Appendicitis ayen060589

7/26/2019 Appendicitis ayen060589

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COMPARTMENTCOMPARTMENT

SYNDROMESSYNDROMES


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The Doctors Must Learn toThe Doctors Must Learn to

Recognize the Presence of SuchRecognize the Presence of SuchInjuries, i!e ACSInjuries, i!e ACS Occur in "# $ of %atientsOccur in "# $ of %atients

&ho sustain 'unt trau(a&ho sustain 'unt trau(a

))(uti%e trau(a(uti%e trau(a

**

Protect fro( futherProtect fro( futher

+isa'iit+isa'iit

Pre-ent co(%icationsPre-ent co(%ications


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Compartment SyndromeCompartment Syndrome

Crush Injury with Compartment SyndromeCrush Injury with Compartment Syndrome


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Compartment syndromeCompartment syndrome

The deep fasciaThe deep fascia

envelops the limbsenvelops the limbs

Other fascial planesOther fascial planes

divide the limbs intodivide the limbs into

compartmentscompartments

The forearm hasThe forearm has twotwo


The thigh hasThe thigh has threethree


The lower leg thereforeThe lower leg therefore

hashas four compartmentsfour compartments


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Compartment SyndromeCompartment Syndrome

Compartment pressureCompartment pressure

Nerve / muscle ischemiaNerve / muscle ischemia necrosisnecrosis

!ain" paresthesia" paresis" swelling!ain" paresthesia" paresis" swelling #elease constricting devices#elease constricting devices

Suspect in tibial" forearm fracture" afterSuspect in tibial" forearm fracture" after

revasculari$ation" inrevasculari$ation" in unconsciousunconsciouspatientpatient%arly surgical consult%arly surgical consult


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ACUTE COMPARTMENT SYNDROMEACUTE COMPARTMENT SYNDROME

DiagnosisDiagnosisClassic 5 P signs :Classic 5 P signs : Pain, Paraesthesia, Pallor,Pain, Paraesthesia, Pallor,

Pulselessness, Poikiloth!iaPulselessness, Poikiloth!ia

NOT clinicall relia"le, !ani#est in $ATE stageNOT clinicall relia"le, !ani#est in $ATE stage

%MPORTANT :%MPORTANT : PainPain: increasing, out o# &ro&ortion: increasing, out o# &ro&ortion

to the original in'ur,to the original in'ur, STRETC(STRETC(&ain&ain

) Paraesthesia * t+o &oint) Paraesthesia * t+o &oint

iscri!inationiscri!ination

Pain +illPain +ill a#ter &ressure inuce ische!ia a-ectsa#ter &ressure inuce ische!ia a-ects

conucti.it o# ner.esconucti.it o# ner.es &ainless state /&ainless state /

Ani!al !oel : loss o# ner.e conuction occursAni!al !oel : loss o# ner.e conuction occurs+ithin 0 hours a#ter onset ische!ia+ithin 0 hours a#ter onset ische!ia


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Patho&hsiologPatho&hsiolog

%n'ur%n'ur

Arterial in'urArterial in'ur

Trau!aticTrau!atic%n1a!!ator%n1a!!ator

Res&onseRes&onse

(ae!orrhage(ae!orrhage

Ee!aEe!a

%sche!ia%sche!ia

%CP%CP

Per#usiPer#usi

223icious ccle43icious ccle4


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!athophysiology!athophysiology

The nor(a o&er i(' -enous %ressure isThe nor(a o&er i(' -enous %ressure isa fe& ((.ga fe& ((.g

Nor(a intraco(%art(enta %ressures areNor(a intraco(%art(enta %ressures are

in the range / 0 1/ ((.gin the range / 0 1/ ((.gCo(%art(enta %ressure +oes notCo(%art(enta %ressure +oes not

interfere &ith 'oo+ fo&interfere &ith 'oo+ fo&S&eing &ithin a facia co(%art(entS&eing &ithin a facia co(%art(ent

resuts in increase+resuts in increase+intraco(%art(entaintraco(%art(enta%ressure%ressure


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!athophysiology!athophysiology

Initia -enous co(%ro(ise (a %rogressInitia -enous co(%ro(ise (a %rogressto re+uce+to re+uce+ ca%iar fo&ca%iar fo&

This e2acer'ates the ischae(ic insut an+This e2acer'ates the ischae(ic insut an+

further increases %ressurefurther increases %ressureA -icious cce of increasing %ressuresA -icious cce of increasing %ressures

can 'e initiate+can 'e initiate+

Arteria info& rare re+uce+ unessArteria info& rare re+uce+ uness%ressure e2cee+ sstoic 'oo+ %ressure%ressure e2cee+ sstoic 'oo+ %ressure


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Patho&hsiologPatho&hsiolog

Conce&ts o#Conce&ts o# Critical Closing PressureCritical Closing PressureCCP6 :CCP6 :

&ressure i-erence "et+een intralu!inal&ressure i-erence "et+een intralu!inal

&ress an interstitial &ress %CP6&ress an interstitial &ress %CP6 &re.ent&re.ent

colla&se o# arteriolescolla&se o# arterioles sustain localsustain local&er#usion&er#usion

%n ACS%n ACS %CP%CP CCPCCP ecrease &er#usionecrease &er#usion

ische!iaische!ia ca&illar &er!ea"ilitca&illar &er!ea"ilit 1ui1ui into interstitial s&aceinto interstitial s&ace %CP%CP ische!iaische!ia

.icious ccle.icious ccle


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&etiology&etiology

Ortho%ae+icOrtho%ae+icTi'ia fractures )es%ecia co((inute+Ti'ia fractures )es%ecia co((inute+

fractures*fractures*3orear( fractures3orear( fractures

4ascuar4ascuar

Ischae(ia0re%erfusion injurIschae(ia0re%erfusion injur.ae(orrhage.ae(orrhagePheg(asia caeruea +oensPheg(asia caeruea +oens


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&etiology&etiology

IatrogenicIatrogenic

4ascuar %uncture in anticoaguate+ %atients4ascuar %uncture in anticoaguate+ %atients

Intra-enous or intra0arteria +rug injectionIntra-enous or intra0arteria +rug injection

Soft0tissue injurSoft0tissue injur

Proonge+ i(' co(%ressionProonge+ i(' co(%ression

Crush injurCrush injur

5urns5urns


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Clinical featuresClinical features

Co(%art(ent sn+ro(es are nor(a seen &ithCo(%art(ent sn+ro(es are nor(a seen &ith

6" hours of injur6" hours of injur

T%ica cinica features incu+e7T%ica cinica features incu+e7

Increasing %ain +es%ite i((o'iisation of fractureIncreasing %ain +es%ite i((o'iisation of fractureAtere+ sensation in the +istri'ution of ner-es %assingAtere+ sensation in the +istri'ution of ner-es %assing

through the co(%art(entthrough the co(%art(ent

Musce ten+ernessMusce ten+erness

E2cessi-e %ain on %assi-e (o-e(entE2cessi-e %ain on %assi-e (o-e(ent

Peri%hera %uses (a sti 'e %resentPeri%hera %uses (a sti 'e %resent


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DiagnosisDiagnosisClinical assess!ent nee aClinical assess!ent nee a (%7( %NDE8(%7( %NDE8

o# sus&icion :o# sus&icion :

%MPORTANT : CS can occur a#ter an in'ur%MPORTANT : CS can occur a#ter an in'ur regarless o# etiologregarless o# etiolog

M%SCONCEPT%ON : Unlikel to occur a#terM%SCONCEPT%ON : Unlikel to occur a#ter

o&en #9o&en #9

Reuction #9Reuction #9 lengthens ) narro+s co!&lengthens ) narro+s co!&

.olu!e co!&.olu!e co!& %CP%CP nger tra&nger tra&

&heno!enon&heno!enon


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!ressure monitoring!ressure monitoring

Intraco(%art(enta %ressure )ICP* can 'eIntraco(%art(enta %ressure )ICP* can 'e(easure+ ' se-era (eans incu+ing7(easure+ ' se-era (eans incu+ing7

8ic! catheter8ic! catheterSi(%e nee+e (ano(etrSi(%e nee+e (ano(etrInfusion techni9uesInfusion techni9ues

Pressure trans+ucersPressure trans+ucersSi+e0%orte+ nee+esSi+e0%orte+ nee+es


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!ressure monitoring!ressure monitoring

Critica %ressure for +iagnosing co(%art(entCritica %ressure for +iagnosing co(%art(entsn+ro(e uncearsn+ro(e uncear

Different authors consi+er surgica inter-entionDifferent authors consi+er surgica inter-ention

if7if7A'soute ICP greater than :/ ((.gA'soute ICP greater than :/ ((.gDifference 'et&een +iastoic %ressure an+Difference 'et&een +iastoic %ressure an+

ICP greater than :/ ((.gICP greater than :/ ((.g

Difference 'et&een (ean arteria %ressureDifference 'et&een (ean arteria %ressurean+ ICP greater than 6/ ((.gan+ ICP greater than 6/ ((.g


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Co(%art(ent sn+ro(eCo(%art(ent sn+ro(e4o!(ann;s Ische(ia4o!(ann;s Ische(ia

Sint catheter Rora'ec!7Sint catheter Rora'ec!7

Nor(a resting intraNor(a resting intra

co(%art(ent7co(%art(ent7

/ < " ((.g/ < " ((.g

8ic! catheter Mu'ara!78ic! catheter Mu'ara!7

Pressures o-er7Pressures o-er7 :/ ((.=:/ ((.=

A'soute in+ication forA'soute in+ication for+eco(%ression>+eco(%ression>


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DiagnosisDiagnosis

Dee& &al&ation : tense, +ooen #eeling ;6Dee& &al&ation : tense, +ooen #eeling ;6

$a" : < Creatin Phos&ho =inase CP=6$a" : < Creatin Phos&ho =inase CP=6 ,,

seru! !oglo"in, !oglo"inuria seru! !oglo"in, !oglo"inuria

< Detect le.el o# !uscle necrosis, hi< Detect le.el o# !uscle necrosis, hi

CP=CP= rha"o!olsisrha"o!olsis


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$ess * non in.asi.e %CP !easure!ent *$ess * non in.asi.e %CP !easure!ent *

alternati.e !ethosalternati.e !ethos

< $aser Do&&ler 1o+!etr< $aser Do&&ler 1o+!etr < 8enon scanning< 8enon scanning

< Phos&hate Nuclear Magnetic Resonance< Phos&hate Nuclear Magnetic Resonance

PNMR6PNMR6


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TreatmentTreatment

#emove constricting casts" splints etc#emove constricting casts" splints etc

If no improvement prompt fasciotomies re'uiredIf no improvement prompt fasciotomies re'uired

Need to divide s(in and deep fascia for the whole length of theNeed to divide s(in and deep fascia for the whole length of the

compartmentcompartment

)ust be O#%* / O#I* for fracture +simple immobili$ation,)ust be O#%* / O#I* for fracture +simple immobili$ation,

-ounds should be left open-ounds should be left open

)ay re'uire delayed closure or)ay re'uire delayed closure or

s(in graftings(in grafting


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Surgical treat!entSurgical treat!ent::eco!&ression *eco!&ression *

#ascioto! in the lo+er leg#ascioto! in the lo+er leg

>hitesies>hitesies: Single lateral incision: Single lateral incision "ulecto"ulecto

li!ite .ie+ an ae@uate #ascial release isli!ite .ie+ an ae@uate #ascial release is

iculticult

MatsenMatsen: A.oi e9cision "ula thus reuce: A.oi e9cision "ula thus reuce

incience o# a!age to su&ercial &eronealincience o# a!age to su&ercial &eroneal

ner.ener.e &eri * &ara "ular a&&roach&eri * &ara "ular a&&roach


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Mu"arakMu"arak: T+o * Dou"le incisions techni@ue: T+o * Dou"le incisions techni@ue

anterolateral ) &ostero!eial incisionsanterolateral ) &ostero!eial incisions

< Sa#er access to all B co!& +ith goo< Sa#er access to all B co!& +ith goo.isualiation o# i!&ortant su&ercial an.isualiation o# i!&ortant su&ercial an

ee& structuresee& structures


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< Treat!ent o# choice #or ACS in the lo+er leg< Treat!ent o# choice #or ACS in the lo+er leg

< %ncision : the >(O$E length o# co!&< %ncision : the >(O$E length o# co!&

Der!oto! ) ascioto!6Der!oto! ) ascioto!6

T%MET%ME#actor .er i!&ortant :#actor .er i!&ortant :

consensus : F0 hoursconsensus : F0 hours

G F0 hours : catastro&hic clinical resuG F0 hours : catastro&hic clinical resu

< #ull reco.er i# +ithin H hours< #ull reco.er i# +ithin H hours

< e9act ti!e o# onset : icult< e9act ti!e o# onset : icult


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Post #ascioto!Post #ascioto!$ea.e the +oun$ea.e the +oun OPENOPEN

>oun co!&lications in 5FI o# cases>oun co!&lications in 5FI o# cases

+ith PR%MARY * DE$AYED closure+ith PR%MARY * DE$AYED closure

onl 5I in s&lit skin gra#t &atientsonl 5I in s&lit skin gra#t &atients

Skin gra#t &er#or!e a#ter F J K +eeksSkin gra#t &er#or!e a#ter F J K +eeks

A.oi skin gra#t : silicone sheet co.erageA.oi skin gra#t : silicone sheet co.erage

ACUTE COMPARTMENT SYNDROME


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Treat!entTreat!ent

DO NOT ele.ate the li!"DO NOT ele.ate the li!" arterial 1o+arterial 1o+

a. Pressure graienta. Pressure graient ische!iaische!ia

Plaster cast : release one siePlaster cast : release one sie reuce %CPreuce %CP " KLI? i.al.ing : aitional K5I reuction" KLI? i.al.ing : aitional K5I reuction

Cutting >e"ril FL J 0LI reuction %CPCutting >e"ril FL J 0LI reuction %CP

(&er aric O9gen (O6 : i!&ro.es tissue(&er aric O9gen (O6 : i!&ro.es tissue

o9gen tension an sur.i.al o# !arginallo9gen tension an sur.i.al o# !arginall.ia"le tissue.ia"le tissue , e!arcation o# non.ia"le, e!arcation o# non.ia"le

tissue "ettertissue "etter

Reco!!enation : T+ice ail treat!ent #orReco!!enation : T+ice ail treat!ent #or

L J F0L #or 5 J asL J F0L #or 5 J as


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ACUTE COMPARTMENTACUTE COMPARTMENT

SYNDROMESYNDROME

Co!&licationCo!&lication

3olk!ann contracture : F J FLI o# all cases3olk!ann contracture : F J FLI o# all cases

o# ACSo# ACS

%n#ection : Matsen in late cases surgical%n#ection : Matsen in late cases surgical

eco!& FF*0B cases e.elo& in#ectioneco!& FF*0B cases e.elo& in#ection

5 cases nee5 cases nee AMPUTAT%ONAMPUTAT%ON

(&esthesia * Pain#ul sesthesia(&esthesia * Pain#ul sesthesia

Sste!ic : Acute Renal ailure, se&sis,Sste!ic : Acute Renal ailure, se&sis,

Acute Res& Distress Snro!e ARDS6Acute Res& Distress Snro!e ARDS6


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Contrainication : i# ACS in iagnoseContrainication : i# ACS in iagnose

$ATE J #ascioto! little "enet J &ro"a"l$ATE J #ascioto! little "enet J &ro"a"l

contrainicate a#ter K J B ascontrainicate a#ter K J B as

%# &er#or!e $ATE%# &er#or!e $ATE se.ere in#ectionse.ere in#ection!a e.elo&s in the necrotic !uscle,!a e.elo&s in the necrotic !uscle,

e.en eathe.en eath

< Painlessness * Paralsis ;6< Painlessness * Paralsis ;6 no useno use

o# #ascioto!o# #ascioto!

Malpractice award in US :Malpractice award in US :

USD 225.000 500.000 !!USD 225.000 500.000 !!

Co!&licationCo!&lication


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ConclusionConclusion

NO conclusi.e ans+er #or CR%T%CA$ thresholNO conclusi.e ans+er #or CR%T%CA$ threshol

o# %CPo# %CP

A"solute or i-erential &ressure elta P6 QA"solute or i-erential &ressure elta P6 Q

A"solute iagnostic criteria re!ainA"solute iagnostic criteria re!ain

contro.ersialcontro.ersial

%n the !eanti!e :%n the !eanti!e :

F Rel on EST a.aila"le clinical e.ienceF Rel on EST a.aila"le clinical e.ience

(%7( %NDE8 o# sus&icion * 3%7%$ANCE *(%7( %NDE8 o# sus&icion * 3%7%$ANCE *

A>ARENESS, Causa : roa s&ectru! o#A>ARENESS, Causa : roa s&ectru! o#

conitions //conitions //

00 Monitoring %CP onl in Unconcious,Monitoring %CP onl in Unconcious,

Uncoo&erati.e, ChilrenUncoo&erati.e, Chilren

C CO S O


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ConclusionConclusion K U$$ ) E8TENS%3E #ascioto!ies shoul "eK U$$ ) E8TENS%3E #ascioto!ies shoul "e

&er#or!e +ithin H hours&er#or!e +ithin H hours

B PROP(Y$ACT%C #ascioto! to a"ort ACS QB PROP(Y$ACT%C #ascioto! to a"ort ACS Q

ascioto! is NOT a "enign &roceureascioto! is NOT a "enign &roceure

ascioto! cause &oor cal# !uscle #unctionascioto! cause &oor cal# !uscle #unctionleas to chronic .enous insuciencleas to chronic .enous insucienc againsagains

&ro&hlactic #ascioto!&ro&hlactic #ascioto!


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.uestion.uestion


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OutcomeOutcome

Ti(e surger %ro+uces a goo+ functionaTi(e surger %ro+uces a goo+ functiona

outco(eoutco(e

Dea resuts in (usce ischae(ia an+Dea resuts in (usce ischae(ia an+

necrosisnecrosis

Musce fi'rosis %ro+uces the t%icaMusce fi'rosis %ro+uces the t%ica

4o!(ann?s ischae(ic contracture4o!(ann?s ischae(ic contracture


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Appendicitis ayen060589

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