Poisoning-induced acute atraumatic compartment syndrome

Acute Atraumatic Compartment Syndrome (AACS) can be a potentially life and limb threatening complication of either drug abuse or medication injection. Prompt recognition followed by emergency fasciotomy is required to avoid permanent disability. A better understanding of the different clinical presentations may lead to improved outcomes through more expedient diagnosis and treatment. We describe five new cases of AACS caused by illicit drug abuse within the McGill University Hospitals, with a review of all 102 similar patients previously documented in the literature between January 1970 and May 1997. The average age for all cases was 29 years, with 74% being male. The presence of edema, pain, tension, and skin changes were the most frequent symptoms and signs reported. There appear to be two distinct mechanisms of poisoning-induced AACS: (1) direct vasotoxicity and (2) limb compression caused by prolonged comatose state. Direct vasotoxicity is more likely to lead to eventual amputation, whereas prolonged limb compression is more likely to progress to systemic complications such as azotemia, hypotension, cardiac arrhythmia, and renal failure (Crush Syndrome). Long-term sequelae of motor loss, sensory disruption, and development of contracture were common in AACS of both causes. Because Compartment Syndrome is a surgical emergency, primary care and emergency physicians must have a high index of suspicion to promptly recognize and treat this problem.     

Orthopedic pitfalls in the ED: acute compartment syndrome

Acute compartment syndrome is a rare but potentially disastrous complication of orthopedic injury to the extremities. Compartment syndrome occurs when the circulation and function of muscle within a closed fascial space are compromised by increased pressure within that space. Early diagnosis and treatment is crucial to prevent the devastating complications of this condition. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner.     

Missed acute isolated peroneal compartment syndrome

This paper outlines 3 cases of acute isolated peroneal (lateral) compartment syndrome following exertion, minor trauma or overuse. Compartment syndromes are usually associated with crush injuries or fractures; they are an uncommon development following minor trauma or overuse. In acute isolated peroneal compartment syndrome the diagnosis is often delayed, resulting in permanent impairment. Persistent or worsening pain following a minor injury or overuse is typical, and the initial physical findings are often nonspecific, although swelling and tenderness out of proportion to the described injury are common. Marked increase in pain with passive inversion and dorsiflexion of the ankle should suggest the diagnosis. In cases that present late or where the diagnosis is initially missed, there is often a common peroneal nerve palsy. As with all compartment syndromes, prompt diagnosis and surgical decompression is necessary to prevent permanent impairment.     

Pulmonary capillary pressures during the acute respiratory distress syndrome

Objectives (1)To describe the evolution of pulmonary capillary pressure (Pcap) and of the pressure drop across the pulmonary venous bed from early to established acute respiratory distress syndrome (ARDS), (2) to assess Pcap under different levels of positive end-expiratory pressure (PEEP) and (3) to compare the visual method and a mathematical model to determine Pcap.Design Prospective, intervention study.Setting Intensive care unit in a teaching institution.Patients Nine ARDS patients, according to the ARDS Consensus Conference criteria.Interventions Pulmonary arterial pressures were measured during routine respiratory mechanics measurements throughout ARDS. Four PEEP levels (6, 9, 12 and 15 cmH₂O) were studied.Measurements and results Pulmonary artery occlusions were made in triplicate at each PEEP level. Pcap was determined for every occlusion trace by three observers (visual method) and a mathematical model. Diastolic pulmonary artery pressure (PAPd) and pulmonary artery occlusion pressure (PAOP) were measured. The visually determined Pcap showed a bias of 2.5±2.1 mmHg as compared to the mathematical estimation. PAPd, Pcap and PAOP tended to decrease from early to late ARDS (p=0.128, 0.265, 0.121). Pcap–PAOP (6.3±2.7 mmHg) did not change throughout ARDS. Higher PEEP levels were associated with increased PAPd, Pcap and PAOP, as well as with larger Pcap–PAOP throughout ARDS.Conclusions Pulmonary capillary pressure cannot be predicted from PAOP during early and established ARDS. The high variability in Pcap–PAOP increases the risk for underestimation of filtration pressures and consequently the risk for lung edema. Pcap can be estimated at the bedside by either the visual or mathematical methods.     

Theophylline toxicity causing rhabdomyolysis and acute compartment syndrome

A case of acute compartment syndrome is described in a young man as a result of theophylline toxicity. Profound hypokalaemia and grand mal seizures are considered as potential causes of rhabdomyolysis and the subsequent development of compartment syndrome.     

超声诊断急性肢体骨筋膜室综合征进展

早期诊断并及时处理急性肢体骨筋膜室综合征(AECS)十分重要，而漏诊率较高。目前多基于临床表现和有创骨筋膜室压力检测诊断AECS,尚未达成相关标准共识，导致难以确定手术干预时机。超声已用于评估骨筋膜室综合征。本文就超声诊断AECS进展进行综述。     

Opening pressures and atelectrauma in acute respiratory distress syndrome

Purpose

Open lung strategy during ARDS aims to decrease the ventilator-induced lung injury by minimizing the atelectrauma and stress/strain maldistribution. We aim to assess how much of the lung is opened and kept open within the limits of mechanical ventilation considered safe (i.e., plateau pressure 30 cmH₂O, PEEP 15 cmH₂O).

Methods

Prospective study from two university hospitals. Thirty-three ARDS patients (5 mild, 10 moderate, 9 severe without extracorporeal support, ECMO, and 9 severe with it) underwent two low-dose end-expiratory CT scans at PEEP 5 and 15 cmH₂O and four end-inspiratory CT scans (from 19 to 40 cmH₂O). Recruitment was defined as the fraction of lung tissue which regained inflation. The atelectrauma was estimated as the difference between the intratidal tissue collapse at 5 and 15 cmH₂O PEEP. Lung ventilation inhomogeneities were estimated as the ratio of inflation between neighboring lung units.

Results

The lung tissue which is opened between 30 and 45 cmH₂O (i.e., always closed at plateau 30 cmH₂O) was 10 ± 29, 54 ± 86, 162 ± 92, and 185 ± 134 g in mild, moderate, and severe ARDS without and with ECMO, respectively (p < 0.05 mild versus severe without or with ECMO). The intratidal collapses were similar at PEEP 5 and 15 cmH₂O (63 ± 26 vs 39 ± 32 g in mild ARDS, p = 0.23; 92 ± 53 vs 78 ± 142 g in moderate ARDS, p = 0.76; 110 ± 91 vs 89 ± 93, p = 0.57 in severe ARDS without ECMO; 135 ± 100 vs 104 ± 80, p = 0.32 in severe ARDS with ECMO). Increasing the applied airway pressure up to 45 cmH₂O decreased the lung inhomogeneity slightly (but significantly) in mild and moderate ARDS, but not in severe ARDS.

Conclusions

Data show that the prerequisites of the open lung strategy are not satisfied using PEEP up to 15 cmH₂O and plateau pressure up to 30 cmH₂O. For an effective open lung strategy, higher pressures are required. Therefore, risks of atelectrauma must be weighted versus risks of volutrauma.

Trial registration

Clinicaltrials.gov identifier: NCT01670747 (www.clinicaltrials.gov).

     

A rare case of acute compartment syndrome after saphenectomy

Saphenectomy is one of the most validated criteria to treat varicose veins of the lower legs. Although many complications were well described, little is known about compartment syndrome due to muscle ischemia caused by constrictive bandages applied after stripping of varicose veins. We presented a case of successful conservative treatment of compartment syndrome after saphenectomy. Rehabilitation was found effective in improving fatigue, stiffness and tenderness showing the effectiveness of the combined conservative-rehabilitative treatment. However conservative treatment could not be considered the treatment of choice in daily practice. A severity score assessment of compartment syndrome should be useful to assess to which patients is allowed to not perform fasciotomy.     

小腿急性骨筋膜室综合征灰阶超声表现

目的探讨小腿急性骨筋膜室综合征(OCS)灰阶超声表现,评价超声在急性OCS中的诊断价值.方法回顾性分析21例小腿急性OCS的超声检查资料.结果 21例患侧小腿皮下层均增厚,13例皮下层与肌肉之间见液性无回声,骨筋膜室增厚,深筋膜完整,室内肌肉肿胀,回声不均匀增强,肌纹理不清或消失,15例肌间出现液性无回声或血肿.小腿皮下层及骨筋膜室变化范围越大,小腿OCS病变程度越重.结论小腿急性OCS灰阶超声声像图表现具有一定的特征性,超声检查可作为临床诊断OCS的重要参考依据.     

重症急性胰腺炎并发腹腔间隔室综合征的治疗

近年来,随着重症急性胰腺炎（SAP）并发腹腔间隔室综合征（ACS）的患者逐渐增多和病死率居高不下,研究SAP并发ACS的临床医师越来越多,但迄今在治疗方面仍未找到一套标准的治疗方案,本文将就最新的SAP并发ACS的治疗方案做一综述。     

Rhabdomyolysis associated with compartment syndrome resulting in acute renal failure.

Compartment syndrome has rarely been reported associated with acute rhabdomyolysis. In the case described, the rhabdomyolysis was severe enough to cause compartment syndrome and acute renal failure after moderate exercise and alcohol intake and had the appearance of a myositis. The case emphasizes the importance of early recognition of compartment syndrome, as loss of pulses is a very late sign, and the examination of the urine to detect myoglobinuria in rhabdomyolysis. Measurement of creatine kinase is predictive of the extent of muscle damage and the development of renal failure.     

重症急性胰腺炎合并腹腔间隔室综合征的治疗

腹腔间隔室综合征(ACS)是重症急性胰腺炎(SAP)病情严重的标志。它是由腹膜后炎症、内脏水肿、腹水、急性胰周积液、麻痹性肠梗阻和积极液体复苏共同作用的结果。SAP并发ACS的治疗包括保守治疗、微创,还有一些不确定的适当的手术干预。但仍有一些尚未解决的问题包括药物治疗、适应证、时机和介入技术。本文将对SAP并发ACS的治疗进行综述,以期通过及时有效的内科治疗和必要时的介入治疗来预防ACS的发生和发展,从而降低SAP的病死率。     

基于健康人急性骨筋膜室综合征模型的超声监测价值研究

目的:探讨超声在急性骨筋膜室综合征模型早期无创监测中的应用价值,为进一步的临床应用提供参考。方法:为前瞻性自身对照研究。通过袖带加压法建立小腿急性骨筋膜室综合征的健康志愿者模型,随机数字法确定一侧小腿为实验组,袖带依次给予0、20、30、40、50、60、70、80 mmHg (1 mmHg=0.133 kPa)压力,对照组的小腿袖带不加压。实验组每个压力水平持续5 min,期间应用超声测量双侧腘动脉、腘静脉及足背动脉的血流频谱及血管结构指标。采用重复测量方差分析和多变量方差分析进行统计分析。结果:研究共纳入25名健康志愿者,双侧小腿围和胫前筋膜室厚度的差异无统计学意义（ P=0.314、0.678）,小腿袖带加压期间心率及血压稳定（ P=0.235、0.358）。实验组腘动脉收缩期最大血流速、最小血流速均随袖带压力的增大而增加,从加压30 mmHg起实验组腘动脉最大血流速明显高于对照组[(73±19) cm/s vs (59±14) cm/s, P=0.023)],从加压20 mmHg起实验组腘动脉最小血流速显著高于对照组[(-28±8) cm/s vs (-22±6) cm/s, P=0.012)]。随着压力的增加,实验组腘动脉舒张期反向血流比增加（ P<0.001）,加压20 mmHg时即显著大于对照组[(0.42±0.14）cm/s vs (0.30±0.12) cm/s, P=0.009)]。实验组足背动脉正向血流比随压力增加而减小（ P=0.024）。 结论:在健康人急性骨筋膜室综合征模型中,随着筋膜室压力的增加,近端动脉的收缩期最大血流速、舒张期反向血流比例明显增加,远端动脉的收缩期正向血流比例明显减少,提示超声可用于急性骨筋膜室综合征的早期监测,值得进一步的临床研究。     

控制引流治疗腹腔积液继发腹腔间隙综合征

目的：观察腹腔置管持续控制引流治疗急性腹腔积液所致儿童腹腔间隙综合征（ abdominal compartment syndrome , ACS）的临床疗效。方法回顾性分析2011-05～2013-05收住中山大学附属第一医院PICU的12例急性腹腔积液所致儿童ACS采用腹腔持续置管控制性引流治疗的患儿,并与8例未能接受引流的急性腹腔积液所致儿童ACS病例进行对比。结果12例急性腹腔积液继发ACS 患儿中,病因为腹腔肿瘤破裂出血7例（7／12）,肝肾移植术后3例（3／12）,尿瘘致尿性腹水2例（2／12）。引流组在治疗前的腹腔压力、脏器受累数量及危重病评分与未引流组比较差异无统计学意义。在ACS患儿中,呼吸道及胃肠道为受累最多的器官,腹腔压力越高,脏器损害数量及病死率越高。引流组较未引流组死亡率明显降低（引流3／12 vs未引流8／8,P＜0．001）。腹腔置管引流偶有发生腹腔感染和电解质紊乱的并发症。结论腹腔置管持续控制性引流是一个微创、高效而安全的治疗急性腹腔积液继发ACS的方法,能有效降低IAP,减少脏器损害的发生,大大降低了死亡率,为原发病的救治争取更多的时间。