1. Compartment syndromes
Dr Tultul K Sangma
Fellow- ICU
Maharaja Agrasen Hospital, Delhi

2. Overview Introduction Etiology Disease progression Diagnosis
Conclusion

3. Introduction Compartment syndrome
Mainly a disorder of the extremities and is most common in lower leg and forearm
However, can also occur in other locations eg, upper arm, abdomen, thoracic, buttock
It is the increased tissue pressure within a closed fascial space, resulting in tissue ischemia
The earliest symptom is pain out of proportion to the severity of injury
Abdominal compartment syndrome significantly contribute to the morbidity and mortality of both medical and surgical patients alike in ICU

4. Etiology: extremity compartment syndrome
Crush
Ischaemia
Arterial injury
Vascular ligation
Fracture
Direct blunt trauma with hematoma/oedema
Prolonged external pressure
Electrical injury

5. Etiology: Secondary extremity compartment syndrome
Hypotension
Massive volume resuscitationwhole body oedema including muscles (post resuscitation systemic inflammatory response syndrome)

7. Disease progression
Begins with tissue edema that normally occurs after injury (eg, soft-tissue swelling or a hematoma).
Edema within a closed fascial compartmentlittle room for tissue expansion interstitial (compartment pressure) increases. If >8 mm Hg which exceeds normal capillary pressure, cellular perfusion slows and may ultimately stop.
Because 8 mm Hg is much lower than arterial pressure, cellular perfusion can stop long before pulses disappear. Resultant tissue ischemia further worsens edema in a vicious circle.
As ischemia progresses, muscles necrose, sometimes leading to rhabdomyolysis, infections, and hyperkalemia; these complications if untreated, can result in death.
Hypotension or arterial insufficiency can compromise tissue perfusion with even mildly elevated compartment pressures, causing or worsening compartment syndrome. In limbs, contractures may develop after necrotic tissue heals.

8. Diagnosis Pain disproportionate to injury
Neurologically compromised patient
Tense or tight compartments to touch
Increased pain with passive muscle stretch, classical for anterior calf compartment-dorsiflexion of great toe
Hypoesthesia/muscle weakness

9. Abdominal compartment syndrome (ACS)
Etiology:
Primary ACS
Abdominal injury or disease
Post operative abdominal surgery
Ascites in critically ill cirrhotic patients
Secondary ACS
massive volume resuscitation
Sepsis, multiple organ failure
Space occupying fluid in the abdomen
Oedematous tissue in abdomen
Space occupying hematoma in retroperitoneum

10. Diagnosis
Tensely distended abdomen, however often normal, with oliguria
Decreased cardiac output, decreased pulmonary function, raised ICP
Intra-abdominal pressure measurement
Bladder pressure measurement
Inferior vena cava pressure measurement
Organ dysfunction

11. How to measure bladder pressure?
Clamp foley
Instill ml NS
Measure pressure at level of symphysis
Normally 5-7mmHg in critically ill adults. Increased in increased body mass index
>12mmHg intra- abdominal hypertension
>20mmHg abnormal
25-35mmHg needs operative decompression

12. Complications Multiorgan failure: renal, pulmonary, cardiovascular
Physiological impairment: splanchnic, neurological
Death: 100% if not treated, 40-70% if treated

13. Treatment Urgent decompression laparotomy. Avoid reperfusion syndrome
Temporary abdominal fascial closure
Close abdomen
Gastric and colonic decompression
Neostigmine or other prokinetic drugs
Neuromuscular blockade
Diuresis
Avoid head elevation > 30 degrees
Avoid prone position
Ultrafiltration
Percutaneous drainage of intraperitoneal fluid or gas

14. Thoracic compartment syndrome
May occur after trauma and after mediastinal and cardiac procedures.
Cl features: Elevated airway pressure, low cardiac output, worsening acidosis
May result in cardiopulmonary collapse
Treatment: opening the chest, and often pericardium, through median sternotomy

15. Conclusion
Identification of patients at risk, early recognition, and timed intervention is key to effective management of compartmental syndrome.
If left untreated, abdominal compartment syndrome is almost uniformly fatal