Compartment syndromes in obtunded patients.

A high index of suspicion for a compartment syndrome in the upper extremity should be maintained in all obtunded patients who are at risk for the condition. Obtunded patients are those with a dulled or altered physical or mental status secondary to injury, illness, or anesthesia; those with diminished or absent sensation in the upper extremity because of nerve injury or anesthesia; and those whose ability to communicate is impeded, such as infants and young children and the mentally ill or disabled. These patients represent a vulnerable group whose inability to demonstrate the hallmark symptoms and signs of the syndrome puts them in jeopardy of a late diagnosis of a compartment syndrome and its potentially devastating sequelae. The most likely causes of a compartment syndrome in this population are skeletal or soft-tissue trauma, prolonged limb compression, thrombolytic therapy after myocardial infarction, arterial or intravenous fluid administration, and upper extremity Surgery. Whenever a compartment syndrome of the hand, forearm, or upper arm is suspected, the obtunded patient should be examined closely and frequently, and any changes over time should be documented carefully. Intracompartmental pressure measurement provides a useful adjunct to the physical examination and history in these patients and may be diagnostic if other symptoms and signs are obscured. Once the compartment syndrome is diagnosed, emergent fasciotomy is indicated. To avoid a loss of function in the obtunded patient, special care must be taken postoperatively to assure that early motion exercises are carried out.