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The incidence of the abdominal compartment syndrome (ACS) after severe abdominal and/or pelvic trauma is 3%. ACS occurs within hours and causes severe organ dysfunction. Decompressive emergency laparotomy restores this impaired organ function.
An unusual case of acute anterior thigh compartment syndrome promptly recognized and successfully treated in a young athletic patient is presented and the literature reviewed. With the increased interest in physical fitness in today's society, this condition may occur more frequently than it is recognized. Prompt diagnosis and treatment can reduce morbidity.
The use of various forms of thrombolytic treatment in acute myocardial infarction has been widespread for many years and their potential to cause haemorrhagic complications well recognised. Haemorrhagic sequaelae are usually minor and consist of oozing from venepuncture or cannula sites or minor haemorrhage from mucosal membranes. The potential for more serious bleeding complications is acknowledged, but is fortunately less common. Isolated cases of compartment syndrome have been reported in the past, but these usually follow some degree of local trauma. The case is reported of a patient who developed atraumatic compartment syndrome of the thigh after single dose thrombolysis.
Symptomatic liquefaction and calcification of muscle tissue as a late sequela of compartment syndrome of the lower leg is rare. The literature shows a high complication rate involved with simple debridement of these compartments. In our limited experience, complete compartmental debridement and immediate introduction of functional viable muscle may prevent the documented complications of chronic drainage and infection.
One hundred fifty-nine patients were referred to the authors for evaluation of chronic exertional leg pain from 1978 to 1987. The records of 131 patients were complete and available for retrospective review. Forty-five patients were diagnosed as having a chronic compartment syndrome (CCS) and seventy-five patients had the syndrome ruled out by intramuscular pressure recordings. The only significant difference found between the two groups on history and physical examination was a 45.9% incidence of muscle herniae in the patients with CCS, compared to a 12.9% incidence in those without the syndrome. One-third of the patients with the syndrome and over one-half of those without it reported persistent, moderate to severe pain at 6 month to 9 year followup. Modified, objective criteria were developed for the diagnosis of CCS. The criteria were based upon the intramuscular pressures recorded with the slit catheter before and after exercise in 210 muscle compartments without CCS. In the presence of appropriate clinical findings, we consider one or more of the following intramuscular pressure criteria to be diagnostic of chronic compartment syndrome of the leg: 1) a preexercise pressure greater than or equal to 15 mm Hg, 2) a 1 minute postexercise pressure of greater than or equal to 30 mm Hg, or 3) a 5 minute postexercise pressure greater than or equal to 20 mm Hg.
A case of an acute compartment syndrome of the triceps muscle complicating a surgical neck fracture of the humerus is presented. Diagnosis was suspected because of pain with passive elbow flexion and pain out of proportion to the clinical situation. Diagnosis was confirmed with intracompartmental pressure measurements. An emergency fasciotomy was performed. The patient had an excellent result.
A second case of compartment syndrome affecting the dorsal aspect of the foot has been presented. The syndrome was arrested by fasciotomy. There were no permanent neurologic, vascular, or musculoskeletal sequelae. Although techniques exist to obtain quantitative measurements of intracompartmental pressure, the diagnosis rests heavily on clinical assessment. Practitioners who encounter trauma victims must recognize the symptoms of the condition and be familiar with the procedures necessary to interrupt it.
This case report documents an acute tear of the gastrocnemius muscle which resulted in an acute compartment syndrome of the anterior, lateral, and superficial posterior compartments of the leg. Prompt diagnosis by physical examination and Wick catheter, followed by surgical compartment release, resulted in a well-functioning extremity. Followup at 18 months revealed a normally functioning extremity, and Cybex evaluation revealed increased muscle strength in the involved extremity.
Calf swelling, associated with an intra-articular effusion of the knee, should be considered a dissecting popliteal cyst until proven otherwise. The posterior compartment syndrome caused by an increase in pressure within the deep posterior compartment of the leg is usually secondary to trauma. This case history of a dissecting popliteal cyst reports another unusual cause of the posterior compartment syndrome. Popliteal cysts, especially dissecting ones, are typical of connective tissue diseases, and are not limited to rheumatoid arthritis.
In an experimental study in dogs of the anterior tibial compartment syndrome, three measurements were taken before, during, and following raising pressure in the compartment: blood flow, muscle function, and peroneal nerve conduction. If fasciotomy was performed within 4 hours, peroneal nerve conduction velocity always returned to normal regardless of amount of pressure or length of time pressure was applied; if performed after 12 hours peroneal nerve conduction velocity did not return to normal at any pressure or time condition, suggesting that irreversible damage to the nerve had occurred. Blood flow, as measured by rate of clearance of Xe133, always returned to normal within 2 hours of fasciotomy regardless of the time postinjury or amount of pressure applied. Muscle function (CPK and LDH) did not always return to baseline with fasciotomy and in some instances the absolute values were higher after fasciotomy. Further clinical studies using these measurements are recommended.
Acute abdominal compartment syndrome has recently been shown to raise intracranial pressure (ICP). This may increase the risk of ischemic neuronal damage by decreasing cerebral perfusion pressure. We report the successful management of a patient with severe multisystem injury in whom abdominal decompression dramatically reduced high ICP unresponsive to medical measures.
Acute compartment syndrome (CS) is a limb threatening condition which warrants emergency treatment. We describe a case of a 37-year-old man with acute CS developed without major trauma. Early diagnosis and prompt treatment by decompressive fasciotomy is of vital importance in order to preserve limb function and to avoid complications. As a consequence of this case the department purchased a pressure transducer. Measurement of high pressure could have saved the patient for an undue risk of serious complications.
Physiologic changes in renal transplant patients, such as transiently low central venous pressure, may be related to increased intra-abdominal pressure, from the volume of the transplanted kidney itself. Using intraoperative and postoperative Doppler ultrasound of the transplant renal vessels, we identified changes in flow dynamics following closure of the abdomen and reversal of the changes when the abdomen was reopened. This was attributed to abdominal compartment syndrome and a fasciotomy was created in the abdominal wall to accommodate the transplanted kidney. The findings in this case, in keeping with abdominal compartment syndrome, are not often considered in transplant recipients, but may explain some of the postsurgical physiology in some patients, particularly in the pediatric population.
BACKGROUND: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are known to occur in patients after major abdominal surgery. The incidence of IAH and ACS in the burn population is not known. METHODS: We prospectively recorded the intra-abdominal pressures of major burn patients admitted to our burn center from February 1999 to September 1999. A bladder pressure greater than 25 mm Hg was diagnosed as IAH. ACS was diagnosed when pulmonary compliance decreased in association with persistent IAH and was treated with abdominal decompression. RESULTS: Ten patients were placed on the protocol; of these, seven developed IAH. Five responded to conservative treatment. Two patients with 80% body surface area burns developed ACS and required decompression. CONCLUSIONS: IAH occurs commonly in major burn patients, and ACS is seen regularly in patients with more than 70% body surface area burns. We recommend bladder pressure measurements after infusion of more than 0.25 L/kg during the acute resuscitation phase and for peak inspiratory pressures greater than 40 cm H2O. Whereas ACS warrants surgical decompression of the abdominal cavity, IAH usually responds to conservative therapy.
BACKGROUND: Burn patients with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) undergo vigorous resuscitation and accumulate peritoneal fluid (PF) that is a plasma ultra-filtrate. This study compared antithrombin (AT) and cytokine levels in burn patient plasma and peritoneal fluid (PF). METHODS: Twenty-nine patients were studied: 22 developed IAH and 9 progressed to ACS. Burn + inhalation injury was present in 22 patients; 5 had burn only and 2 had inhalation only. Sixteen patients died: of these, 9 survived less than 48 h due to the severity of their injuries. Flow cytometry utilized the Cytometric Bead Array kit for Human Th1/Th2 cytokines. AT levels were determined by the Accucolor method spectrophotometrically. RESULTS: All cytokine levels were significantly elevated in burn plasma and PF compared to normal plasma, p < 0.001. AT plasma levels were decreased compared to normal. AT and cytokines were present in peritoneal fluid of burn patients with IAH and ACS. Patients who died had decreased plasma levels of AT and increased IFN-gamma, IL-10, IL-6, IL-4, IL-2 peritoneal fluid levels compared to survivors. CONCLUSIONS: Peritoneal fluid may be a reservoir for cytokines during initial resuscitation and contributes to homeostatic perturbations in burn patients.
BACKGROUND: Abdominal compartment syndrome (ACS) is a rapid increase in intra-abdominal pressure asssociated with multi-organs dysfunction. It is caused mostly by abdominal bleeding und massive volume compensation. CASE REPORT: We reported a 76-year-old patient admitted to the hospital with aortic abdominal aneurysm, 13.7 cm in diameter, ruptured in vena cava, which caused intraabdominal hypertension, the liver and kidney dysfunction, as well as circulation, respiration and metabolic disorders. Intraabdominal pressure was measured by bladder manometry. Central venous pressure and systemic arterial pressure were monitored continuously. Clinical signs were thrill and typical abdominal bruit. Aorto-caval fistula was diagnosed by the use of contrast computerized tomography. Caval endoaneurysmatic suture and aortobiiliac bypass with 18 x 9 mm Dacron prothesis were performed. Haemodynamic changes were mostly corrected during the surgery. The complete correction of haemodynamics, liver, kidney, respiration and metabolic changes was established in the next few weeks. CONCLUSION: The ACS was caused by rupture of abdominal aortic aneurysm in vena cava followed by edema of the abdominal organs, retroperitoneum, abdominal wall and ascites. Caval endoaneurysmatic suture and aortobiiliac bypass with 18 x 9 mm Dacron prothesis solved aortocaval fistula as well as all the organs and metabolic dysfunctions caused by ACS.
Anterior and posterior motor compartment syndrome have been observed in four burn patients. Recognition was difficult because of multiple concurrent problems, including burns and thrombophlebitis of the involved extremities. Early fasciotomy was performed in one case, with good return of function. Muscle necrosis occurred in two patients in whom diagnosis was delayed. Electromyography is of benefit in confirming the diagnosis and providing follow-up management. It is important to maintain a high index of suspicion of this syndrome in patients with overlying burns.
A patient developed a persistent, disabling, bilateral anterior tibial compartment syndrome after salicylate self-poisoning. Prolonged tetany is postulated as the probable mechanism.