Compartment syndrome in the critically injured following massive resuscitation: case reports

Bilateral thigh compartment syndrome following intraoperative pelvic binder reduction of open pelvic fracture: a case report and review of literature

CASE

A 22-year-old man with a type IIIA open AO/OTA 61C2.2b pelvis fracture and hypotension received exploratory laparotomy, temporary open ligation of the bilateral internal iliac arteries, and retroperitoneal packing. After prompt fracture debridement, a pelvic binder was positioned over the thighs as a reduction aid and maintained for six hours during pelvis open reduction internal fixation. Bilateral anterior thigh compartment syndrome was diagnosed three hours after packing and binder removal.

CONCLUSION

Prolonged application of a pelvic binder to the thighs as an intraoperative reduction tool, shortly after temporary internal iliac artery ligation, may be associated with reperfusion injury and thigh compartment syndrome.

Review article: A comprehensive review of unusual causes of acute limb compartment syndrome

Acute limb compartment syndrome (ALCS) is a surgical emergency that can have serious consequences unless promptly diagnosed and treated, which is particularly challenging when there is an unusual cause. This is a comprehensive review of reported causes of ALCS. From 1068 included articles, we found 299 discrete causes of ALCS including toxins, infections, endocrine pathology, haematological emergencies, malignancy and iatrogenic ALCS. Familiarity with this wide range of ALCS causes may assist in early diagnosis of this limb-threatening condition.

Postoperative extremity compartment syndrome in a cancer center: Incidence and risk factors

OBJECTIVE

Postoperative compartment syndrome is a reported complication with known patient- and treatment-specific risk factors. Cancer patients carry unique risk factors associated with their underlying disease and long, complex procedures. While elevated serum lactate in traumatic and intensive care settings portends higher risk, no laboratory parameter has demonstrated utility in postoperative risk stratification. Postoperative extremity compartment syndrome in the study institution's cancer population was examined and whether intraoperative serum lactate correlates with postoperative compartment syndrome risk was investigated.

METHODS

A 1:2 case-control study was performed, which compared cancer patients with postoperative compartment syndrome to those who underwent similar surgical procedures without this complication. Twelve patients were matched to 24 controls by sex, age, surgical procedures, and duration of surgery. Patient and operative variables were analyzed for prognostic significance.

RESULTS

The compartment syndrome rate was 0.09% of all cases (n = 13,491); 0.12% of cases ≥ 3 h' duration (n = 9,979), and 0.25% of cases ≥ 5 h (n = 4,811). Compared with controls, the case group had higher median BMI (31.7 kg/m2 vs. 25.4 kg/m2, P = 0.001), and median intraoperative lactate level (4.05 mmol/L vs. 1.5 mmol/L, P = 0.047).

CONCLUSION

Our institutional incidence of postoperative compartment syndrome was similar to that of non-oncologic institutions. While many traditional risk factors did not prove to be influential in our patients, elevated median body mass index and intraoperative serum lactate were identified as risk factors for postoperative compartment syndrome in a cancer population.

Preserving Vision: Rethinking Burn Patient Monitoring to Prevent Orbital Compartment Syndrome

Burn patients receiving aggressive fluid resuscitation are at risk of developing orbital compartment syndrome (OCS). This condition results in elevated orbital pressures and can lead to rapid permanent vision loss. Risk factors and monitoring frequency for OCS remain largely unknown. A retrospective review was therefore conducted of admitted burn patients evaluated by the ophthalmology service at an American Burn Association verified Burn Treatment Center. Demographic, burn, examination, and fluid resuscitation data were compared using two-sided t-tests, Fisher's exact tests, and linear regression. Risk factors for elevated intraocular pressures (IOPs; a surrogate for intraorbital pressure) in patients resuscitated via the Parkland formula were found to be total body surface area (% TBSA) burned, resuscitation above the Ivy Index (>250 ml/kg), and Parkland formula calculated volume. Maximum IOP and actual fluid resuscitation volume were linearly related. Analysis of all patients with elevated IOP found multiple patients with significant IOP increases after initial evaluation resulting in OCS within the first 24 hours postinjury. While %TBSA, Ivy Index, and resuscitation calculated volume are OCS risk factors in burn patients, two patients with facial burns developed OCS (25% of all patients with OCS) despite not requiring resuscitation. Orbital congestion can develop within the first 24 hours of admission when resuscitation volumes are the greatest. In addition to earlier and more frequent IOP checks in susceptible burn patients during the first day, the associated risk factors will help identify those most at risk for OCS and vision loss.

Regional anesthesia or patient-controlled analgesia and compartment syndrome in orthopedic surgical procedures: a systematic review

A systematic review of the literature on the use of regional anesthesia (RA) and patient-controlled analgesia (PCA) was conducted in patients who require orthopedic extremity procedures to determine whether either analgesic technique contributes to a delayed diagnosis of compartment syndrome (CS). A total of 34 relevant articles (28 case reports and six research articles) were identified. Of all case report articles published after 2009, the majority (75%) concluded that RA does not put the patient at an increased risk of a delayed diagnosis of CS. Of these, only two relevant prospective research studies focusing on RA or PCA and their relationship to CS were identified. Neither study resulted in any cases of CS. However, both had relatively small sample sizes. Given the lack of evidence identified in this systematic review, prospective studies or large-scale retrospective data reviews are needed to more strongly advocate the use of one modality of analgesia over the other in this patient population.

Compartment Syndrome following Open Femoral Fracture with an Isolated Femoral Vein Injury Treated with Acute Repair

Acute compartment syndrome is a surgical emergency and its diagnosis is more difficult in obtunded or insensate patients. We present the case of a 34-year-old woman who sustained a Gustilo-Anderson grade III open midshaft femur fracture with an isolated femoral vein injury treated with direct repair. She developed lower leg compartment syndrome at 48 hours postoperatively, necessitating fasciotomies. She was subsequently found to have a DVT in her femoral vein at the level of the repair and was started on therapeutic anticoagulation. This case highlights the importance of recognition of isolated venous injuries in a trauma setting as a risk factor for developing compartment syndrome.

Limb intracompartmental sepsis in burn patients associated with occult infection

BACKGROUND

Intracompartmental sepsis (IS) is a rare complication in burn patients. IS presents in patients with inadequate perfusion of intracompartmental tissues with subsequent ischaemic necrosis and infection. Contributing factors include high-volume resuscitation, delayed escharotomies and previous bacteraemias. We describe the profile of a series of patients who developed IS in our Intensive Care Burn Unit (ICBU).

METHODS

We carried out a retrospective chart review of patients admitted to an ICBU over a 5-year period.

RESULTS

Seven patients of 659 admissions (1.0%) developed IS involving the extremities. Diagnosis was based on the identification of purulent drainage and local swelling associated with signs of sepsis of unknown origin. Total body surface area (TBSA) burned averaged 67.4% and full-thickness body surface area (FTBSA) burned averaged 48.4%. All patients were sedated and mechanically ventilated. The first 24-h fluid requirements averaged 6.0 ml kg(-1) per %TBSA burn (range 3.5-7.0 ml kg(-1)per %TBSA). Escharotomies were performed in five patients within the first 24h of admission. Median time of diagnosis of IS was 23 days from admission (range 11-45 days). Four patients developed bacteraemia caused by the same microorganism infecting the soft tissue. In five cases, the infecting microorganism had previously colonised the overlying burned skin. Three patients required amputation of the affected limb.

CONCLUSION

IS is a devastating infectious complication which appears late after large burns. Predisposing factors include high-volume resuscitation, delayed escharotomies, colonisation of the overlying skin and previous bacteraemias. Earlier diagnosis and management are needed to attain a better outcome.

Blast injuries

Health-care providers are increasingly faced with the possibility of needing to care for people injured in explosions, but can often, however, feel undertrained for the unique aspects of the patient's presentation and management. Although most blast-related injuries (eg, fragmentation injuries from improvised explosive devices and standard military explosives) can be managed in a similar manner to typical penetrating or blunt traumatic injuries, injuries caused by the blast pressure wave itself cannot. The blast pressure wave exerts forces mainly at air-tissue interfaces within the body, and the pulmonary, gastrointestinal, and auditory systems are at greatest risk. Arterial air emboli arising from severe pulmonary injury can cause ischaemic complications-especially in the brain, heart, and intestinal tract. Attributable, in part, to the scene chaos that undoubtedly exists, poor triage and missed diagnosis of blast injuries are substantial concerns because injuries can be subtle or their presentation can be delayed. Management of these injuries can be a challenge, compounded by potentially conflicting treatment goals. This Seminar aims to provide a thorough overview of these unique primary blast injuries and their management.

Extended (16-hour) tourniquet application after combat wounds: a case report and review of the current literature

We present a case of emergency tourniquet use of unusually long duration. The patient was wounded during combat operations, and the subsequent battle and evacuation caused a significant delay in surgical treatment of his wounds. Emergency tourniquets can be lifesaving, but are not benign interventions. In general, the extent of tourniquet injury increases with increasing time of application. Despite having a tourniquet in place for 16 hours, the limb was salvaged and significant functional recovery was accomplished. We conducted a search of the published literature including the Medline database, and present a review of the relevant articles concerning emergency tourniquet use, tourniquet injury, and mitigating treatments. Given the widespread use of tourniquets in ongoing military operations, it seems likely that tourniquets will transition to civilian use. Thus it is important for physicians to understand tourniquet injury and appreciate that even extended tourniquet application times does not necessarily doom the affected limb.

Elevated Orbital Pressure: Another Untoward Effect of Massive Resuscitation after Burn Injury

BACKGROUND

Fluid resuscitation remains a fundamental component of early burn care management. However, recent studies suggest that excessive volumes of resuscitation are being administered. Overresuscitation results in negative sequelae including abdominal and extremity compartment syndromes. Elevated intraocular pressure (IOP) has been described as another potentially devastating effect of massive fluid resuscitation in trauma patients. The orbit, similar to the abdomen and extremity, is a compartment, limited to expansion from edema anteriorly by the eyelids and orbital septum, and posteriorly by the bony orbital walls. The purpose of this study was to review the incidence of elevated IOP in a series of patients with major burn injury.

METHODS

We retrospectively reviewed the charts of 13 consecutive patients admitted to our burn center with burn sizes >25% total body surface area (TBSA). All patients underwent serial IOP measurements for the first 72 hours following admission. Medical records were reviewed for fluid resuscitation volume, IOP measurements, need for canthotomy, and results of canthotomy procedures.

RESULTS

Five of 13 patients had IOP >30 mm Hg and required lateral canthotomy. Canthotomy immediately reduced IOP (p = 0.009). Patients who developed elevated IOP received a significantly larger fluid resuscitation (9.0 cc/kg/%TBSA versus 6.0 cc/kg/%TBSA, p = 0.02). Elevated IOP was significantly associated with delivery of larger fluid resuscitation volume (p = 0.027).

CONCLUSIONS

Massive fluid resuscitation following burn injury can result in orbital compartment syndrome requiring lateral canthotomy. Early diagnosis and treatment of orbital compartment syndrome should be incorporated into the management of patients with major burn injury receiving large fluid resuscitation volume.

Arterial injury associated with acute compartment syndrome of the thigh following blunt trauma

BACKGROUND

Acute compartment syndrome of the thigh is a rare condition, and the basic causes of high pressure within a muscle compartment have been considered to be intramuscular haematoma and soft-tissue oedema. However, the importance of arterial injury has not been well recognized.

METHODS

Among 3658 blunt trauma patients admitted to our Level 1 Trauma Centre between 1994 and 2001, there were eight patients (nine thighs) who had undergone emergency fasciotomy and these were the subjects of the present study. Arteriography of the proximal lower limb had been performed after the fasciotomy in patients with prolonged hypotension and persistent bleeding from the fasciotomy wound.

RESULTS

All the patients had sustained high-energy trauma, systemic hypotension and local trauma to the proximal lower limb. Among them, four (five thighs) had undergone arteriography and four (four thighs) were confirmed as having sustained arterial injuries. In those patients with definitive arterial injuries, the time from injury to the onset of the compartment syndrome was less than 5 h.

CONCLUSIONS

Acute compartment syndrome of the thigh in blunt trauma patients may be the result of associated arterial injuries. It is suggested that patients with local trauma to the proximal lower limb who exhibit an acute compartment syndrome together with haemodynamic instability should undergo arteriography soon after fasciotomy.

Intravenous catheter complications in the hand and forearm

BACKGROUND

We studied the complications of peripheral intravenous (i.v.) catheters in the hand and forearm in a teaching hospital over a 3-year period.

METHODS

The records of 67 patients who developed i.v. catheter-related complications were reviewed.

RESULTS

The most common sites for developing complications in order of frequency were the forearm, hand, wrist, and antecubital fossa. There were 56 minor and 11 major complications. More than 50% of minor complications occurred in the hand and wrist, and more than 50% of major complications occurred in the hand. In 68% of minor complications, the patients were aged 50 years or older and 68% were women. Minor complications comprised 26 intravenous infiltrations, 23 cases of thrombophlebitis, and 7 cases of cellulitis. Ninety percent of major complication patients were aged 50 or older and 82% were women. Major complications included septic thrombophlebitis in three; hematomas resulting in skin necrosis in two; and infiltration related complications in six, resulting in skin necrosis in two, compressive nerve lesions in two, digital stiffness in one, and compartment syndrome in one. Ten patients with major complications were over the age of 50 years and nine were women. Two patients receiving anticoagulation developed large dorsal subcutaneous space hematomas. Chemotherapeutic agents contributed to two minor complications and one major complication.

CONCLUSION

The hand is a common site for minor and major i.v. catheter complications. Women and older patients are more susceptible to these complications. Peripheral i.v. line complications are not uncommon and can result in morbidity and increased health care costs from prolonged hospitalization, extended use of i.v. antibiotic therapy, and surgical intervention.

Elastic tourniquet technique for decompression of extremity compartment syndrome

Compartment syndrome of the extremities is usually associated with direct trauma and often requires surgical fasciotomy to avert potential complications and morbidity. We present a case of upper extremity compartment syndrome resulting from pressurized infusion of autologous whole blood, in which fasciotomy was avoided by the application of a simple and effective technique using an elastic Esmarch bandage. Guidelines for surgical fasciotomy and the hazards associated with pressurized infusion of fluids in the anesthetized patient are discussed.

Acute noncontact compartment syndrome

Although acute compartment syndrome is considered a surgical emergency, controversies exist regarding diagnosis, surgical indications, and techniques of management. Acute compartment syndrome is associated with numerous causes, including fractures, crush injuries, burns, soft tissue injuries, and vascular trauma. Prolonged positioning of an extremity has not been previously described as a cause of compartment syndrome. The authors present a case of an acute compartment syndrome occurring because of prolonged extrication after a motor vehicle accident and without direct trauma to the involved extremity.

Raised intracompartmental pressure and compartment syndromes

Raised intracompartmental pressure (ICP) has become recognized as the final common pathway of a variety of pathologies which lead to failure of the microcirculation with resultant tissue hypoxia and cell death. While commonly seen after trauma, either accidental or operative, raised ICP may result from either an increase in the volume of tissue within a closed osseo-fascial or fascial compartment or by the application of an external force compressing a compartment, and it is associated with a wide variety of insults. The advent of reproducible techniques of measuring ICP has added science to a well-recognized clinical picture and allowed a rational approach to management. Controversies still remain, particularly in regard to the level of pressure at which intervention becomes mandatory, and the role of prophylactic interventions. This review attempts to present current thinking on the pathophysiology of the microcirculation and the background to these controversies.