2nd Surgery Journal club presentation

By A. Mbuyi Tshimpanga

Presentation outline

Objectives Definition Pathophysiology Clinical evaluation Diagnosis Management Complications Summary References

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Objectives

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To recognise the importance of ACS

To identify and manage ACS

To know how to measure and monitor ICP

To Prevent the occurrence of ACS

To possibly develop a guideline for BPH

Definition

Clinical manif. due to sudden and severe microvascular compromise caused by raised interstitial pressure in a closed osteofascial compartment

>> neuromuscular malfunction

>> irreversible tissue damage.

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HISTORY

1872- R.V. Volkmann described contracted state believed due to ischemic muscle

1906-Hildebrand :“Volkmann’s ischemic contracture”

1914 - Murphy recommended fasciotomy to prevent contracture

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HISTORY

1940-Griffiths ‘4 Ps’

1941- Bywaters made researches during World war II

1968: wick catheter introduced, made popular by Mubarak in 1976

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Demographics

36-45% # tibial shaft (open/closed)23% soft tissue injury without #19% with isolated vascular injury require

fasciotomy10% on anticoagulantsHigh energy = low energy incidence

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European journal of trauma & emergency surgery, 2007, MC Queen & al. 2007www.emedicine.com/ Acute Compartment Syndrome

Sites of ACS

Can develop anywhere a skeletal muscle is surrounded by a fascia.

ACS may occur in foot, leg, thigh, buttocks, lumbar paraspinous muscles, hand, forearm, arm and shoulder.

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Compartments

Foot 9: separated into 4gps: (- central/calcaneal - intrinsic/interosseous – medial and – lateral)

Leg: 4 (anterior, lateral, sup & deep posterior)

Thigh 3 (anterior, posterior, medial)

Gluteal region: 3. maximus, tensor, and medius/minimus.

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Aetiology Externally applied pressure: - tight closed casts/dressing/bandage - lying on limb for long period* - MAST / PASG - malfunctioning pneumatic boot - circular burn eschar* - prolonged tourniquet - crash injury - Excessive trans-osseous traction in #

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During surgery

Limb malposition during traction / procedure

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Aetiology (2)Expanding IC volume

tissue oedema: - contusion (e.g. crush injury)

- fracture/osteotomy (tibial #)

- post-op, closing fascial gap

- post-ischemic swelling - snakebite Myositis, Intra-compartmental fluid infusion, etc.

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Pathophysiology

ICP → vascular compromise → local/distal tissue ischaemia

Muscle metabolism: 5-7 mmHg O2 tension, which can readily be obtained with a CPP of 25 mmHg and an interstitial tissue pressure of 4-6 mmHg.

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Pathophysiology of ACS

Local blood flow = (Pa-Pv)/R.

Perfusion pressure ∆P = DBP – ICP (Whiteside theory)

The elevated ICP increases the local venous pressure leading to narrowed arterio-venous perfusion gradient and compartment tamponade, resulting in nerve injury and muscle ischemia in 4-6 hrs.

ICP: normal <10 mmHg

10 – 30: latent CS

>30: manifest CS

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Emedicine online/acute compartment syndrome physiopathology

Ischemia – oedema cycle

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Further cell

damage

Raised ICP

Injury raised capillary permeability

Oedema

Cell death/ mediator

release Hypoxia

Vascular compromise

Rhabdomyolysis &Nerves injury

Clinical evaluation: 6P’s

History: - aetiological factor - mechanism of injury - additional info (coagulopathy, CRF, angiopathy…)

Complaints:- Pain- Paresthesia - Weakness of limb

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- Limb: Pale, tensely swollen & shiny

- Wooden feeling, Tenderness*

- Dysesthesia with loss of 2 points discrimination

- Paresis / Paralysis

- Pulselessness*

- Poikilothermia

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Physical examination:

Clinical Evaluation The diagnosis of ACS may be delayed in : - patients with multiple injuries, - altered consciousness*, - drug abuse - patients with altered neurological function

caused by vascular injuries, peripheral nerve injury

- continuous epidural anesthesia

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Intracompartment pressure measurement

N.B: Diagnosis of ACS is always clinical, pressure measurement provides additional information

Compartment pressure measurement should be taken on the maximum swelling site (see the diagram)

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Intracompartmental pressure measurement

ICP can be measured using different devices:

- stryker pressure monitor (hand-held) - slit catheter - wick catheter - fiberoptic transducer (Camino catheter)

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Measurement technique

Patient in a comfortable position Mark the site, skin disinfection Assemble the system Zero the stryker monitor Subfascial catheter tip insertion Get the reading in mmHg. For intermittent ICP monitoring

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Gadgets for ICP measurement

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If the electronic gadget not available:

- intravenous tubing filled by NS

- NS 15 mls in

- a syringe (20mls)

- a 3 way stopcock

- a G18 side-port needle / cannula

- Mercury manometer

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ICP measurement procedure Prepare the site Connect the system set at horizontal level with

puncture site Insert the needle into muscle Depress gradually the syringe plunger vs. ICP and

watch the mercury column; When the pressure in the system surpasses the ICP, a

small amount of NS will be injected in muscle Get the reading

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Management of ACSNON INVASIVE Rx

- Release of constrictive - Correction of coagulopathy - Elevation of limb

- Treat systemic hypotension / shock

- Antivenin*

- Hyperbaric oxygen*

- Use of mannitol*

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Mannitol treatment for acute compartment syndrome. Nephron. Aug 1998;79(4):4923 . -www.emedecine.com/acute compartment syndrome/ updated Feb. 2009

Management of ACS

If symptoms don’t resolve in 30 to 60 min after appropriate treatment, repeat pressure measurement, and if equivocal fasciotomy is indicated.

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INVASIVE Rx: FASCIOTOMY

Kuri JA, Difelice GS. Acute compartment syndrome of the thigh following rupture of the quadriceps tendon. J Bone Joint Surg Am 2006;88:418–20.

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Surgical emergency Fasciotomy

ACS clinically suspected and not resolving after 1h of non invasive Rx;

Elevated pressure

- ICP > 30 mmH

- or ∆P < 30 mmHg (∆P = DBP – ICP

Kuri JA, Difelice GS. Acute compartment syndrome of the thigh following rupture of the quadriceps tendon, 2006;88:418–20.

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Fasciotomy

Pre-op antibiotics (antistaphylo.) Local anaesthesia Limb disinfection Dermato-fasciotomy* Other relevant procedures Muscle debridement should be kept to a minimum

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Fasciotomy follow-up

After decompression: wound is packed with moist dressing

Splinting in functional position

OR for 2nd look in 2-5 days: debridement.

If no evidence of muscle necrosis the skin is loosely closed

the debridement is repeated after another 72h, then skin closure/skin grafting

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Correction of associated disorder

- Hyperkalemia- Dehydration- ARF - Infection- Coagulopathy- Etc.

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Lab studies

Serum: - serial CK, Myoglobin - electrolytes (K+)

- BUN - Creatinine CBC - anemia (worsens ischemia)

- wbc Coagulation profile Culture/sensitivity…

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DDg of ACS

Cellulitis Osteomyelitis / periostitis DVT Gas gangrene Necrotizing fasciitis Peripheral vascular injury Rhabdomyolysis

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Prognosis

Excellent to poor, depending on how quickly it is diagnosed and treated;

20% of patients may have persistent sensory or motor deficits at 1-year follow-up.

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Acute complications

Rhabdomyolysis - Acidosis Hyperkalemia - DIC and sepsis Myoglobinuric renal failure ARDS Loss of limb Death (sepsis-MOF)

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Chronic complications

Persistent sensory or motor deficits at 1-year f-up: 20%

Volkmann’s syndrome

Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green's Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1996, quoted in www.emedicine.com

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Summary High index of suspicion remains the

cornerstone of diagnosing ACS ACS is a clinical Dg ICP measurement gives additional info. In doubt, cut! Avoid delays in management Promptly recognize vascular compromise Vacuum sealing

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References M. King & P. Bewes, primary surgery vol 2, 81.14, ed. Oxford

NY, 2009, p. 345-346

JP Wyatt, RN Illingworth, CA Graham, MJ Clancy, CE Robertson, Oxford Handbook of Emergency medicine 3rd ed, 2008, p. 396

Whitesides TE, Heckman MM, Acute compartment syndrome: update on diagnosis and treatment. J Am Acad Orthop Surg. 1996;4(4):209‑218. quoted by the American Journal of Orthopedics

European Journal of Emergency Surgery, 2007 – NO. 6, Urban & Vogel

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References Daniels M, Reichman J, Brezis M. , Mannitol treatment

for acute compartment syndrome.  Nephron. Aug 1998;79(4):492- 3. [Medline].

Kuri JA, Difelice GS. Acute compartment syndrome of the thigh following rupture of the quadriceps tendon, 2006;88:418–20.

www\CochranFirm\resources\doc-compartment-syndrome.html on line by Samuel E. Greenberg

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thanks

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