Compartment syndromes from head to toe

Atraumatic Polycompartment Syndrome Secondary to Cardiogenic Shock: A Case Report

We report the case of a 53-year-old male who developed polycompartment syndrome (PCS) secondary to cardiogenic shock. After suffering a cardiac arrest, a self-perpetuating cycle of intra-abdominal hypertension (IAH) and vital organ damage led to abdominal compartment syndrome (AbCS), which then contributed to the precipitation of extremity compartment syndrome (CS) in bilateral thighs, legs, forearms, and hands. This report is followed by a review of the literature regarding the pathophysiology of this rare sequela of cardiogenic shock. While the progression from cardiogenic shock to AbCS and ultimately to PCS has been hypothesized, no prior case reports demonstrate this. Furthermore, this case suggests more generally that IAH may be a risk factor for extremity CS. Future studies should examine the potential interplay between IAH and extremity CS in patients at risk, such as polytrauma patients with tibial fractures.

Orchio-Septopexy: A new technique to cover and fix detorsed testis undergoing fasciotomy of tunica albuginea

Purpose

Compartment Syndrome (CS) has been recognized as a potential factor that worsens testicular viability after detorsion, especially in borderline cases of prolonged ischemia. Fasciotomy of the testicular tunica albuginea to relieve the pressure associated with CS has been proposed to accommodate edema after detorsion, embracing the raw fasciotomy area with tunica vaginalis flap (TVF) or graft. Fashioning the TVF can be tedious in cases of severe scrotal edema. Herein we present a technique that facilitates and expedites the procedure, maintaining the fasciotomy area decompressed.

Materials and Methods

In testicular torsion, where the testis remains with dark coloration and questionable viability after detorsion a longitudinal releasing incision is made in the tunica albuginea (fasciotomy) to decrease compartmental pressure. If signs of parenchymal recovery (bleeding points, better color) are seen an orchio-septopexy is performed, suturing the incised albuginea’s edges to the septum with a running suture, avoiding CS as well as re-torsion.

Results

Orchio-septopexy was performed in 11 cases with a mean age of 11.9 years (3-17). All cases had clinic follow-up and testicular Doppler US with a mean of 9.5 months (6-24). 6/11 cases (54%) were salvaged, with good vascularity in the Doppler US and maintained more than 50% testicular volume compared to the contralateral side.

Conclusion

Orchio-septopexy after testicular fasciotomy is a simple and fast technique that can be utilized in cases of prolonged testicular ischemia and questionable viability. More than half of the testes recovered, encouraging us to propose its utilization as well as its validation by other surgeons.

Life-threatening abdominal compartment syndrome as a complication of supine super mini percutaneous nephrolithotomy, the first case report and literature review

Abdominal compartment syndrome is a life-threatening complication of conventional percutaneous nephrolithotomy (PCNL), with few cases reported in different positions. We present the first case of abdominal compartment syndrome as a complication of supermini percutaneous nephrolithotomy (SMP) in The Galdakao-modified supine Valdivia position, possibly predisposing factors, diagnosis, and management.

Although it is a challenging diagnosis and life-threatening condition, morbidity and mortality can be decreased with early detection and drainage of the intra-peritoneal fluid, causing increased abdominal pressure, which is the most important prognostic factor.

Timing of surgical intervention for compartment syndrome in different body region: systematic review of the literature

Compartment syndrome can occur in many body regions and may range from homeostasis asymptomatic alterations to severe, life-threatening conditions. Surgical intervention to decompress affected organs or area of the body is often the only effective treatment, although evidences to assess the best timing of intervention are lacking. Present paper systematically reviewed the literature stratifying timings according to the compartmental syndromes which may beneficiate from immediate, early, delayed, or prophylactic surgical decompression. Timing of decompression have been stratified into four categories: (1) immediate decompression for those compartmental syndromes whose missed therapy would rapidly lead to patient death or extreme disability, (2) early decompression with the time burden of 3-12 h and in any case before clinical signs of irreversible deterioration, (3) delayed decompression identified with decompression performed after 12 h or after signs of clinical deterioration has occurred, and (4) prophylactic decompression in those situations where high incidence of compartment syndrome is expected after a specific causative event.

Compartment syndrome of the leg after thyroid hormone withdrawal; two cases and a systematic review of the literature

BACKGROUND

Acute compartment syndrome is a rare complication of severe hypothyroidism. If the symptoms are not recognized promptly and treatment initiated immediately, there is a high risk of permanent damage. Only few other cases of compartment syndrome due to hypothyroidism have been published and the exact pathophysiological mechanism remains unknown.

CASE PRESENTATIONS

A 59 year old male developed acute compartment syndrome of his right lower leg after thyroid hormone withdrawal prior to radioiodine remnant ablation after total thyroidectomy for follicular thyroid cancer. He underwent emergency fasciotomy of all four compartments of the lower leg. The muscle tissue in the anterior and lateral compartment was necrotic and was therefore excised. The second patient was a 62 year old female with Hashimoto's thyroiditis, who developed acute compartment syndrome of both lower legs after thyroid hormone withdrawal due to non-compliance. Emergency fasciotomy of all four compartments of both legs was performed. The muscle tissue was viable in all compartments.

CONCLUSION

Although compartment syndrome due to hypothyroidism is uncommon, it is a complication physicians should be aware of. The majority of reported cases are caused by an acute withdrawal of thyroid hormones and not by undetected hypothyroidism. No previous case of compartment syndrome caused by an iatrogenic hormone withdrawal in preparation for radioactive iodine has been published. However, as shown in this report, it may be beneficial to inform patients of this rare complication prior to hormone withdrawal in preparation for remnant ablation after thyroidectomy.

Use of Oxygen Tissue Monitoring in Patients With Compartment Syndrome: Two Clinical Cases and Literature Review

Compartment syndrome is defined as the pathology caused by the increase of pressure within a muscular compartment to the point where the vascular perfusion necessary for the viability of the tissues included therein is reduced. The diagnosis is established by clinical exam and pressure measurement. Measurement of intracompartmental pressure is an invasive method with no option of easy continuous monitoring. Continuous tissue oximetry, using near-infrared light spectroscopy, can estimate soft-tissue oxygenation several centimeters below the sensor placement. This method of monitoring has been used successfully in the diagnosis of compartment syndrome, presenting itself as a non-invasive method of continuous measurement that can be a very useful alternative in complex situations or doubtful cases. We present two clinical cases of patients with acute compartment syndrome, in which the use of near-infrared light spectroscopy was determinant, both for the diagnosis and to verify the surgical treatment performed.

Compartment syndrome of the muscles of mastication in a working dog following a traumatic training incident

OBJECTIVE

To describe acute compartment syndrome (CS) of the muscles of mastication in a working dog associated with a traumatic training event.

CASE SUMMARY

A 2.5-year-old male Belgian Malinois was evaluated for acute blindness, severe diffuse swelling of the head, and inability to close the jaw following a traumatic incident during a bite training drill. During the exercise, the maxillary canine teeth were locked on a bite sleeve. Magnetic resonance imaging of the head and ocular system identified diffuse muscle swelling and hyperintensity, most severe in the muscles of mastication. Ocular abnormalities were not identified. Rhabdomyolysis, CS, and indirect optic nerve injury were supported by measurement of increased intramuscular pressure. Bilateral decompressive fasciotomies over the masseter and temporalis muscles resulted in immediate and marked resolution of the swelling and jaw movement. Blindness, however, did not resolve.

NEW OR UNIQUE INFORMATION PROVIDED

CS involving the muscles of mastication may occur as a complication of bite training and may result in irreversible and even life-threatening complications. Emergent decompressive fasciotomy is indicated to reverse swelling; however, visual deficits may not resolve.

Nontraumatic Compartment Syndrome in a Patient with Protein S Deficiency: A Case Report

CASE

Protein S deficiency, a hypercoagulable thrombophilia, often results in venous thromboembolism. Nontraumatic compartment syndrome in a patient with protein S deficiency has not been well publicized. Herein, we present a rare case of nontraumatic compartment syndrome of the hand and the thigh in a 48-year-old woman with a known history of protein S deficiency; emergency fasciotomies were needed.

CONCLUSION

Based on our patient and a review of the current literature, we advocate for a heightened awareness of compartment syndrome in patients with protein S deficiency.

Lower extremity compartment syndrome

Lower extremity compartment syndrome is a devastating complication if not rapidly diagnosed and properly managed. The classic symptoms of compartment syndrome can be deceiving as they occur late. Any concern for compartment syndrome based on mechanism, or the presence of pain in the affected extremity, should prompt a compartment pressure check. Both absolute compartment pressures above 30 mm Hg and a pressure differential of less than 30 mm Hg are used to make the diagnosis. The treatment goal is first to save the patient’s life and second to salvage the affected limb. Fasciotomy is the only accepted treatment of compartment syndrome and should be performed quickly after the diagnosis is made. Outcomes after fasciotomy are best when there is no delay in treatment.

Intracompartmental Sepsis With Burn: A Case Report

Intracompartmental sepsis (IS) is a rare complication in patients with burns. Intracompartmental sepsis presents in patients with inadequate perfusion of intracompartmental tissues and subsequent ischemic necrosis and infection. Contributing factors include high-volume resuscitation, delayed escharotomies, and previous bacteremia. We describe a case of massive burns from a gas explosion and the subsequent development of IS in our intensive care burn unit. The patient presented with a 75% total body surface area burn on admission, with 39% superficial, deep partial-thickness and 26% full-thickness burns. Intracompartmental sepsis was diagnosed 45 days after admission. Anterior compartment muscles, including the tibialis anterior, extensor hallucis longus, and extensor digitorum longus, were necrotic with relatively fair nerve and vascular structures. Intracompartmental sepsis is an overwhelming, infectious complication that appears late and can occur easily in patients with major burns. Early diagnosis and management are a must for improving outcomes.

Secondary extremity compartment syndrome after traumatic cardiac arrest

The objective of this case report is to investigate the pathophysiology, diagnosis, and surgical management of secondary extremity compartment syndrome. This case-based review documents the development of secondary extremity compartment syndrome in the setting of high-volume fluid resuscitation for a hemorrhagic cardiac arrest complicated by a global ischemia-reperfusion injury. A 21-year-old male presented with traumatic, hemorrhagic cardiac arrest. Following a resuscitative thoracotomy, massive transfusion and return of spontaneous circulation, the patient underwent damage control surgery. Over the first 48 h following the injury, the patient developed progressive diffuse interstitial edema ultimately culminating in compartment syndrome of the remaining three uninjured extremities as well as both uninjured gluteal compartments. The patient underwent bilateral lower extremity, thigh, gluteal, and right upper extremity compartment fasciotomies, with the left lower extremity being the single, traumatically injured extremity. To our knowledge, this is the only case of secondary extremity compartment syndrome in which bilateral gluteal compartments and bilateral thigh compartments were involved in addition to the bilateral upper and right lower extremities. The goal of this case report is to examine the pathophysiology of the development of secondary extremity compartment syndrome, with an emphasis on early recognition and surgical intervention.

Diagnosis and treatment of acute extremity compartment syndrome

Acute compartment syndrome of the extremities is well known, but diagnosis can be challenging. Ineffective treatment can have devastating consequences, such as permanent dysaesthesia, ischaemic contractures, muscle dysfunction, loss of limb, and even loss of life. Despite many studies, there is no consensus about the way in which acute extremity compartment syndromes should be diagnosed. Many surgeons suggest continuous monitoring of intracompartmental pressure for all patients who have high-risk extremity injuries, whereas others suggest aggressive surgical intervention if acute compartment syndrome is even suspected. Although surgical fasciotomy might reduce intracompartmental pressure, this procedure also carries the risk of long-term complications. In this paper in The Lancet Series about emergency surgery we summarise the available data on acute extremity compartment syndrome of the upper and lower extremities in adults and children, discuss the underlying pathophysiology, and propose a clinical guideline based on the available data.

Abdominal compartment syndrome in children

Abdominal compartment syndrome is defined as sustained intra-abdominal pressure greater than 20 mm Hg (with or without abdominal perfusion pressure <60 mm Hg) associated with new organ failure or dysfunction. The syndrome is associated with 90% to 100% mortality if not recognized and treated in a timely manner. Nurses are responsible for accurately measuring intra-abdominal pressure in children with abdominal compartment syndrome and for alerting physicians about important changes. This article provides relevant definitions, outlines risk factors for abdominal compartment syndrome developing in children, and discusses an instructive case involving an adolescent with abdominal compartment syndrome. Techniques for measuring intra-abdominal pressure, normal ranges, and the importance of monitoring in the critical care setting for timely identification of intra-abdominal hypertension and abdominal compartment syndrome also are discussed.

Measurement of intra-abdominal pressure in dogs and cats

OBJECTIVE

To review and summarize the human and veterinary literature on intra-abdominal pressure measurement techniques.

DATA SOURCES

Human and veterinary clinical studies, research articles, reviews, and textbooks with no date restrictions with a focus on techniques for intra-abdominal pressure (IAP) measurement and their limitations.

HUMAN DATA SYNTHESIS

Human literature has established the intravesicular method as the gold standard for indirect measurement of IAP. However, current research has explored the intragastric method as a valid alternative. Recently, debate has focused on the shortcomings of the various measurement methods.

VETERINARY DATA SYNTHESIS

Early human literature using dogs as models contributed to the original data for IAP measurements in small animals. Since that time, a number of clinical studies and 1 case report have contributed to that original information. A reference interval for IAP measured by the intravesicular method has recently been determined in healthy cats.

CONCLUSIONS

Further studies investigating IAP in critically ill veterinary patients are required to establish the optimal technique for this measurement in veterinary medicine.

A child with gemcitabine-induced severe radiation recall myositis resulting in a compartment syndrome

Chemotherapeutic induction of radiation recall (RR) is a rare event in which a chemotherapeutic agent given days to years after radiation therapy causes an inflammation reaction of the tissues within the irradiated area-"recalling" increased radiation effects to that area. In this unique case, a 14-year-old girl with a synovial sarcoma of the forearm was treated with neoadjuvant chemotherapy and radiation therapy. Gemcitabine was administered in an adjuvant setting inducing a RR reaction. The severity of the inflammation resulted in a forearm myositis secondarily causing a compartment syndrome that was treated with several prolonged courses of corticosteroids. The symptoms of RR and compartment syndrome have resolved 1 year postonset, although magnetic resonance imaging continues to show myositis and soft-tissue edema. This case highlights the need to maintain a heightened awareness to recognizing the signs and symptoms of RR and the potential severity of RR in pediatric cancer patients in conjunction with chemotherapeutic agents used more frequently in adults.

Evaluation of military trauma system practices related to complications after injury

BACKGROUND

The Joint Theater Trauma System (JTTS) was developed with the vision that every soldier, marine, sailor, and airman injured on the battlefield would have the optimal chance for survival and maximum potential for functional recovery. In this analysis, we hypothesized that injury and complication after injury surveillance information diffusion through the JTTS, via the dissemination of clinical practice guidelines and process improvements, would be associated with improved combat casualty clinical outcomes.

METHODS

The current analysis was designed to profile different aspects of trauma system performance improvement, including monitoring of frequent posttraumatic complications, the assessment of an emerging complication trend, and measurement of the impact of the system interventions to identify potential practices for future performance improvement. Data captured from the Joint Theater Trauma Registry on patients admitted to military medical treatment facilities as a result of wounds incurred in Iraq and Afghanistan from 2003 to 2010 were retrospectively analyzed to determine the potential impact of complication surveillance and process improvement initiatives on clinical practice.

RESULTS

Developed metrics demonstrated that the surveillance capacity and evidence-based quality improvement initiatives disseminated through the JTTS were associated with improved identification and mitigation of complications following battlefield injury.

CONCLUSION

The Joint Trauma System enables evidence-based practice across the continuum of military trauma care. Concurrent data collection and performance improvement activities at the local and system level facilitate timely clinical intervention on identified trauma complications and the subsequent measurement of the effectiveness of those interventions.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Abdominal hypertension characterised by severe haemodynamic changes as a complication of percutanous nephrolithotomy

Percutanous nephrolithotomy (PCNL) was performed on a patient in a prone position. During the first hour of intervention, some unwanted haemodynamic complications arose, which included a decrease in systemic blood pressure, an increase in heart rate and an increase in peak inspiratory pressures. Owing to worsening of those unexplained haemodynamic abnormalities, surgery was terminated. As the patient turned from prone to supine position, abdominal distention was noticed. Later, 3 litres of fluid were removed from the abdomen via peritoneal lavage. Upon fluid removal, a dramatic haemodynamic improvement was observed. The problem was thought to have been caused by a technical error in placing the dilator inside the abdomen, which allowed the irrigation fluid to accumulate inside the abdominal cavity. The aim of this presentation is to raise awareness of intra-abdominal hypertension when the aforementioned haemodynamic abnormalities are detected during PCNL. Early detection and treatment may prevent morbidity and mortality in similar cases.

Developing a new experimental model of abdominal compartment syndrome

OBJECTIVE

To describe an experimental, unprecedented model that mimics the abdominal compartment syndrome (ACS).

METHODS

twenty rats were randomly divided into four groups. To simulate ACS intra-abdominal hypertension (IAH) was induced by inserting cotton surgical dressing (Zobec ®), 15x15cm (intra-abdominal pressure constant and equal to 12 mmHg) associated with hypovolemia induced by withdrawing blood, keeping mean arterial pressure (MAP) around 60 mmHg (HYPO). To dissociate the effects of those IAH-induced hypovolemia per se, two other groups were analyzed: one with only with IAH and another with only hypovolemia. The simulation group (sham) underwent the same surgical procedure performed earlier, however, the levels of intra-abdominal pressure and MAP were kept in 3 mmHg and 90 mmHg, respectively.

RESULTS

By analyzing the impact of IAH on the small intestine, we observed necrosis of the villi, congestion, and neutrophilic infiltration. Hypovolemia induced only inflammation and edema of the villi. However, the association of IAH and HYPO led to hemorrhagic infarction, besides worsening of the aforementioned parameters.

CONCLUSION

This model was effective in inducing ACS expressed by the effects found in the small intestine.

Compartment syndrome: pathophysiology, clinical presentations, treatment, and prevention in human and veterinary medicine

OBJECTIVE

To review the human and veterinary literature pertaining to all forms of compartment syndrome (CS).

DATA SOURCES

Data sources included scientific reviews and original research publications from the human and veterinary literature.

HUMAN DATA SYNTHESIS

While CS affecting the extremities has been recognized in people for decades, other forms of CS in the abdominal and thoracic cavities are recently gaining more attention. The role of CS in critically ill people is a rapidly growing area of interest. More research on prevention and treatment of CS is being conducted in people because some studies have found mortality rates as high as 80% for those suffering from these conditions.

VETERINARY DATA SYNTHESIS

While a significant amount of experimental studies of CS have been performed on small animals, there is a marked lack of primary veterinary studies. The majority of the veterinary literature includes case reports and series, and many of these studies were published over a decade ago. However, the increased recognition of CS in people has sparked an interest in veterinary critical care medicine and this has been demonstrated by the recent increased evaluation of compartment pressures in veterinary patients.

CONCLUSIONS

CS is a complex clinical condition where increased pressure within a compartment can cause significant adverse effects within the compartment as well as throughout the body. Systemic inflammatory responses and local ischemia-reperfusion elements can contribute to the detrimental effects seen in CS. This cascade of events results in increased mortality rates and contributes to the development of CS elsewhere. A better understanding of CS will help veterinarians improve patient care and outcome. Future studies on incidence, prevention, and treatment of CSs in the critical care patient are needed in veterinary medicine.