compartment syndrome
TRANSCRIPT
![Page 1: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/1.jpg)
Compartment Syndrome
By Ajay Raveendranadh
Guided by: Dr Riju R Menon
![Page 2: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/2.jpg)
• What is Compartment syndrome?
An elevation of the interstitial
pressure in a closed osteofascial compartment
that results in microvascular compromise.
![Page 3: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/3.jpg)
• Compartments are groups of muscles surrounded by inelastic fascia.
• Increased pressure within a muscle compartment causes decreased blood supply to affected muscles.
• Any swelling of muscles leaves no room for expansion and blood supply is progressively shut off.
• If affected muscles are deprived of blood supply for > 6 hours, nerve and muscle tissue can be permanently damaged.
![Page 4: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/4.jpg)
Anatomy:Compartment Muscles Vessels Nerves
Anterior Tibialis anterior Anterior tibial Deep peroneal
Ext. halusic longus
Ext digitorumcommunis
Deep Posterior Tibialis posterior Posterior tibial Tibial
Flexor hallusic longus Peroneal
Flexor digitorumlongus
Superficial Gatronemius
Soleus
Plantaris
Lateral Peroneus longus & brevis
![Page 5: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/5.jpg)
![Page 6: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/6.jpg)
• Types of Compartment syndrome:
I. Acute compartment syndrome (ACS)
medical emergency
caused by a severe injury
can lead to permanent muscle damage.
II. Chronic compartment syndrome (CCS)
known as exertional compartment syndrome
not a medical emergency
most often caused by athletic exertion.
![Page 7: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/7.jpg)
Etiology:
I. Decrease compartment size
-Tight dressings/closure of fascial defect
-External pressures : casts, splints , burn eschar,
lying on limb for long period, lithotomy position
![Page 8: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/8.jpg)
II Increase compartment contents
Fractures : the most common are
• In adults --- closed and open tibial
shaft fracture
• In children --- radial head or neck
fracture.
![Page 9: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/9.jpg)
Increase compartment
contents
• Hemorrhage -- vascular
injury, coagulopathy
• Muscle edema --
severe exercise , crush
injury
• Burn -- increase
capillary permeability
![Page 10: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/10.jpg)
Pathophysiology Increased intra compartmental
Pressure
increases local venous P
narrowed AV perfusion gradient
compartment tamponade
decrease capillary blood flow
O2 deprivation
local tissue necrosis
nerve injury and muscle ischemia
![Page 11: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/11.jpg)
• Whiteside’s Theory:
The development of a compartment syndrome also
depends on
• MPP = DBP(Diastolic BP) – CP(Intracompartment P)
• Muscle perfusion pressure(MPP) < 30 mmHg
Tissue hypoxia
![Page 12: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/12.jpg)
Clinical Presentation:
• Swelling/ Tightness of compartment
• Inappropiate and uncontrolled pain
• Severe pain at rest or passive stretching
• Pallor/Cyanosis
• Hyperesthesia/Paresthesia
• Paralysis : full recovery is rare
![Page 13: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/13.jpg)
5 P’s
1.Pain
2.Paraesthesia
3. Pallor
4.Paralysis
5.Pulselessness
![Page 14: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/14.jpg)
Evaluation:• Physical examination :
• Pain at compartment on passive stretching :
• test each compartment separately
• Thigh : - anterior compartment - passive knee flexion
- posterior compartment - passive knee extension
- medial compartment - passive hip abduction
• Hyperesthesia/Paresthesia
• Peripheral pulses absent - amputation usually inevitable
![Page 15: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/15.jpg)
Measuring the pressure:• Indications : High risk injuries in
• polytrauma patients
• patient not alert/unreliable
• inconclusive physical exam findings
• Technique : performed each compartments at
close to the fracture site as possible (highest pressure) or maximal swelling area.
![Page 16: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/16.jpg)
• Devices:
Stryker hand-held system Stryker slit catheter
![Page 17: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/17.jpg)
![Page 18: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/18.jpg)
![Page 19: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/19.jpg)
Management:• Early Management:
- Remove cast/bandage
- Positioning of the limb at the level of the heart
Do not elevate the affected limb decreases arterial pressure
- IV hydration
- Oxygen supplement
![Page 20: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/20.jpg)
Management:
I Non-operative
Observation
ΔPressure >30 mmHg, no clinical
presentation of compartment syndrome
II Operative
Emergency fasciotomy
Positive clinical presentation
CP = 30-45 mm Hg
Δ Pressure <30 mmHg
![Page 21: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/21.jpg)
FASCIOTOMY
• Surgical incision to the fascia to relieve tension or pressure.
• Complete opening of all fascial envelopes.
• The wound should be left open and inspected 2 days later.
• If there is muscle necrosis debridement.
• If the tissues are healthy, the wound can be
- sutured (without tension)OR
- skin-grafted OR
- allowed to heal by secondary intention
![Page 22: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/22.jpg)
If ∆P < 30mmHg
FASCIOTOMY
If no facilities for compartmental
pressure measurement, the decision to operate
will make on clinical grounds
Examine the limb at 15 minutes intervals. If no improvement within 2 hours of removing the
dressings
Muscle will be dead after >4 hours of total
ischemia
![Page 23: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/23.jpg)
Types:
I Single Incision:
![Page 24: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/24.jpg)
![Page 25: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/25.jpg)
II. Double Incision:
![Page 26: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/26.jpg)
![Page 27: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/27.jpg)
Complications:
I. Myonecrosis : after an ischemic insult of > 4 hrs.
Treatment:
fasciotomy + debridement of the muscles + neurolysis
• May lead to myoglobinuria and eventually renal failure.
• Diuresis ( by mannitol,diuretics or IV fluids ) should be prompted to increase the tubular flushing and eliminate the proteinaceous material.
![Page 28: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/28.jpg)
II. Reperfusion syndrome : influx of myoglobin, potassium, and
phosphorus into the circulation
characterized by hypovolemic shock and hyperkalemia
• Evaluation :
• Fluid loss, Shock
• Acidosis
• Hyperkalemia
• Myoglobinuria, Renal failure
• Management :
• Preoperative hydration
• Mannitol
• Bicarbonate
![Page 29: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/29.jpg)
III. Neurovascular injury
IV. Infection
V. Amputation
VI. Death
![Page 30: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/30.jpg)
![Page 31: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/31.jpg)
Abdominal Compartment Syndrome
![Page 32: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/32.jpg)
ACS is a sustained IAP greater
than 20 mm Hg associated with
new organ dysfunction or failure.
![Page 33: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/33.jpg)
Burch Grading system for intra-abdominal hypertension:
Grade Intra-abdominal pressure (mmHg )
I 12 - 15
II 16 - 20
III 21 - 25
IV ≥25
![Page 34: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/34.jpg)
Abdominal Compartment syndrome:
I. Primary
II. Secondary
III. Tertiary
![Page 35: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/35.jpg)
Primary:
• Sustained acute elevation of 10-20 mm Hg
• Physiologic effects are generally well compensated
and thus usually clinically non-significant.
• Non-operative therapy may be required.
![Page 36: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/36.jpg)
Secondary:
• Sustained acute elevation of 21-35 mm Hg.
• Therapy is generally necessary.
Caused by Non-abdominal conditions:
–Major burns
–Sepsis
–Conditions requiring massive fluid resuscitation
![Page 37: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/37.jpg)
Tertiary:
• Sustained acute elevation >35 mm Hg.
• Also known as recurrent ACS, develops after
treatment of primary and secondary ACS.
• Operative abdominal decompression is always
indicated (ACS).
![Page 38: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/38.jpg)
Factors leading to Abdominal
Compartment syndrome:
• Hypothermia
• Massive transfusions
• Sepsis
• Mechanical ventilation
• Pneumonia
• Acidosis
• Excessive fluid resuscitation
![Page 39: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/39.jpg)
Clinical Presentation:
I. Abdominal pain
II. Increased abdominal girth
III. Difficulty in breathing
IV. Decreased urine output
V. Syncope
VI. Malaena
VII.Nausea & vomiting
VIII.H/O Pancreatitis
IX. Cyanosis
![Page 40: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/40.jpg)
Cardio Vascular Effects of ACS:• ↑ Intra-thoracic pressure transmitted through
diaphragm
• Compression IVC
• ↑ Central Venous pressure
• ↓ Preload
• ↓ Cardiac Output
![Page 41: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/41.jpg)
• Tachycardia is the common response
to elevated IAP, compensating for the
decrease in stroke volume in order to
maintain cardiac output.
![Page 42: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/42.jpg)
Pulmonary Effects of ACS:• Both diaphragms are pushed upwards decreasing
the thoracic volume.
• Decreased volume predisposes to atelectasis and
decreases alveolar clearance.
• Pulmonary infections may result.
• Pneumonia is a typical early complication in
abdominal hypertension from diffuse peritonitis.
![Page 43: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/43.jpg)
• ↑ Airway pressure
• ↑ End-inspiratory pressure
• Mechanical impairment of diaphragm
• Decreased pulmonary blood flow
All lead to…
• Decreased PaO2
• Intractable hypercarbia
![Page 44: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/44.jpg)
Renal Effects of ACS:
• Renal vein compression
• Renal parenchymal compression
• Shunting blood away from cortex and functioning glomeruli
• ↑ Anti-Diuretic Hormone release
• Oliguria/Anuria
![Page 45: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/45.jpg)
GI Effects• As IAP increases ,abdominal vascular pressure increases.
• causing diminished arterial blood flow to the organs and resistance to drainage into the veins.
• The diminished oxygenation to the gut leads to intramucosal acidosis.
• The ischemic intestine loses its protective mucosal barrier and becomes more permeable to the intestinal contents.
• Edema develops in the intestinal wall and further increases the IAP.
![Page 46: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/46.jpg)
• blood flow decreases in both the hepatic artery
and the portal vein.
• This change in blood flow leads to:
decreased glucose metabolism,
mitochondrial malfunction
decreased lactate clearance
• Diminished lactate clearance leads to lactic
acidosis.
![Page 47: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/47.jpg)
Measuring Methods:
Direct:– Direct needle puncture and transducer
Intermittent Indirect:– Bladder pressure transducer
Continuous Indirect:– Continuous bladder irrigation method
![Page 48: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/48.jpg)
![Page 49: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/49.jpg)
![Page 50: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/50.jpg)
![Page 51: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/51.jpg)
Methods to lower the IAP:
I. Drainage of intra-abdominal fluid
collection
II. Muscle relaxation
III. Avoiding primary closure of the
incision by applying mesh or Vacuum
assisted closure.
![Page 52: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/52.jpg)
Treatment:
I. Treatment should not be based only upon IAH but
also associated organ dysfunction.
II. Move the patient to emergency immediately
III. Remove any constricting garments
IV. Avoid overly aggressive fluid resuscitation.
![Page 53: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/53.jpg)
Bladder Pressure Treatment
• 10-15 mmHg Monitor
• 16-25 mmHg Monitor
• 26-35 mmHg Decompression
• > 35 mmHg Decompression &
re-exploration
![Page 54: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/54.jpg)
Complication:
The correction of IAH can lead to
ischemia reperfusion injury and send
inflammatory cytokines to other
organs, causing multisystem organ
failure.
![Page 55: Compartment Syndrome](https://reader030.vdocuments.net/reader030/viewer/2022032421/55a646f71a28ab492e8b468d/html5/thumbnails/55.jpg)
THANK YOU