Interesting Case of extremity weakness

 

 

HPI 

41 y.o. female PMHx familial hypokalemic periodic paralysis p/w weakness. 

  • Mechanical fall from bed after a night of binge drinking. 
  • Awoke with RUE, RLE weakness
  • Notes hx weakness in past secondary to hypokalemia but never this severe

 

Physical Exam

BP 120/77  | Pulse 91 | Temp 98.8 °F (37.1 °C) (Oral)  | Resp 15 | SpO2 93%

  • Distal R-sided extremities cold to touch
  • Pulses intact 
  • 2/5 strength in RUE/RLE

 

DDX

  • CVA, ICH, hypokalemic periodic paralysis, peripheral nerve palsy, cervical neck/sacral injury, rhabdomyolysis

 

Management

  • Stroke alert → imaging unrevealing for acute abnormality
  • Labs results: hyperkalemia (8.4), elevated Cr (1.52), CK 63,780, 3+ blood on UA
  • Re-examined patient → improving RUE strength but remains weak RLE with significant pain in the right hip and thigh
    • R gluteal compartment: firm and tender → compartment pressure 34 mmhg
  • Level 1 OR for gluteal compartment syndrome

 

Take Home Points

  • ALWAYS fully examine the patient!
  • Compartment syndrome
    • Causes: fractures AND soft tissue injuries
      • Soft tissue injuries: crush, exertional, prolonged immobilization, tissue infection, seizures, burns
    • Complicated by rhabdo, renal failure
    • 6P’s: pain, pallor, pulselessness, paralysis, paresthesia, poikilothermia 
  • Compartment pressures indicating fasciotomy
    • Absolute > 30 mmHG
    • Delta pressure < 30 mmHG

 

For a refresher on direct measurement of compartment pressures - click here!