# A 50-year-old construction worker is admitted to the emergency department 6 hours after sustaining a closed fracture of the right tibia and fibula from a fall. The patient reports severe, unrelenting pain in the right lower leg that is not relieved by prescribed analgesics. On assessment, the nurse notes the patient's right foot is pale, cool to touch, and capillary refill is 4 seconds. The patient states he cannot feel his toes and is unable to dorsiflex his foot. What is the nurse's priority action?

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## 문제

A 50-year-old construction worker is admitted to the emergency department 6 hours after sustaining a closed fracture of the right tibia and fibula from a fall. The patient reports severe, unrelenting pain in the right lower leg that is not relieved by prescribed analgesics. On assessment, the nurse notes the patient's right foot is pale, cool to touch, and capillary refill is 4 seconds. The patient states he cannot feel his toes and is unable to dorsiflex his foot. What is the nurse's priority action?

The nurse is caring for a patient with a tibial fracture who is developing signs of compartment syndrome.

## 보기

1. Administer additional pain medication as ordered
2. Notify the physician immediately for emergency fasciotomy **✔ 정답**
3. Elevate the affected extremity above heart level
4. Apply ice packs to reduce swelling and inflammation

**정답: 2**

## 해설

The patient shows signs of compartment syndrome (pain, pallor, paresthesia, paralysis), a surgical emergency requiring immediate fasciotomy to prevent tissue damage. Other options are contraindicated as they can worsen ischemia.

## 심화 해설

This question presents a classic clinical picture of acute compartment syndrome, a limb-threatening emergency that requires immediate surgical intervention. The nurse's priority action is to recognize the syndrome and facilitate definitive treatment.

The patient's history of a closed tibia-fibula fracture is a major risk factor, as bleeding and edema within the confined osteofascial compartments can drastically increase intracompartmental pressure. The hallmark symptom is severe, unrelenting pain that is disproportionate to the injury and unresponsive to analgesics. This pain is ischemic in nature, caused by rising pressure that collapses capillaries and deprives muscles and nerves of oxygen. The classic description of rest pain in the context of vascular compromise is a critical finding [1]. The assessment data confirms the progression of ischemia: the pale, cool foot with a capillary refill of 4 seconds indicates arterial insufficiency, while the sensory loss (inability to feel toes) and motor deficit (inability to dorsiflex) signify progressive nerve and muscle damage. These are late and ominous signs of irreversible injury.

The nurse's priority action is to immediately notify the physician, as definitive treatment for compartment syndrome is an emergency fasciotomy to relieve the pressure and restore tissue perfusion. Any delay can lead to irreversible muscle necrosis, nerve damage, and eventual limb amputation, a significant adverse limb event highlighted in the context of vascular pathology [1].

The incorrect options are dangerous because they delay definitive care or worsen the condition.

- Administering additional pain medication is inappropriate because the pain is a critical diagnostic symptom of ischemia, not a simple nociceptive pain problem. Masking it without addressing the underlying cause will only delay the fasciotomy.

- Elevating the affected extremity above heart level is contraindicated. Elevation decreases arterial perfusion pressure, further worsening the ischemia in an already compromised limb.

- Applying ice packs is also contraindicated. Cold causes vasoconstriction, which will further reduce blood flow to the hypoxic tissues, accelerating tissue damage.References (research sources)

- [1]Clinical Assessment of Peripheral Arterial Disease in the Office: What Do the Guidelines Say?GuidelineTummala S, Scherbel D. (2018) · DOI: 10.1055/s-0038-1676453

## 임상 시나리오

Acute Compartment Syndrome: Emergency ResponseRecognizing the 6 P's and Acting Immediately
The priority for suspected compartment syndrome is immediate physician notification for an emergency fasciotomy. This is a limb-threatening emergency where intracompartmental pressure exceeds 30 mmHg, causing muscle and nerve ischemia.

The hallmark sign is pain disproportionate to the injury that is unrelenting and unresponsive to opioids. Late findings include paresthesia, paralysis (e.g., inability to dorsiflex), and pulselessness, which indicate irreversible damage.

CautionNever elevate the limb above the heart as it reduces arterial inflow. Do not apply ice, which causes vasoconstriction. Both actions worsen ischemia and are contraindicated.

## 핵심 개념

- **Compartment Syndrome** — A limb-threatening condition where increased pressure within a confined fascial space compromises circulation, leading to muscle and nerve ischemia.
- **Fasciotomy** — A surgical procedure where the fascia is cut to relieve pressure and restore tissue perfusion, the definitive treatment for acute compartment syndrome.
- **6 P's of Compartment Syndrome** — Classic assessment findings: Pain (disproportionate), Pallor, Pulselessness (late sign), Paresthesia, Paralysis, Poikilothermia.
- **Capillary Refill** — A test of peripheral perfusion; a time greater than 3 seconds indicates poor arterial flow.
- **Dorsiflexion** — Movement of the foot upward toward the shin; inability to perform this indicates motor nerve deficit from anterior compartment ischemia.

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