9.2 Core Workflows and Decision Points

Compartment Syndrome: The Highest-Yield Workflow

Acute compartment syndrome (ACS) occurs when pressure inside a closed fascial compartment rises high enough to collapse capillary perfusion, causing ischemia of muscle and nerve. Common triggers: tibial and forearm fractures, crush injuries, tight casts, burns, and reperfusion after vascular repair.

The tested hallmark is the 6 Ps: Pain (out of proportion, worsened by passive stretch of the muscles-the single most sensitive early sign), Paresthesia, Pallor, Poikilothermia (coolness), Pulselessness, and Paralysis. The trap the CEN sets: pulselessness and paralysis are late findings. A limb with intact pulses is not reassuring-by the time the pulse is lost, muscle and nerve may already be dead.

The time pressure is steep: irreversible muscle and nerve damage begins after roughly 4-6 hours of ischemia, which is why a suspected compartment syndrome is escalated immediately rather than trended over a shift. Reliable warning signs in an awake patient are the subjective ones-disproportionate pain and a sense of tightness-so a sedated, intubated, or regional-block patient who cannot report pain is at especially high risk and warrants a low threshold for direct pressure measurement.

The delta-P threshold and immediate nursing actions

Diagnosis is confirmed by measuring intracompartmental pressure. The exam-tested rule uses delta P:

Delta P = diastolic blood pressure - measured compartment pressure. A delta P of 30 mmHg or less indicates the need for emergent fasciotomy. Absolute compartment pressure >30-40 mmHg is also an indication.

Fasciotomy should ideally occur within ~6 hours to preserve muscle. Nursing priorities while awaiting the surgeon:

Elevation feels intuitive for swelling but is wrong in suspected ACS-it drops perfusion pressure.

Traumatic Amputation: Hemorrhage First, Then the Part

The workflow order is fixed and frequently tested. Patient before part.

1. Control hemorrhage - direct pressure first; if uncontrolled, apply a tourniquet proximal to the injury and note the time. Treat for hypovolemic shock (large-bore IVs, blood as needed).
2. Preserve the amputated part to maximize replantation viability. Wrap the part in saline-moistened sterile gauze, place it in a sealed plastic bag, then place that bag in a container of ice water (or on ice). The part must never touch ice directly and must never be submerged in water or saline, which causes frostbite or maceration and ruins the tissue.
3. Transport part with the patient to a replantation-capable center; label with patient name and time.

Cold ischemia tolerance is roughly 12-24 hours for a properly cooled part versus only ~6 hours if left warm, so correct preservation can be the difference for replantation.

Open Fracture and Contaminated Wound Pathway

An open fracture combines a fracture with a skin/soft-tissue wound, classed by the Gustilo-Anderson system (Type I clean, <1 cm wound; Type II 1-10 cm; Type III extensive contamination/soft-tissue loss). All open fractures share one emergency pathway:

• Cover with a sterile saline-moistened dressing; do not reduce exposed bone back under the skin.
• Early IV antibiotics (within hours of injury) - delay is the strongest modifiable predictor of infection.
• Tetanus prophylaxis assessment (covered in 9.3).
• Irrigation and surgical debridement in the OR; splint for transport.

For any wound, the nurse also estimates blood loss, applies direct pressure for bleeding, and removes gross contamination, deferring deep exploration to definitive care.

Hemorrhage Control: The Stepwise Algorithm

Because musculoskeletal trauma is a leading source of preventable death from exsanguination, the CEN tests a fixed escalation for external bleeding:

1. Direct pressure with a gauze dressing-the first and most effective step for most wounds.
2. Pressure dressing and continued manual pressure if bleeding persists.
3. Tourniquet placed proximal to the wound when direct pressure fails or for a mangled/amputated extremity; tighten until bleeding stops and document the time applied. A tourniquet is not loosened in the field once placed.
4. Hemostatic dressing for junctional wounds (groin, axilla) not amenable to a tourniquet.

The trap is choosing "elevate the limb" or "apply a proximal pressure point" before maximizing direct pressure; current trauma practice favors direct pressure then tourniquet.

Wound Infection: Recognition and the Time Factor

Wound infection is the downstream complication that ties this domain together. Local signs are erythema, warmth, swelling, increasing pain, and purulent drainage, sometimes with fever or red streaking (lymphangitis) tracking proximally. Risk rises with contamination, devitalized tissue, retained foreign bodies, delayed closure, bites, and diabetes or immunocompromise. The single most important prevention measure remains copious pressure irrigation with normal saline, plus debridement of dead tissue and judicious prophylactic antibiotics for high-risk wounds (bites, open fractures, heavily contaminated injuries).

For an open fracture specifically, antibiotic timing-getting the first IV dose in early-is the strongest modifiable predictor of whether the bone becomes infected, which is why it sits in the immediate workflow rather than later care.