Kompartmentsyndrom

[Delayed occurrence of compartment syndrome of the upper arm after shovelling snow by a patient under oral anticoagulation]

This article reports the case of an 81-year-old male patient under treatment with oral anticoagulation who suffered delayed compartment syndrome of the upper arm from arterial capillary hemorrhage after shovelling snow. The diagnosis was made 48 h after the initial symptoms in the emergency surgical department of the Klinikum rechts der Isar (München) with the presence of clear neurological deficits. Following computed tomography angiography (CTA) imaging an emergency dermatofasciotomy was carried out as well as a vascular ligature via a medial approach. Compartment syndromes are the result of pathologically elevated tissue pressure and as a rule with a rapid clinical course. A delayed diagnosis can therefore lead to irreversible tissue and nerve damage up to the loss of the extremity. Compartment syndromes are particularly frequent in the lower extremities whereas those of the upper extremities are rare. This case report is intended to raise awareness for an insidiously occurring compartment syndrome of the upper arm due to repetitive microtrauma (in this case shovelling snow) and arterial peripheral vascular hemorrhage with simultaneous anticoagulation. The necessary diagnostic and treatment steps are also elucidated.

The First Aid and Hospital Treatment of Gunshot and Blast Injuries

BACKGROUND

When gunshot and blast injuries affect only a single person, first aid can always be delivered in conformity with the relevant guidelines. In contrast, when there is a dynamic casualty situation affecting many persons, such as after a terrorist attack, treatment may need to be focused on immediately life-threatening complications.

METHODS

This review is based on pertinent publications retrieved by a selective search in Medline and on the authors' clinical experience.

RESULTS

In a mass-casualty event, all initial measures are directed toward the survival of the greatest possible number of patients, in accordance with the concept of "tactical abbreviated surgical care." Typical complications such as airway obstruction, tension pneumothorax, and hemorrhage must be treated within the first 10 minutes. Patients with bleeding into body cavities or from the trunk must be given priority in transport; hemorrhage from the limbs can be adequately stabilized with a tourniquet. In-hospital care must often be oriented to the principles of "damage control surgery," with the highest priority assigned to the treatment of life-threatening conditions such as hemodynamic instability, penetrating wounds, or overt coagulopathy. The main considerations in initial surgical stabilization are control of bleeding, control of contamination and lavage, avoidance of further consequences of injury, and prevention of ischemia. Depending on the resources available, a transition can be made afterward to individualized treatment.

CONCLUSION

In mass-casualty events and special casualty situations, mortality can be lowered by treating immediately life-threatening complications as rapidly as possible. This includes the early identification of patients with lifethreatening hemorrhage. Advance preparation for the management of a masscasualty event is advisable so that the outcome can be as favorable as possible for all of the injured in special or tactical casualty situations.

[Diagnosis and management of peripheral vascular injuries]

Peripheral vascular injuries are the cause of high morbidity in trauma patients. Up to 5 % of all patients with injuries of the extremities present with concomitant vascular lesions. While open peripheral vascular injuries are associated with a high mortality at the scene of the accident, closed vascular injuries present the danger of developing critical tissue ischemia with a high risk of amputation and limb loss. Early diagnosis is crucial in order to rapidly restore and maintain adequate blood flow and downstream tissue perfusion. A correct diagnosis and early treatment of peripheral vascular injuries place enormous demands on interdisciplinary teams consisting of emergency physicians, orthopedic surgeons, vascular surgeons, anesthesiologists and radiologists. The top priority in the context of emergency care is hemorrhage control by applying direct pressure and dressings until definitive surgical treatment. Hypovolemic shock, reperfusion injury and compartment syndrome are complications of peripheral vascular injuries that must be recognized and treated in the early stages.