Medication Treatment for Entrapped Compartment Syndrome
Decompressive surgery, not medications, is the definitive treatment for compartment syndrome, as medications alone cannot effectively treat this surgical emergency.
Understanding Compartment Syndrome
- Compartment syndrome occurs when tissue pressure within a closed anatomic space exceeds perfusion pressure, leading to tissue necrosis, permanent functional impairment, and potentially renal failure and death if untreated 1
- It can develop following crushing injuries, fractures, burns, arterial injuries, and other trauma to extremities 2
- Diagnosis is primarily clinical, with symptoms including extreme pain unrelieved by analgesia, subjective pressure sensation, pain with passive muscle stretching, paresis, paresthesia, and physically tight compartment 2
Medical Management Options
Pain Management
- Multimodal analgesia is recommended while preparing for definitive surgical treatment:
- Paracetamol (acetaminophen)
- Non-steroidal anti-inflammatory drugs (if not contraindicated)
- Opioids and adjuncts 3
- Regional analgesia with low-concentration local anesthetic solutions may be used with caution, preserving some sensation to monitor for breakthrough pain 3
- Pain relief is considered a fundamental human right and should remain central to medical management while preparing for definitive treatment 3
Neuromuscular Blockade
- Brief trials of neuromuscular blockade can be considered as a temporizing measure in the treatment of intra-abdominal hypertension and abdominal compartment syndrome 3, 4
- This may temporarily improve abdominal wall compliance but is not a substitute for definitive treatment 4
Optimizing Analgesia and Sedation
- Ensuring optimal pain and anxiety relief is suggested to improve compliance in abdominal compartment syndrome 3, 4
- This should be implemented while preparing for surgical decompression 4
Abdominal Compartment Syndrome Specific Interventions
Gastrointestinal Decompression
- Liberal use of enteral decompression with nasogastric or rectal tubes is suggested when stomach or colon are dilated in the presence of intra-abdominal hypertension 3, 4
- Neostigmine may be considered for established colonic ileus not responding to other simple measures 3, 4
Fluid Management
- Protocols to avoid positive cumulative fluid balance after initial resuscitation are recommended 3, 4
- Enhanced ratios of plasma to packed red blood cells are suggested for resuscitation of massive hemorrhage 3, 4
Percutaneous Drainage
- Percutaneous catheter drainage (PCD) is suggested to remove intraperitoneal fluid when technically possible 3, 4
- This may alleviate the need for decompressive laparotomy in some cases 3, 4
Important Considerations
- Medications alone cannot effectively treat compartment syndrome; they are adjuncts to surgical decompression 2, 5
- Compartment syndrome is a surgical emergency requiring prompt treatment by fasciotomy 2
- Time is critical; longer duration of elevated tissue pressure increases potential for disastrous sequelae 2
- For extremity compartment syndrome, immobilization, elevation, and cooling are recommended prehospital interventions 1
- For abdominal compartment syndrome, decompressive laparotomy remains the definitive treatment for cases with organ dysfunction 4
Monitoring Recommendations
- Serial measurements of intra-abdominal pressure are recommended when any risk factor for intra-abdominal hypertension is present 3
- Protocolized monitoring and management of intra-abdominal pressure is recommended versus no monitoring 3
- Abdominal perfusion pressure (APP = MAP - IAP) may be considered as a resuscitation endpoint 4
Surgical Management
- Decompressive surgery (fasciotomy) remains the standard treatment for compartment syndrome 5
- For abdominal compartment syndrome, decompressive laparotomy is strongly recommended when medical management fails 3, 4
- Alternative surgical approaches like subcutaneous linea alba fasciotomy may be considered in specific cases 6