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Compartment Syndrome. Bugbears of Emergency MedicineWhat is it?CausesWhen to testMaking the DiagnosisManagement. Bugbear Diagnoses. Failure to diagnose is threatening to life, limb and walletClinical findings suggesting need to test are extremely commonClinical findings excluding disease are
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1. Acute Compartment SyndromeGrand Rounds Paris Lovett, MD
November 2003
2. Compartment Syndrome Bugbears of Emergency Medicine
What is it?
Causes
When to test
Making the Diagnosis
Management
3. Bugbear Diagnoses Failure to diagnose is threatening to life, limb and wallet
Clinical findings suggesting need to test are extremely common
Clinical findings excluding disease are not reliable
Actual disease may be uncommon
Onerous, expensive, or risky test
Ability of test to rule out disease may be limited
Large number of negative studies
Large number of false positive tests
4. Bugbear diagnoses PE
DVT
TAD (Ansari-Ritter Disease)
Traumatic Aortic Rupture
Ovarian Torsion
Testicular Torsion
Ischemic Bowel
Subarachnoid Hemorrhage
Cavernous Sinus Thrombosis
Intussusception
Compartment Syndrome
5. What is compartment syndrome?
6. What is compartment syndrome? Limb Compartment Syndrome
Acute
Chronic
Abdominal Compartment Syndrome
7. Acute Limb Compartment Syndrome Raised Pressure within a closed fascial space
Reduction in capillary perfusion below level needed for tissue viability
Describes local manifestations and complications
Dont confuse with crush injury (systemic: acidosis, hyperkalemia, myoglobinemia, shock, ARF)
8. (Chronic Compartment Syndrome) Athletes with hypertrophied leg muscles
Hyperemic muscles become painful during exercise
Pain relieved by rest
Compartment pressures elevated even at rest
Treated with fasciotomy
9. (Abdominal Compartment Syndrome) An ICU diagnosis, rarely an ED diagnosis
Round, tense abdomen
Trauma, post-op
Decreased Cardiac Output
Increased Peak Inspiratory Pressure and decreased ventilation
Oliguria and Renal Failure from venous and renal compression
Treated with laparotomy
10. Limb Compartment Syndrome: Causes Orthopedic
Fractures: open or closed
Management of fractures
Vascular/Iatrogenic
Vascular puncture: esp. anticoagulated
Intra-arterial drug administration
Extravasation
Others
Soft-tissue injury
Crush
Burns
Hypotension: worsens all causes
11. Orthopedic Causes Tibial Fx.
Incidence ranges 1.5 to 29%. Depends upon threshold for diagnosis/treamtent
Anterior compartment most common
Forearm Fx
Volar (Flexor/Ventral) compartment most common
Comminuted fractures increased risk
Open fractures roughly halve risk
Treatment of fractures increasing risk of CS: cylindrical casting; padding; traction; manipulation; intramedullary nail; elevation (Matsen)
14. Vascular Causes Arterial Injection
Venous Extravasation
Traumatic Vessel Injury esp. popliteal
Revascularization and re-perfusion: up to 20% of re-perfused limbs. Dependent upon ischemic time. 8-12h is the critical period for irreversible damage (Whitesides)
Aortic Balloon pump: 6-19%
Phlegmasia Cerulea Dolens: Profound distal propagation of iliofemoral thrombosis, and venous gangrene, usu. in setting of malignancy
IVDA
16. Soft Tissue Injury Causes Direct blow to compartment
Crushing injury
Burns
Much more common in hypocoagulable
Continued use of limb may increase risk
17. Where? Lower leg
Forearm
Also: Femoral, Foot, Hand, Calcaneal, Buttocks, Shoulder
18. Demographics (McQueen) Pediatrics and young adults
Male > Female
21. Mechanisms Issue is venous return
Initial problem is edema, hemorrhage, or external compression
This raises compartment pressure
22. Mechanisms Raised compartment pressure causes compression of small venules
Wosening edema and raised compartmental pressure
Eventually arteriolar compression
Muscle and nerve ischemia
23. Some History For years I have called attention to the fact that the pareses and contractures of limbs following application of tight bandages are caused not by pressure paralysis of nerves, as formerly assumed, but by the rapid and massive deterioration of contractile substance and by
reactive and regenerative processes.
Die ischämischen Muskellähmungen und Kontracturen. Centralblatt für Chirurgie, Leipzig, 1881, 8: 801-803
24. Volkmann Advanced the introduction of antiseptic wound treatment in Germany
Performed the first excision of carcinoma of the rectum in 1878
Under the pen name Richard Leander wrote poetry and a book entitled "Dreams by French Firesides
Described Volkmann-Kontraktur, or Ischämische Muskelnekrose
25. Volkmanns Ischemic Contracture
26. Historical Development 1881 Volkmann condition of irreversible contractures of the flexor muscles of the hand due to ischemic processes occurring in the forearm. The problem: massive venous stasis and arterial insufficiency secondary to overly tight bandages
1906 Hildebrand: term Volkmann ischemic contracture for result of untreated compartment syndrome. Elevated tissue pressure cause.
1909 Thomas reviewed 112 published cases. Fractures predominant cause. Also tight bandages, arterial embolus or insufficiency
1914, Murphy: fasciotomy might prevent the contracture
1958 Ellis 2% incidence with tibia fractures
mid-1960s Seddon, Kelly, and Whitesides 4 compartments in the leg
1970s: Mubarak: Wick method of measurement
27. Clinical Features Pain out of proportion to injury
Paresthesia / Altered sensation (esp. 2-point)
Tense, swollen compartment
Pain on passive stretch
Weakness (late)
Progression over a short time period
According to Rorabeck CH, Halpern AA, Ellis H, Pain on passive stretch and progression of pain most reliable in making an early diagnosis
28. Missing the boat Pale
Pulseless
Paralyzed
29. Clinical Sensitivity (Ulmer T 02)
31. Who gets tested? Anyone you truly suspect
Mechanism
Clinical features
Progression
Pediatrics and Sedated/Altered
Inability to obtain accurate clinical data
32. Testing Wick Catheter: suture material. Continuous
Simple needle
Infusion
Side-ported needle
Digital: Stryker
Give tissue pressure in mmHg
33. What number to treat?1. Using the absolute CP Normal resting intramuscular 0-8 mmHg
20-30 mmHg: pain and paresthesia
30 mmHg+ for 6+ hours: irreversible necrosis (Mubarak SJ 78)
25 mmHg without signs; 15 mmHg with signs (Ouellette EA 96; 17 patients)
40 mmHg observe; 50 mmHg operate (Allen MJ 85) No adverse sequelae.
34. What number to treat?2. Using a relative CP
DBP Compartment Pressure. If < 30 perform fasciotomy (Whitesides, McQueen). Greater specificity without any sacrifice in sensitivity (116 patients).
MAP CP. Treat if < 30 (Mars and Hadley). More accurate, in a study involving children, and a dog study
Balancing minimization of unneccesary surgery against minimization of an appalling outcome
35. What does this tell us? The receiver operator characteristics of compartment pressure are by no means a perfect way of predicting who would develop ischemic contracture in the absence of a fasciotomy.
As you drive up the sensitivity curve, how much specificity do you have to sacrifice?
36. So, what do we do? Serial exam
Clinically obvious ? Call Surgery
Clinically equivocal ? Measure CP
Serial CP measurement
30 mmHg is the standard
Low threshold
37. Surgery
38. Treatment
39. And what else? Elevation of limb?? (May increase compartment pressures by worsening ischemia)
Hyperbaric Oxygen Therapy (better wound healing post-op)
Mannitol (Animal studies; Small non-randomized human study by Shah et. al.)
40. Summary You have to suspect it
Early versus late clinical findings
Pain out of proportion
Palpably Tense Compartment
Pain on passive stretch
Progressive pain
Paresthesia (Altered sensation)
Weakness
Serial observations
Serial CP measurements
No definitive numbers for Compartment Pressures
41. Bibliography Allen MJ. Stirling AJ. Crawshaw CV. Barnes MR. Intracompartmental pressure monitoring of leg injuries. An aid to management. [Journal Article] Journal of Bone & Joint Surgery - British Volume. 67(1):53-7, 1985
Elliott KGB. J. Bone Joint Surg 2003;85(5) 625-632
Jensen SL. Sandermann J. Compartment syndrome and fasciotomy in vascular surgery. A review of 57 cases. [Journal Article] European Journal of Vascular & Endovascular Surgery. 13(1):48-53, 1997
Matsen FA, Krugmire RB, King, RV. Increased Tissue Pressure and its Effects on Muscle Oxygenation in Level and Elevated Human Limbs. Clinical Orthopedics and Related Research. 1979;144:311-320
McQueen, M. M.; Gaston, P.; Court-Brown, C. M Acute compartment syndrome: WHO IS AT RISK?
Mubarak SJ. A practical approach to compartmental syndromes part II: diagnosis. In: Everts CM, (ed): American Association of Orthopedic Surgeons: Instructional Course Lectures. St. Louis: Mosby, 1983
Tiwari A et. al. Acute Compartment Syndromes. Brit. J. Surg. 2002; 89: 397-412.
Ulmer T. Journal of Orthopaedic Trauma 16, No. 8, pp. 572577
Whitsides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop 1975; 113:43-51