Case of the Month
September 2005

52-year-old male - leg injury

Dispatch
"Engine 34, Aid 34, report of a 52-year-old male with a leg injury, possibly pinned under a car." En route your crew discusses the following considerations:

• Need for a rescue tool
• Aid vs. medic transport
• Extent of injury

Scene Survey
You arrive at a residence and the wife of the patient leads you into the garage. You find a male patient lying on the ground pinned under the front end of the vehicle. The block of wood that had been supporting the front end of the car kicked out and the car fell on to the patient. The wheel and front left suspension had been removed allowing a section of the frame to drop to the ground. His leg is pinned between the frame and the garage floor. The auto is stable and there are no other hazards.

Initial Assessment
The patient is in considerable pain and reports he cannot feel his foot. There is blood on the floor and on his pants but not a significant amount. The patient is pale and diaphoretic. He is alert and complains of no other injuries. Your partner takes an initial assessment which includes the following information:

CC/MOI	—	Leg pinned under an automobile, complaining of lower leg pain
RR	—	26/min
Pulse	—	Radial at 110/min
Mental Status	—	Alert: knows person, place, time, and events
Skin	—	Pale, with wet skin
Body Position	—	Lying on floor, lower leg trapped under car

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Short report to dispatch?
• Upgrade the call to a medic response?

Initial Treatment
You decide that this patient is SICK based on mechanism of injury and skin signs. You request a medic unit and give a short report that includes the information above. You begin administering oxygen at a flow rate to meet the patient's needs using a non-rebreathing mask. You initiate measures to keep the patient warm.

Engine 34 provides a hydraulic rescue tool and airbags to safely lift the car off the patient's leg. In the meantime the patient is warmed using blanket both below and on top of him. The patient is shivering and has become slightly hypothermic from being motionless on the cold garage floor. Once the car is lifted and the patient removed, it is found that he has a crushed lower left leg with extensive tissue damage and severe swelling. The patient's foot is cool, pale, pulseless and lacks sensation. The leg is splinted.

Physical Exam
Your partner gives you the following:

HEENT	—	Pale and sweaty. You notice alcohol on his breath.
Chest	—	No obvious trauma. Bilateral breath sounds, equal.
Abdomen	—	No complaint
Extremities	—	Left lower leg was pinned under the car. Once removed it is evident that it has been crushed with severe bruising and distal loss of pulses and sensation (consider compartment syndrome)
Neuro	—	Alert, knows person, place, time, and events

SAMPLE

S	What are the signs and symptoms?	Lower left leg pain and loss of feeling
A	Are you allergic to any medication?	None
M	Are you currently taking any medication?	Cholesterol med, unknown name, Lotensin for high blood pressure
P	Any medical history I should know about?	HTN and High cholesterol
L	When was the last time you ate or drank anything? What was it?	Ate breakfast this morning, about 6 hours ago, had "a few beers" for lunch
E	How did this happen?	Car fell off of makeshift jacks pinning the patient's leg to the floor. As he was prying on one of the linkages he noticed the vehicle shift. He started to move out from under the car but one of the improvised jacks kicked out and the car landed on his left lower leg. This occurred about three hours ago-just after his wife left to go shopping. When she returned she found him and called 911.

Second Set of Vital Signs

Respirations	—	24 and non-labored
Pulse	—	Radial at 110--full and regular
BP	—	130/76
Breath Sounds	—	Equal with good tidal volume

The EMTs package the patient. The medics arrive and transport him to the local emergency room. In the emergency room the patient is found to have compartment syndrome of the left lower leg. The tissue is opened from knee to ankle (fasciotomy) to relieve pressure inside the fascia. This allows for the reperfusion of the leg and return of sensation. Next the fracture is reduced and splinted. This is only temporary, as the eventual fix will require a rod and screw. The patient recovers with full function in his foot but has extensive scarring of his leg and requires several months of rehab to regain 95% function.

Compartment Syndrome
Compartment syndrome is a condition in which increased pressure within a muscle compartment causes a decrease in blood supply to the affected muscles. A compartment is a group of muscles surrounded by inelastic fascia. Swelling of muscle tissues leaves no room for expansion and blood supply is progressively reduced.

Compartment syndrome can be acute -- as is seen in high-energy trauma (e.g., car accidents) and burns -- or chronic, which is seen as an overuse injury in an athlete. The acute situation is generally a medical emergency since rapidly increasing pressure may completely cut off blood flow and cause necrosis of the affected limb. It can cause complications such as chronic disability or rhabdomyolysis with acute renal failure.

Traditionally, treatment of acute compartment syndrome involves surgical intervention. Large longitudinal incisions are made in each of the affected compartments. These incisions are left open to allow for the swelling. Infection is a risk for this procedure and prolonged rehabilitation is often necessary.

The lesson learned from this case
Acute compartment syndrome is an acute emergency. EMS providers need to maintain a high index of suspicion in cases of severe trauma or crush injury, especially if patient complaints seem to outweigh physical findings. Acute surgical fasciotomy is an effective treatment and should be carried out quickly by trained medical personnel if compartment pressures are suspected.

View the History and Causes sections of this article about rhabdomyolysis (external link: eMedecine.com)