Management of Acute Compartment Syndrome
Acute compartment syndrome is a rare but severe complication of massive resuscitation. Early diagnosis is the key to successful treatment, which involves surgical decompression of the compartment. This chapter reviews the guidelines for diagnosis and trea
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Ming-Jim Yang, Frederick A. Moore, and Janeen R. Jordan
Case Presentation An 82 year old female with a history of liver cirrhosis secondary to hemochromatosis, coronary artery disease, CHF, and COPD was brought through the ED after a head-on motor vehicle collision. She complained initially of abdominal pain and right leg pain. Physical exam revealed a tender and distended abdomen in the right and left upper quadrants and a visible right lower leg deformity with a 4 cm wound over the lateral aspect of her thigh with exposed bone. A FAST exam was positive in the right upper quadrant. CT scan revealed a grade 2 liver laceration with active contrast extravasation (Fig. 81.1), a grade 3 splenic laceration, and a distal comminuted femur fracture (Fig. 81.2). An emergent hepatic and splenic artery embolization was performed followed by application of an tibial traction pin. Postoperatively, she continued to have episodes of hypotension requiring continued resuscitation. Within the first 24 h, the patient received 6 L of crystalloid, 3U pRBC, and 500 cc of albumin. Despite the resuscitation, the patient developed acute renal failure requiring CVVH.
M.-J. Yang • F.A. Moore • J.R. Jordan (*) Department of Surgery, University of Florida, Gainesville, FL, USA e-mail: [email protected]
Question What differential diagnoses should be considered? Answer Abdominal and extremity compartment syndrome. Old age, trauma and high volume resuscitation are risk factors for abdominal and extremity compartment syndromes. Since clinical exam is unreliable in predicting intra-abdominal pressures (IAP), surveillance of intra-abdominal pressures using transbladder pressure monitoring should be implemented. The fractured leg should be assessed with serial exams and intracompartmental pressure measurements. For this patient, transbladder pressures were monitored every 4 h. Postinjury day 3, she presented with poor oxygenation while still on mechanical ventilation with peak pressures of 41. IAP was found to be 29. She was taken emergently to the operating room for a decompressive laparotomy. Her open abdomen was managed using a damage control technique employing a negative pressure therapy dressing. She continued to experience hypotensive episodes requiring cystalloid boluses. On post-decompression day 2, her nurse noted increased swelling of her right lower extremity. On physical exam, passive movement of the leg seemed to cause her “agitation” that would not improve with normal doses of pain medication. Intracompartmental pressures in her right anterior compartment showed an absolute value of 40 mmHg with a diastolic blood pressure of 57 mmHg ( ∆ P = 17 ) . An emergent 4
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_81
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postinjury day 14. Delayed primary closure of her fasciotomy wound was achieved after 5 days of negative pressure therapy.
Principles of Management Diagnosis
Fig. 81.1 CT Scan abdomen, Grade 2 liver
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