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------=_NextPart_01C68EEE.FADB1420 Content-Location: file:///C:/227ACA05/CompartmentSyndrome_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C68EEE.FADB1420 Content-Location: file:///C:/227ACA05/CompartmentSyndrome_files/slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Compartment Syndrome
Compartment Syndrome
Tracy Sabeno PA-S4
St. Barnabas Hospital
General Surgery
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Case
3D"*"27 yo M BIBEMS as trauma code, multiple gunshot wounds to medial left thigh, right anterior thigh, right buttock and right arm
3D"*"HPI- multiple gun shot wounds
•
3D"*"PMH- O<= /span>
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Case
3D"*"Surgical Hx- O
3D"*"Social = Hx- lives in an apt in the Bronx, work and/or school unknown
3D"*"Allergi= es- NKDA
3D"*"Meds- O
3D"*"Habits- unknown
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Case
•
3D"*"Ht- 5’10”
3D"*"Wt- 85 kg
3D"*"BMI- 26.8
<= span class=3DBB>3D"*"Vitals-= HR:164 RR:14 BP: O in trauma bay
3D"*"Sat- 95= %
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Physical Exam
3D"*"= General- AAOx3
3D"*"= HEENT-PERRLA, EOMI
3D"*"= Neck- supple, O mass
3D"*"<= span style=3D'font-size:75%'>Pulmonary- CTA B/L
3D"*"= Cor- S1, S2, = Tachycardia
3D"*"<= span style=3D'font-size:75%'>Abdomen- soft, NT
3D"*"<= span style=3D'font-size:75%'>Extremities- RUE 2 GSW, RLE motor intac, LLE + swelling and foot cool to touch, B/L palpable femo= ral, popliteal and radial pulses, O palpable DP, PT pul= ses in LLE
3D"*"= Neuro- RLE active ROM of toes and leg, LLE O activ= e ROM
3D"*"<= span style=3D'font-size:75%'>GU- O
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Labs on admission 9/16
= 3D"*"CBC  7.1=         = ;    185
6.9
19.8
143  116   17
3.3   13    1.5
253
CPK: 1= 33
15.1
29.2
1.8
Ca: 5.8
Trop: <0.1
EtOH: O=
V/S: HR:118, RR: 20 BP: 119/84
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Operation #1
3D"*"= 9/16/05 Pre-Op Dx: gun shot wound to L thigh <= /span>
3D"*"= Operation- repair of LLE popliteal artery and popl= iteal vein with reversed right greater saphenous vein grafts
3D"*"= On presentation no motor or sensory function of RL= E and it was white and cadaveric with very firm calf= muscles. On exam of the LLE there was no pulses below the femoral and the foot was cold and white,= also no motor or sensory function. Unable to passi= vely = doriflex left foot.
3D"*"= Procedure: A longitudinal incision was made along = the ant. Border of the Sartorius and carried down = through the skin and subcutaneous tissue and fasci= a. A = hematoma below the fascia was evacuated.
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Fasciotomy
3D"Compartment
•Lateral incision- the fascia of the lateral and anterior compartments are incised&= #13;
•Medial Incision- the fascia of the superficial and deep posterior compartments ar= e incised
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Fasciotomy
3DFasciotomy
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Labs on 9/17
3D"*"    = 11.0        = ;       93
3D"*"
3D"*"UA Drug Screen: Cocaine Neg
•      Opiates Pos
•        = ;            &n= bsp;             Benzo Pos
•        = ;            &n= bsp;             THC Pos
•        = ;            &n= bsp;             Barb Neg
3D"*"ABG: 7.205/41/96.7/-10.= 9/15.5/50%
3D"*"CPK at 3:52 am: 12789
3D"*"CPK at 10:00 am: 29085
3D"*"CPK at 6:47 pm: 37895
22
7.8
  135  108  12
3.4  22    1.2
125
Ca: = 6.2
14
29.9
1.5
UA:
    Spec. Gravity: 1.017
    pH: 6.5
    Protein: 30
   Glucose: 1000
    LG Blood <= /div>
    RBC: 1
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Operation #2
3D"*"9/17/05 Irrigation and debridement, open reduction and application of external fixator, Right comminuted displaced distal radius Fx
------=_NextPart_01C68EEE.FADB1420 Content-Location: file:///C:/227ACA05/CompartmentSyndrome_files/slide0029.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Compartment Syndrome
Labs 9/18
3D"*"  12.= 3        109
3D"*"
3D"*"CPK: 40525
•
•9/19        = ;  9/20         9/21     =      9/22         9/23        = ;   9/24
•49152 <= /span>    40903       31239       265= 38       393= 0         2323
•
19.7
6.9
CPK
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Operation #3
3D"*"9/22/05 Pre-Op Dx- Gangrene of L leg
3D"*"Operation- L AKA
3D"*"On presentation the left leg was cold, pulseless, bluish/purple in col= or, hard to the touch, shiny and contained multiple bullae. Prior to anesthesia the pt. was unable to doriflex, plantarflex, evert = or invert his left foot. It had also demarcated at the level above his left knee.
3D"*"Pathology-
nshowed mult. Stapled wounds, hemorrhage, marked edema with bullae and epidermal denudation
nProximal margin of resection is viable =
nSkin over leg is cyanotic
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Radiologic Studies
3D"*"<= span style=3D'font-size:88%'>Radiographs-
nChest- O Fx infiltrate, pleural effusion, pneumo&#= 13;
nRt arm- comminuted  distal radius Fx & mult. Metallic foreign bodies
nR Femur- O Fx
nL Femur- metallic foreign bodies overlying = metaphyseal region of distal femur, irreg. Lucency= in the diaphyseal region of L femur, Cannot R/O Fx= 3;
nL Tibia Fibula- O Fx
nPelvis- O Fx or hip dislocation
------=_NextPart_01C68EEE.FADB1420 Content-Location: file:///C:/227ACA05/CompartmentSyndrome_files/slide0007_image049.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhFAAYAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAQAS ABYAgAAAAAAmTAIjhI9poX3sGoxp0neVzft2+kWhmCGjVGIpcKJrW62sDMevDBQAOx== ------=_NextPart_01C68EEE.FADB1420 Content-Location: file:///C:/227ACA05/CompartmentSyndrome_files/slide0007_image050.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhDwAYAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAQAN ABYAgAAAAAAmTAIdhI8WybB9HlSTVjlx07s6zzEhMpLgiWbed6WqVwAAOw== ------=_NextPart_01C68EEE.FADB1420 Content-Location: file:///C:/227ACA05/CompartmentSyndrome_files/slide0007_image051.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhFAAYAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAQAS ABYAgAAAAAAmTAIjhI9poX3sGoxq0neTzft2nyFfNDqlFIrpsgJn1b7wKqt0CxQAOx== ------=_NextPart_01C68EEE.FADB1420 Content-Location: file:///C:/227ACA05/CompartmentSyndrome_files/slide0007_image052.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhEAAYAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAQAO ABcAgAAAAAAmTAIfhI8XybCdHjRyOkvx1RV2z4Wi9TVlNJLpdCKtom1YAQA7 ------=_NextPart_01C68EEE.FADB1420 Content-Location: file:///C:/227ACA05/CompartmentSyndrome_files/slide0008.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Compartment Syndrome
A/P
3D"*"OR for evaluation of L thigh
3D"*"Ortho evaluation
3D"*"Vascular Surgery consult
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Post-Hospice Care
3D"*"Rehab, prosthetic
3D"*"Trauma Clinic F/U
3D"*"Ortho Clinic F/U
3D"*"Neuro D= r. Fredo
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Compartment Syndrome
3D"*"Definition- Compartment syndrome is a limb-threatening and life-threatening condition that is caused= by bleeding or edema in a closed space.  This leads to a decrease in perfusion pressure to fall below the tissue <= /span>pressure in a closed anatomic space. If untreated CS lead= s to tissue necrosis, permanent functional impairment, and,= if severe renal failure and death. 3D"*"CS can occur in the legs, abdomen, arms, thighs, buttocks and hands
3D"*"
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Causes of CS
3D"*"Arterial hemorrhage
3D"*"Venous ligation/thrombosis
3D"*"Crush injury/trauma
3D"*"Infecti= on
3D"*"Ischemi= a
•
3D"*"
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Compartment Syndrome
3D"*"= Physiology- i= ntracompartmental pressure rises causing autoregulatory mechanisms to become overwhelmed and a cascade of injury develops. Tissue perfusion is determined by measuring capillary perfusion pressure (CPP) minus the interstitial fluid pressure.
3D"*"= Normal cellular metabolism requires 5-7 mm Hg oxygen tens= ion; this is easily maintained with the CPP avera= ging 25 mm Hg and interstitial pressure 4-6 mm = Hg
3D"*"= Venous pressure rises and when it is higher than CPP the capillaries collapse. Intracompartmental pressures greater than 30 mm Hg require intervention. Normal pressure is 0-10 mmHg.
3D"*"= Blood flow through the capillaries stops causing oxygen delivery to stop. Hypoxic injury causes cells to release histamine and serotonin, which increase endothelial permeability. Capillaries allow continued flu= id loss, which increases tissue pressure and advances injury. Nerve conduction slows, tissue pH falls due to anaerobic metabolism, surrounding tissue suffers further damage, and muscle tissue suf= fers necrosis, releasing myoglobin. The end result is loss of the extremity and, possibly, the loss of life.
•
3D"*"=
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What are the compartments?
3D"*"Anterior
3D"*"Deep Posterior
3D"*"Superficial
•    Posterior
3D"*"Lateral
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