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WESTERN STATES MEDICAL MONOGRAPHS

Found Down: Bilateral Lower Extremity in the Setting of Drug-Induced

Lindsey M. VanDyke, DO (1): Mahmood J. Jazayeri, MD (2); and Jennifer Zweig, DO (3) (1) Internal , College Medical Center, Molina Healthcare, Long Beach, CA (2) Orthopedic , College Medical Center, Molina Healthcare, Long Beach, CA (3) Family Medicine, College Medical Center, Molina Healthcare, Long Beach, CA WesternStatesMM TR-03-2015, February 15, 2015 National Technical Information Service PB2015-103682

OPTI-WEST EDUCATIONAL CONSORTIUM in association with the CENTER FOR THE ADVANCEMENT OF HEALTHCARE EDUCATION AND DELIVERY 6660 Delmonico Drive, Suite D205, Colorado Springs, CO 80919, USA Research Report Found Down: Bilateral Lower Extremity Compartment Syndrome in the Setting of Drug- Induced Rhabdomyolysis

Lindsey M. VanDyke, DO; Mahmood J. Jazayeri, MD; and Jennifer Zweig, DO

(Corresponding author: Lindsey M. VanDyke, DO, Department of Internal Medicine, College Medical Center/Molina Healthcare, Long Beach, CA 90806, (562) 305-4928; [email protected])

Abstract

Compartment syndrome is an uncommon afflicon that may be induced by a variety of clinical pictures, inclusive of trauma, , rhabdomyolysis, ischemia-reperfusion , prolonged ssue compression, et al. It may present acutely--a true emergency--or among athletes in a chronic state. It may occur in the extremies, most commonly due to long , or in the abdomen. Quick diagnosis is necessary for limb salvage and improved outcomes. Diagnosis is made with a combinaon of clinical findings, ultrasound doppler and needle manometry. This case will focus on a presentaon of a paent in drug-induced rhabdomyolysis aer being found down, and subsequent development of acute compartment syndrome (ACS) of the bilateral lower extremies.

Introducon

Compartment syndrome is an uncommon afflicon that most oen acutely affects paents who have suffered a trauma, be it long bone fracture--which represents nearly 75% of cases--crush , thermal burns or other forms of constricted ssue. First described by Richard von Volkmann in 1872, it may also be present as a non-emergent chronic state among some athletes. Nontraumac causes are less frequent and include ischemia- reperfusion injury, prolonged ssue compression, thrombosis, bleeding diatheses, nephroc syndrome and, as in the case of our paent, rhabdomyolysis.

There are mulple pathophysiological theories to explain the eology of compartment syndrome and the most prevalent and accepted is the arterio-venous gradient theory. This states that an increase in pressure within the myofascial compartment for any reason will decrease venous oulow. Consequenal increase in venous pressure induces a vicious cycle of ssue that is followed by increased intersal pressures, which will in-turn decrease the AV gradient. While lymphac channels will compensate inially they will soon be overwhelmed and eventually the arteriolar pressure will be insufficient to overcome the increasing intracompartmental pressure. Blood will then shunt away from these ssues to produce the cold, pale, parasthec and pulseless extremies that are harbingers of this

2 orthopedic emergency. Yet, arterial pulses and capillary refill can persist even in a prolonged severe acute compartment syndrome seng. Thus, these famed “Five P’s” of the physical exam are o-inaccurate and a definive diagnosis may only be made by measuring the intracompartmental pressures by means of needle manometry

Normal pressures of the extremies’ compartments are anywhere from 0-8mmHg. Capillary flow is compromised at 25-30mmHg. The paent will report pain at pressures exceeding 20mmHg, and ischemia will occur when the compartment pressure approaches the diastolic blood pressure. A caveat: if the paent has known peripheral vascular disease or is hypotensive, be aware that ischemia will occur at lower compartment pressures. Alternavely, if the paent has hypertension, the ischemia will occur at higher compartment pressures. Of the extremies cases, the anterior compartment is the most common, and is followed in decreasing likelihood by the lateral, deep posterior and superficial posterior compartments.

And so we come to our case.

Case Presentaon

B.D. is a 48yo caucasian male with complex histories inclusive of schizoaffecve disorder, bipolar disorder, diabetes mellitus and who arrived via EMS aer he was found down by his fiancée. She found him unconscious on the floor when she returned home one evening, aer he had aempted suicide by taking all of his benzodiazepine and narcoc prescripons. Unaware of his suicidal intent and unable to arouse him, she covered him with a blanket and le him through the night. The following morning, the paent regained consciousness and experienced dyspnea with cyanosis at the vermillion border, which prompted his fiancée to dial 911. He was admied to intensive care unit for acute respiratory failure requiring intubaon and an addional diagnosis of rhabdomyolysis when his creane kinase was found to be above laboratory range of 10,000. He tolerated inial fluid resuscitaon and subsequent extubaon without further incident. On ICU day # 3 he complained of lower extremity pain and venous ultrasound doppler revealed bilateral edema without flow liming stenosis. Surgical consultaon was obtained to evaluate paent for compartment syndrome.

The physical exam revealed bilateral tense edema of the lower extremies that were markedly tender to palpaon. Capillary refill is < 2 seconds bilaterally and trace dorsalis pedis is detected bilaterally. Skin was warm and dry with tense bullae noted bilaterally in the popliteal fossae. Compartment pressures were measured with Stryker needle manometer in the superficial and deep posterior compartments. Aer appropriate calibraon, readings were obtained as seen in Table 1.

At this me in the addional seng of decreasing hemoglobin/hematocrit readings, surgical planning for fasciotomy began. Repeat compartment pressures were obtained on ICU day #4 and are provided in Table 2. By the me of this measurement, sensaon was not intact to light touch or pain below the . Right was cool to the touch and capillary refill

3 had extended to 3 seconds. Arterial ultrasound doppler revealed absent dorsalis pedis flow on the right side.

Aer the second round of compartment pressures, the orthopedic surgeon determined that the paent would benefit from hyperbaric oxygen treatment in addion to bilateral lower extremity fasciotomy, and subsequent transfer to a neighboring facility with this capability was undertaken. Transfer was successful and paent underwent bilateral lower extremity fasciotomy with delayed closure on the evening of ICU day #4.

Discussion

The diagnosis of acute compartment syndrome is largely a clinical picture. Physical exam findings that reveal any tense painful muscle compartment is highly suggesve of acute compartment syndrome. As previously noted, reliance on the classic “Five P”s is ill-advised. If Stryker needle manometry is available, its results are definive. Appropriate diagnosc numbers are not fixed, but rather must be a difference between the measured intracompartmental pressure and the diastolic blood pressure (Δp). This is in contrast to a long held belief that any reading greater than 30-45mmHg is diagnosc, which was based on studies that demonstrated irreversible nerve damage aer 6-8 hours. This concept fell out of favor when it became clear that the use of absolute values can lead to unnecessary fasciotomies or conversely a failure to perform much needed fasciotomy. The most accurate diagnosis is made when the compartment pressure approaches the diastolic pressure by 20-30mmHg, with a threshold of 20mmHg significantly improving the incidence of false posives. In our paent’s case, the blood pressure during the first round of manometry was 146/65, so a compartment reading greater than 35-45 mmHg would have been diagnosc (see Table 1 for Δp). During the second round of manometry, the blood pressure was noted to be 150/76, and thus would require a minimum compartment pressure of 46-56 mmHg to be diagnosc (see Table 2 for Δp). Serial measurements are warranted if the suspicion for acute compartment syndrome is high, and if these pressures trend down it is usually safe to not intervene.

When a paent presents with a clinical picture consistent with compartment syndrome, be it abdominal or extremity-based, the definive management is decompression of all involved fascial compartments, and appropriate management of the precipitang condion. Near complete recovery of limb funcon is possible if fasciotomy is performed within six hours from the me of diagnosis. Moreover, if fasciotomies are performed within 12 hours aer the onset of ACS, normal limb funcon may be regained in 68% of paents. The deep posterior compartment is the most difficult in which to perform fasciotomy as the procedure inherently carries with it high risk of morbidity. Long term follow up of post- fasciotomy paents shows that the majority return to premorbid state and pain significantly improves. Beware development of the Volkmann , which occurs in 1-10% of cases in the weeks to months following diagnosis.

4 The most serious complicaon of ACS is the development of infecon, especially if diagnosis and fasciotomy are delayed, and a fracon of those who develop infecon may require amputaon of the affected limb. Addionally, most fatalies from infecon are actually due to prolonged intensive care admission with subsequent and mulorgan failure.

Table 1: Inial Compartment Pressures, blood pressure 146/65

Superficial Deep Δp, Δp, Deep Superficial

Le 53 mmHg 50 mmHg 12 mmHg 15 mmHg

Right 56 mmHg 36mmHg 9 mmHg 29 mmHg

Table 2: Repeat compartment pressures, blood pressure 150/76

Superficial Deep Δp, Δp, Deep Superficial

Le 27 mmHg 99 mmHg 49 mmHg 23 mmHg

Right 37 mmHg 108 mmHg 39 mmHg 32 mmHg

Conclusion

In summary, a diagnosis of compartment syndrome can be made in a number of disease presentaons from trauma to drug overdose, and constutes one of the few orthopedic emergencies. Diagnosis is by clinical picture, inclusive of evidence supporng constricted venous and arterial flow on doppler, and definively by Stryker needle manometry readings used to calculate a Δp that is within 20-30mmHg of the diastolic pressure. Definive management is by surgical decompression of all affected compartments.

References

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