherapy does not treat ACS; only decompression. <6h = ~100% recovery; >12h = poor outcome (AAOS 2019; McQueen 1996 PMID 8898137)
2. remove_circumferential_compression Bivalve cast / cut bandage / escharotomy for circumferential burn procedure one-time (mechanical_decompression, first line) — Often resolves ACS without fasciotomy if cast / bandage is sole cause (AAOS 2019)

Setting playbook (ed) — Recognize early signs (pain out of proportion, pain with passive stretch); measure compartment pressure in equivocal or sedated patients; emergent OR for fasciotomy if delta-P <30 mmHg; initiate rhabdo / AKI prevention (AAOS 2019)
3. IV crystalloid LR or NS 1.5 L/h if rhabdo signs, titrate UOP 200-300 mL/h adult IV continuous — CK >5000 / myoglobinuria (AAOS 2019) (Primary rhabdo / AKI prevention)
4. fentanyl 25-50 mcg IV q15min PRN IV q15min PRN — Severe pain awaiting OR (AAOS 2019) (Note: escalating opioid requirement IS a red flag for ACS — communicate to surgeon)
5. sodium bicarbonate 150 mEq / 1L D5W @ 150-200 mL/h titrate urine pH >6.5 IV continuous — Established rhabdo + acidemia (AAOS 2019) (Urinary alkalinization (observational evidence))
6. NPO + anesthesia prep NPO; bivalve cast / remove circumferential dressing mechanical pre-op — Fasciotomy planned (AAOS 2019) (Pre-op + remove reversible cause)

Non-pharmacologic actions:
- Limb at HEART LEVEL — neither elevated (worsens delta-P at compartment) nor dependent (AAOS 2019)
- Cut / bivalve any constricting cast or dressing IMMEDIATELY (AAOS 2019)
- NPO (pre-op) (AAOS 2019)
- Foley if rhabdo / AKI (UOP monitoring) (AAOS 2019)
- STAT orthopedic / GS / vascular consult (AAOS 2019)
- Mark suspected compartments + reassess q30-60min (AAOS 2019)
- AVOID peripheral nerve block in suspected ACS limb (masks pain) (AAOS 2019)

AVOID / contraindication checks:
- Do_not_use_NSAID_or_ketorolac_pre_or_intraop_fasciotomy (AAOS 2019)
- Avoid_mannitol_in_oliguric_AKI (AAOS 2019)
- Do_not_close_fasciotomy_primary_at_index_OR (AAOS 2019)
- Peripheral_nerve_block_masks_ACS_do_not_use_in_at_risk_limb (AAOS 2019)
- Epidural_analgesia_may_mask_ACS_use_caution (AAOS 2019)

Monitoring

Regimen monitoring:
- CK q4 to 6h x 24 to 48h until trending down (AAOS 2019)
- K creatinine lactate q4 to 6h x 24h post fasciotomy (AAOS 2019)
- UOP target above 0.5 mL kg h adult above 1 mL kg h with rhabdo (AAOS 2019)
- urine dipstick for myoglobinuria (AAOS 2019)
- compartment exam q1h x 24h post fasciotomy (AAOS 2019)
- peroneal nerve function pre and post op (AAOS 2019)

Setting (ed) monitoring:
- Compartment / neurovascular exam q30-60min until OR (AAOS 2019)
- UOP hourly if rhabdo (AAOS 2019)
- CK / K / Cr q4-6h (AAOS 2019)

Follow-up plan: Delayed primary closure / skin graft, PT for nerve recovery (Volkmann prevention), orthopedic follow-up at 2 weeks, peroneal nerve assessment (AAOS 2019)
- Close-out criterion: reconstruction + rehab scheduled

Monitoring phase: Serial CK / BMP q4-6h x 24h; UOP target >0.5-1 mL/kg/h; wound check daily; delayed primary closure / skin graft at 3-7 days (AAOS 2019)

Disposition

Current setting: ed — Recognize early signs (pain out of proportion, pain with passive stretch); measure compartment pressure in equivocal or sedated patients; emergent OR for fasciotomy if delta-P <30 mmHg; initiate rhabdo / AKI prevention (AAOS 2019)

Disposition criteria:
- OR (orthopedic / GS / vascular) emergent -> fasciotomy of all involved compartments (AAOS 2019)
- ICU post-op if significant rhabdo / AKI / shock / fluid burden (AAOS 2019)
- Ward post-op if isolated fasciotomy, no rhabdo, stable (AAOS 2019)

Escalation triggers (move to higher acuity):
- Delta-P <30 mmHg OR clinical ACS with risk factors -> STAT OR (AAOS 2019; McQueen PMID 8898137)
- Late P signs (pallor, paresthesia, paralysis, pulselessness) -> emergent OR (AAOS 2019)
- CK >5000 or rising + oliguria -> ICU resuscitation post-fasciotomy (AAOS 2019)
- Hyperkalemia with EKG changes -> hyperK protocol (AAOS 2019)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Delta-P (DBP minus compartment pressure) <30 mmHg in awake or sedated patient — fasciotomy within 6 hours (McQueen 1996 PMID 8898137)
- [LIFE_THREATENING] Pallor + paresthesia + paralysis + pulselessness — late ACS with poor recovery expected (AAOS 2019)
- [SEVERE] CK >5000 + myoglobinuria + rising creatinine — rhabdomyolysis-induced AKI (AAOS 2019)

Citations

- AAOS Clinical Practice Guideline on the Management of Acute Compartment Syndrome 2019 + McQueen 1996 J Bone Joint Surg Br — delta-P <30 mmHg threshold for fasciotomy [PMID:8898137](https://pubmed.ncbi.nlm.nih.gov/8898137/)
- Cited evidence (PMID 1192674) [PMID:1192674](https://pubmed.ncbi.nlm.nih.gov/1192674/)
- Cited evidence (PMID 24973422) [PMID:24973422](https://pubmed.ncbi.nlm.nih.gov/24973422/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AAOS Clinical Practice Guideline on the Management of Acute Compartment Syndrome 2019 + McQueen 1996 J Bone Joint Surg Br — delta-P <30 mmHg threshold for fasciotomy — PMID:8898137
  • Cited evidence (PMID 1192674) — PMID:1192674
  • Cited evidence (PMID 24973422) — PMID:24973422