Compartment syndrome with high criteria2024.pptx

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1. Mohamad Taha, MD Consultant Vascular Surgery MTH and AFHSR 2024 Compartment Syndromes BY

2. Compartment Syndrome A clinical symptom complex resulting from pathologically increased tissue pressure contained in a non expansible space with a potential to cause irreversible damage to the contents of the closed compartment, has been described in a variety of anatomic locations. This condition most commonly is observed after acute injury or ischemia in the lower and upper extremities. The compartments of the leg , foot and the volar (flexor) compartment of the forearm are particularly prone to developing compartment syndrome.

3. Types of Compartment Syndrome

4. Chronic exertional compartment syndrome (CECS) Active people and athletes affected by chronic exertional compartment syndrome (CECS) experience progressive leg pain during exercise, limiting their activity and performance. The mechanism of this pathological condition is an abnormal and progressive increase in intra-compartmental pressure (ICP) in one or more compartments of the leg leading to impaired local tissue perfusion that results in muscle ischemia and oxidative damage. The current diagnostic method is based on subjective clinical assessment confirmed by invasive measurement of the leg’s intra-compartmental pressure (ICP) during exercise. The technique involves inserting multiple needles into the leg compartments and recording ICP changes before, during, and after an exercise protocol.

5. Other Sites Abdominal compartment syndrome is an increasingly recognized, potentially lethal complication of trauma resuscitation or surgical procedures. It is a Symptomatic organ dysfunction that results from increased intr -abdominal pressure (IAP). Other clinical conditions: epidural compartment syndromes, closed head injury, testicular torsion, angle-closure glaucoma and cardiac tamponade.

6. Surgical Management of Compartment Syndrome is DECOMPRESSION OF THE COMPARTMENT

7. Pericardial Compartment Syndrome

8. Is associated with increasing pressures in the pericardial sac and can be secondary to venous, arterial or cardiac injury. Beck's triad of elevated central venous pressure, hypotension, and muffled heart sounds is a late manifestation of the pericardial compartment syndrome. Early detection of post- traumatic hemopericardium should lead to immediate thoracic decompression by pericardiocentesis before the late manifestations develop.

9. Subxiphoid Approach Parasternal Approach

10. Spinal Compartment Syndrome Spinal cord drainage

11. It occurs in patients undergoing operation for extensive thoracoabdominal aortic aneurysm surgery. Although the incidence of paralysis and paraparesis has been less with TEVAR than traditional open repair in most series, it does occur. Spinal cord drainage to a pressure of 10 cm H2O and avoidance of hypotension are effective in reducing paraplegia.

12. Abdominal Compartment Syndrome The new killer

13. Abdominal compartment syndrome (ACS) results from an increase in intra-abdominal pressure (IAP) within the relatively fixed outlines of the abdominal cavity. This increase in abdominal pressure can have harmful consequences on multiple organ systems and amongst the intensive care population is associated with increased morbidity and mortality. Trauma victims commonly have multiple risk factors for the development of ACS. IAH often defined as IAP > 12 mmHg. ACS was defined as a sustained IAP above 20 mmHg with evidence of organ dysfunction or failure.

14. Causes of Intra-abdominal Pressure Elevation Retroperitoneal : pancreatitis, retroperitoneal or pelvic bleeding, contained AAA rupture, aortic surgery, visceral edema. Intraperitoneal : intraperitoneal bleeding, AAA rupture, acute gastric dilatation, bowel obstruction, ileus, mesenteric venous obstruction, pneumoperitoneum, abdominal packing, visceral edema secondary to massive fluid resuscitation. Abdominal Wall : burn eschar, repair of omphalocele, reduction of large hernias, pneumatic anti-shock garments, laparotomy closure under tension, abdominal binders. Chronic : central obesity, ascites, pregnancy, large abdominal tumors.

15. In the abdomen, elevated compartment pressure is manifested by the following triad: Oliguria Reduced cardiac output that does not improve with intravascular fluid replacement Hypoxia and Increased airway pressures

16. MANAGEMENT GRADING OF ABDOMINAL COMPARTMENT SYNDROME ACCORDING TO WSACS Abdominal perfusion pressure (APP)   APP = MAP – IAP In one retrospective study, the inability to maintain an APP above 50 mmHg predicted mortality with greater sensitivity and specificity than either IAP or MAP alone . Studies suggest that maintaining an APP of 60 mmHg represents an appropriate resuscitation goal. Intensive Care Med. 2013 Jul;39(7):1190-206

17. Medical Management The head up position is favoured by many intensive care units. Adequate sedation, analgesia and fluid resuscitation. Muscle relaxation with neuromuscular blockers (NMB). Nasogastric aspiration, rectal drainage or enemas. Prokinetic agents such as metoclopramide or erythromycin. Percutaneous abdominal drainage for fluid, air, abscess or blood.

18. Surgical Management In ACS refractory to medical management, surgical abdominal decompression can be a life saving intervention if IAP is above 25 mmHg (laparotomy with TAC). Surgical decompression results in an abdomen that cannot be definitively closed which requires temporary closure. A number of devices exist to achieve this such as the ‘Bogota bag’ or ‘vacuum pack systems’ . Other options: Laparoscopic decompression and continuous negative extraabdominal pressure.

19. Continuous negative extra abdominal pressure (NEXAP) NEXAP applied by shell on abdomen. Intra-abdominal pressure may be decreased non-invasively by continuous negative extraabdominal pressure (NEXAP). Intensive Care Med 2003; 29(11):2063-7.

20. Abdominal contents contained with a Bogota Bag applied to the anterior fascia OPERATIVE DECOMPRESSION

21. OPERATIVE DECOMPRESSION Vacuum-assisted temporary abdominal closure device: thin plastic sheet, a sterile towel, closed suction drains, and a large adherent operative drape. This dressing system permits increases in intra-abdominal volume, without a dramatic elevation in IAP.

22. Vacuum-assisted temporary abdominal closure device Post-operative dressing Several days post-op

23. 24 Extremity Compartment Syndrome

24. Extremity Compartment Syndrome

25. Compartment syndrome refers to increased intramuscular pressures associated with reperfusion or traumatic injury and confined by the fascial envelopes of the muscles of the extremities and can be defined as myoneural necrosis secondary to elevated pressures within a closed osteofascial compartment. Traditionally, calf compartment syndrome have been the most commonly diagnosed.

26. Recommended threshold for fasciotomy is persistent compartment pressure above 30mmHg. Defining compartment syndrome based on an absolute pressure threshold is appealing in its simplicity but ignores the role of arterial blood pressure in affecting compartmental blood flow

27. Pulses are usually intact as ischemia is at tissue level In one series in management of vascular injuries and their sequelae in pediatric supracondylar humeral fractures, the only patient who developed a Volkmann’s contracture had a palpable pulse until just prior to fasciotomy.

28. The unifying feature of all compartment syndromes, regardless of etiology or anatomic location, is an increase in intracompartmental pressure (ICP) within an unyielding fascial envelope that impairs tissue perfusion.

29. Fractures The most common cause Incidence of accompanying compartment syndrome is of about 10% The incidence is directly proportional to the degree of injury to soft tissue and bone and increased by traction. Blick et al JBJS 1986

30. Blunt Trauma 2 nd most common cause About 23% of CS 25% due to direct blow McQueen et al; JBJS Br 2000

31. Vascular Causes The most common vascular etiologies for compartment syndrome are ischemia-reperfusion injury associated with acute ischemia, arterial and venous traumatic injuries, crush injuries, phlegmasia cerulea dolens , and hemorrhage within a compartment.

32. Pathophysiology

33. Dynamic Intracompartmental Pressure Threshold The pressure at which capillary blood flow ceases has been debated over the decades. The concept of a critical closing pressure was one of the earliest concepts, whereas more recent research suggests that the dynamic ICP threshold more accurately predicts which muscle compartments will develop compartment syndrome. The arterial-venous pressure gradient is the critical determinant of capillary blood flow. The pressure threshold for decompression. J Bone Joint Surg Br. 1996;78:99–104.

34. The most appropriate ICP criteria are ICP minus mean blood pressure < 40 mm Hg or ICP minus diastolic blood pressure < 10 mm Hg. Patients with higher diastolic pressure can tolerate higher tissue pressure without ischemia. However, if patient is hypotensive, they can have significant ischemia at lower compartment pressures. Mean BP = Diastolic BP + 1 third of pulse pressure [MAP − ICP] < 40 mm Hg [DP − ICP] < 10 mm Hg J Orthop Trauma. 1993;7:199–210.

35. Dynamic pressure threshold prevents unnecessary fasciotomy in a number of patients with absolute ICP exceeding 30 mm Hg

36. Tissue Survival Muscle 3-4 hours - reversible changes 6 hours - variable damage 8 hours - irreversible changes Nerve The nerve tissue is the most sensitive to ischemic changes . 2 hours - looses nerve conduction 4 hours - neuropraxia 8 hours - irreversible changes The differential susceptibility to injury between tissues may provide an explanation for those cases in which a delayed fasciotomy fails to restore full neurologic function despite viable muscle in the compartment.

37. Ischemia-reperfusion Injury Ischemia-reperfusion Injury increases compartment volume by causing muscle tissue injury, which leads to increased microvascular permeability with efflux of plasma proteins and progressive interstitial edema. With reperfusion, oxygen radical generation exacerbates microvascular permeability and resulting interstitial edema. Myoglobin is released from ischemia-damaged muscle cells in a severely ischemic limb. The myoglobin enters the general circulation after reperfusion and precipitates in renal tubules resulting in renal failure.

38. Risk factors for compartment syndrome after acute arterial ischemia Prolonged ischemia time (>6 hours) Young age Insufficient arterial collaterals Acute time course for arterial occlusion Hypotension Poor back-bleeding from the distal arterial tree at embolectomy Combined arterial and venous injuries

39. Late Pathologic Consequences Undiagnosed compartment syndrome frequently progresses to skeletal muscle infarction and nerve injury . Infection is a frequent cause of additional morbidity, especially when fasciotomy has been performed and wound closure is delayed. If untreated, compartment syndrome may progress to rhabdomyolysis , with release of multiple metabolic toxins, such as myoglobin , potassium and organic acids. This may lead to myoglobinuric renal failure , progressive organ failure, and a high mortality rate. In this condition, amputation should be considered early because it can be lifesaving.

40. Diagnosis pain Paresthesias Swelling

41. Pain The diagnosis of an acute compartment syndrome begins with a high index of suspicion. Symptoms of a compartment syndrome include pain that is disproportionate to the magnitude of the injury and parasthesia in the distal extremity. The pain is typically not relieved by immobilization or reduction of fractures and responds poorly to analgesic medications. Paresthesias represent an early symptom of ischemia of the nerves traversing the muscle compartment in question.

42. Symptoms : deep muscle pain, pain on passive motion, muscle weakness or paralysis, hyperthesia, and tense swollen muscle compartments. Limb may feel tense or hard. Pulses are usually intact as ischemia is at tissue level. Measurement of intracompartmental pressure. Measurement of dynamic intracompartmental pressure. If accurate measurements can not be performed, or if the results are conflicting a clinical diagnosis should lead to compartment decompression.

43. A careful neurologic examination should document sensory and motor function distal to the compartment, focusing especially on the nerves that traverse the compartment at risk. For example, a compartment syndrome afflicting the anterior compartment of the lower leg may be accompanied by dysfunction of the deep peroneal nerve, causing numbness at the first dorsal webspace of the foot or inability to extend the great toe. Loss of two-point discrimination is a relatively sensitive indicator of developing compartment syndrome.

44. Pressure Measurements Indications Suspected compartment syndrome. Equivocal or unreliable examination. Unconscious patients and pediatric patients Chronic compartment syndrome. Contraindications Clinically evident compartment syndrome. A normal compartment pressure is ≤10 to 12 mm Hg

45. The most commonly used ICP measuring systems are the arterial line manometer and handheld Stryker system. The arterial line manometer is ideally suited for use in the intensive care unit and operating room where pressure transducers and monitors are readily available. In the emergency room the handheld Stryker system is particularly convenient. The anterior compartment of the lower leg and the flexor compartment of the forearm are most prone to compartment syndrome.

46. The Stryker Intra-Compartmental Pressure Monitor System Easy to use Can check multiple compartments Different areas in one compartment

47. Stryker system

48. Measurement of Intra-Compartmental Pressure by an Arterial line manometer

49. Measurement of Intra-Compartmental Pressure by an Arterial line manometer

50. Management

51. Impending compartment syndrome Ensure patient is normotensive, as hypotension reduces perfusion pressure and facilitates further tissue injury. Remove circumferential bandages and cast Maintain the limb at level of the heart as elevation reduces the arterial inflow and the arterio-venous pressure gradient on which perfusion depends. Supplemental oxygen administration.

52. Prevention of Systemic Sequelae Myonecrosis associated with compartment syndrome may liberate intracellular potassium , phosphate, myoglobin, and creatine phosphokinase (CPK). Treatments designed to prevent systemic sequelae of compartment syndrome are aimed at preventing further complications related to the electrolyte disturbances or myoglobinuria that result from extensive myonecrosis . Myoglobinuria exerts its nephrotoxic effects by inducing renal vasoconstriction, tubular cast formation, and direct hemeprotein–induced cytotoxicity. The management of myoglobinuria includes aggressive crystalloid infusion, forced diuresis with mannitol, and alkalinization of the urine with bicarbonate.

53. Emergent Treatment Fasciotomy

54. Indications for Fasciotomy Rutherford 2019

55. Fasciotomy • Surgical Fasciotomy (compartment release) • Often combined with orthopedic reduction or stabilization and vascular repair if needed. • Goal is to restore muscle perfusion within 6 hours. Fasciotomy For All muscle compartments !!!

56. Fasciotomy A technically successful fasciotomy consists of the following: 1. Use a generous incision for complete incision of the skin overlying the affected compartments. 2. Jensen et al. found that 12% of subcutaneous fasciotomies , using minimal incisions, had incomplete decompression requiring reoperation to extend the skin incision. 3. Longitudinal incision of the entire fascia investing each of the compartments. 4. Meticulous local wound care followed by complete closure or coverage when the swelling subsides. Eur J Vasc Endovasc Surg. 1997;13:48–53.

57. Fasciotomies of the Leg Fibulectomy radical procedure, rarely performed Single-incision perifibular fasciotomy Double-incision fasciotomy

58. Single Incision Technique Single lateral incision just posterior to fibula Common peroneal nerve injury Most surgeons no longer perform a fibulectomy Most vascular surgeons now favor the double-incision technique.

59. Double-incision fasciotomy of the lower leg In most instances it affords better exposure of the four compartments. 2 vertical incisions separated by minimum 8 cm One incision over anterior and lateral compartments, 4 cm lateral to the crest of the tibia and 5 cm distal to the fibular head. Superficial peroneal nerve One incision located 1-2 cm behind postero -medial aspect of tibia (a medial incision slightly posterior to the edge of the tibia). Saphenous nerve and vein

60. Two Incision Technique The most commonly injured nerve during a fasciotomy of the lower leg is the superficial peroneal nerve , which branches from the common peroneal nerve at or below the proximal fibular head and descends in the lateral compartment along the intermuscular septum separating the anterior and lateral compartments.

61. Fasciotomy in the Thigh Single lateral incision to release anterior and posterior compartments May require medial incision for adductor compartment Lateral septum Vastus lateralis Thigh compartment syndrome is usually caused by blunt trauma from motor vehicle accidents, contusion or crush injury and the anterior thigh compartment is most commonly involved

62. Gluteal compartment syndrome Gluteal compartment syndrome has been associated with hypogastric artery ligation or embolization during aortic aneurysm repair, hip arthroplasty, and prolonged compression during operative procedures. Gluteal compartment syndrome has been cited as a cause of rhabdomyolysis , renal failure , and sciatic nerve palsy .

63. 2 Dorsal incisions to release the interosseous and adductor compartments 1 Medial incision to release the medial, superficial lateral and calcaneal compartments Compartment Syndrome of the Foot

64. Forearm Compartment Syndrome

65. Four interconnected compartments of the forearm are recognized The forearm is the most frequent site of compartment syndrome in the upper extremity. Within the forearm, there are volar (flexor, superficial, and deep), lateral (mobile wad), and the extensor (dorsal, superficial, and deep) compartments. The volar, or Henry, fasciotomy uses a single incision to decompress both the lateral and volar compartments. If the dorsal ICP is elevated, a long incision from the lateral epicondyle to the wrist. Carpal tunnel releases are controversial and may not be of benefit in isolated forearm compartment syndromes.

66. Forearm Fasciotomy

67. Forearm Fasciotomy

68. Fasciotomy o f the Hand 2 palmar metacarpal incisions + carpal tunnel release 2 longitudinal dorsal incisions over the 2nd & 4th metacarpals

69. FASCIOTOMY WOUND MANAGEMENT Fasciotomy may solve the problem of increased ICP, but resulting wounds may be a source of considerable short and long term morbidity. The goal of wound care early after fasciotomy is preventing further muscle injury or necrosis until muscle swelling subsides sufficiently to permit closure. When muscle viability is questionable, periodic saline dressings permit caregivers the opportunity to inspect and debride the wound at regular intervals. Vacuum-assisted closure ( VAC ) therapy is an alternative means of wound coverage, although the wound should be inspected at frequent intervals early after fasciotomy. After tissue viability is ensured and wound swelling has subsided, the priority shifts to wound closure .

70. Fasciotomy Wound Closure Fasciotomy wound closure has been attained through a variety of approaches. The options include delayed primary closure, closure by secondary intention, gradual dermal apposition, split-thickness skin grafting (STSG), and myocutaneous flap coverage.

71. Fasciotomy wound of the lower leg closed with temporary synthetic skin replacement Gradual dermal apposition Skin graft after fasciotomy VAC

72. Complications Related to Fasciotomies Altered sensation within the margins of the wound (77%) Dry, scaly skin (40%) Pruritis (33%) Discolored wounds (30%) Swollen limbs (25%) Tethered scars (26%) Recurrent ulceration (13%) Muscle herniation (13%) Pain related to the wound (10%) Tethered tendons (7%)