ETM Journal Club: Pressure, perfusion, and compartments

This is a review article (available free online over at The Journal of Trauma and Acute Care Surgery) that covers compartment syndrome by body region, reviewing the latest evidence and challenging some dogma related to this fascinating condition.

Ivatury RR. Pressure, perfusion, and compartments: Challenges for the acute care surgeon. J Trauma Acute Care Surg. 2014 Jun;76(6):1341-8

As the article is available free online, I won’t do a full analysis of it, but anyone who manages trauma, burns, or other critically ill patients should read this article as there’s some great learning points about compartment syndrome.

Take home messages:

  • Recent evidence suggests that the relationship between intracranial pressure (ICP), cerebral perfusion pressure (CPP), cerebral blood flow and the risk of death is not as simple as once postulated, and there are likely pathologic processes in the injured brain that do not directly involve increases in ICP and decreases in CPP.
  • Orbital compartment syndrome occurs in facial trauma, but may also occur in major burns patients who receive too much crystalloid fluid during resuscitation.
  • Post cardiac surgery (for example open heart surgery, or post repair of penetrating cardiac injury), too much intravenous fluid causes cardiac dilation, which causes raised intra-thoracic pressures if the chest is closed, resulting in impaired cardiac filling and hypotension. This may manifest intra-operatively during closure, or days later in ICU with increasing airway pressures and haemodynamic instability.
  • World Society of the Abdominal Compartment Syndrome (WSACS) have published clinical practice guidelines for the management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), available free open access at Intensive Care Medicine. The guidelines cover issues such as abdominal pressure monitoring, sedation and paralysis, role of renal replacement therapy, decompressive laparotomy, open abdomen management, negative pressure wound therapy and more. You can also download free algorithms on ACS assessment and management from WSACS.
  • Poly-compartment syndrome reflects the interplay between pressures in the intracranial, thoracic and abdominal compartments. Examples include increasing ventilator pressures to manage injured lungs which can increase intracranial pressure (negatively impacting on concurrent brain injury), and the relatively new technique of reducing intracranial pressure by opening the abdomen. (There is a great lecture by the pioneer of this technique, Thomas Scalea, over at EMCrit).
  • The classic clinical signs of compartment syndrome in the extremities are specific but not sensitive and the definitive way to diagnose it is with invasive compartment pressure monitoring. However the threshold pressure or exact indication for fasciotomy remains unclear! What is very clear is that delays to fasciotomy result in worse outcomes if the diagnosis is delayed or missed.
  • Newer techniques such as Near Infra-Red Spectroscopy and Raman Spectroscopy are showing promise in being able to diagnose extremity compartment syndrome, but are likely to only be available in tertiary centres.
  • There is an extensive discussion about compartment syndrome in the extremities in the article – well worth a read.

This is a succinct, up to date review that has some very salient learning points for anyone who manages critically ill or  injured patients.

ETM Rating: Highly recommended


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