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Sindrome compartimental

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Sindrome compartimental

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Sindrome compartimental

  1. 1. Dra. Erika Rojas G. Residente de 1er año Febrero 2009 Universidad Central de Venezuela Instituto Nacional de los Seguros sociales Hosp. Dr. Miguel Pérez Carreño Servicio de Traumatología y Ortopedia II
  2. 2. SINDROME COMPARTIMENTAL • DEFINICION • ETIOLOGIA • FISIOPATOLOGIA • SINTOMAS • SIGNOS • EXAMENES PARACLINICOS • DIAGNOSTICO DIFERENCIAL • TRATAMIENTO • COMPLICACIONES • TRABAJOS PUBLICADOS • CONCLUSION • REFERENCIAS CONTENIDO
  3. 3. 1881: Richard Von Volkmann, Contractura postraumatica de la Extremidad lo atribuye a isquemia del musculo esqueletico. 1926: Jepson, Incremento de presion compartimental desarrolla isquemia muscular y descompresion temprana previene contractura. 1940: Segunda Guerra Mundial y Vietnam (Norman Rich), Fasciotomia en Campo de Batalla. SINDROME COMPARTIMENTAL HISTORIA
  4. 4. Síndrome Compartimental (SC) (Compartment Syndrome): Elevación de la presión intersticial, por arriba de la presión de perfusión capilar dentro de un compartimento osteofacial cerrado, con compromiso del flujo sanguíneo en músculo y nervio, lo que condiciona daño tisular. SINDROME COMPARTIMENTAL DEFINICION
  5. 5. SINDROME COMPARTIMENTAL ETIOLOGIA Disminución en el tamaño del compartimento Compresión o constricción externa Pantalón militar antichoque (MAST). Vendaje circunferencial Escara por quemadura o congelacion Cierre quirúrgico de defectos fasciales Uso prolongado de torniquete
  6. 6. Incremento del contenido del compartimento Sangre • Trauma (fractura, lesión vascular) • Desórdenes de la coagulación • Terapia anticoagulante Edema • Isquemia/reperfusión • Lesiones eléctricas • Trombosis venosa • Ejercicio • Posterior a cirugía cardiaca • Choque • Rabdomiólisis • Eclampsia • Síndrome nefrótico Fluidos (exógenos) • Infusión intracompartimental • Infusión interósea SINDROME COMPARTIMENTAL ETIOLOGIA
  7. 7. Síndrome Compartimental Agudo (SCA) Sindrome Compartimental Cronico (SCC) Sindrome por Aplastamiento (Crush Syndrome) SINDROME COMPARTIMENTAL CLASIFICACION
  8. 8. Síndrome Compartimental Agudo (SCA) Presion Intracompartimental Retorno Venoso Perfusion Capilar Presion Arterial ISQUEMIA SINDROME COMPARTIMENTAL CLASIFICACION
  9. 9. Sindrome Compartimental Cronico (SCC) Oxigenación tisular deficiente Secundaria a disminución del retorno venoso Insuficiente perfusión del tejido muscular Incremento de la presión compartimental SINDROME COMPARTIMENTAL CLASIFICACION
  10. 10. Sindrome por Aplastamiento (Crush Syndrome) • Efectos sistémicos secundarios • Isquemia grave de múltiples compartimentos por Ruptura de las células musculares • Libera a la circulación mioglobina y potasio (Hipercalemia) • Respuesta inflamatoria grave • Pérdida de líquidos al tercer espacio • Acidosis metabólica • Falla renal aguda y choque • Requiere de apoyo inmediato por UCI • Manejo agresivo de líquidos y uso de hemodiálisis • Fasciotomía temprana de las extremidades afectadas SINDROME COMPARTIMENTAL CLASIFICACION
  11. 11. SINDROME COMPARTIMENTAL DIAGNOSTICO HISTORIA CLINICA SINTOMAS SIGNOS EXAMENES PARACLINICOS
  12. 12. SINDROME COMPARTIMENTAL SIGNOS Y SINTOMAS SC DOLOR PRESION PARESTESIA PALIDEZ PARALISIS PULSO
  13. 13. SINDROME COMPARTIMENTAL EXAMENES PARACLINICOS LABORATORIO •Hematologia Completa •PT, PTT •INR •Perfil Hepatico •Urea, Creatinina •Mioglobina •CK, CKMB •Electrolitos Sericos •Examen de Orina IMAGENOLOGIA •Rayos X •Ecosonograma Doppler •RMN OTROS •Medicion de Presion Compartimental •Espectroscopia Infrarroja (Oximetro)
  14. 14. SINDROME COMPARTIMENTAL DIAGNOSTICO DIFERENCIAL Distension Muscular Periostitis Fractura Tibial por Estres Fractura Peronea por Estres Neuropraxia del Nervio Peroneo Compresion de la Arteria Poplitea Tendinitis del Tibial Posterior Sindrome de Estres Tibial Interno Trombosis Venosa Profunda Estenosis Raquidea Hernia de un Nucleo Pulposo Lumbar Neuropatia Periferica Diabetica Enfermedad vascular Periferica
  15. 15. SINDROME COMPARTIMENTAL TRATAMIENTO ATENCION DEL PACIENTE POLITRAUMATIZADO (ABCD) Fasciotomia del Muslo Anterior Interno Posterior
  16. 16. ATENCION DEL PACIENTE POLITRAUMATIZADO (ABCD) Fasciotomia de la Pierna Anterior Lateral Posterior Profundo Posterior Superficial SINDROME COMPARTIMENTAL TRATAMIENTO
  17. 17. Fasciotomia del Antebrazo Anterior Posterior Lateral ATENCION DEL PACIENTE POLITRAUMATIZADO (ABCD) SINDROME COMPARTIMENTAL TRATAMIENTO
  18. 18. Contractura Isquemica de Volkmann: Necrosis de musculos isquemicos. SINDROME COMPARTIMENTAL COMPLICACIONES
  19. 19. Treatment for crush syndrome of extremities with antioxidants Zhongguo Gu Shang. 2008 Feb;21(2):109-10. PMID: 19105470 [PubMed - in process] Department of Orthopaedics, Coal General Hospital of Henan Province, Zhengzhou 450002, Henan, China. OBJECTIVE: To study the clinical therapeutic effect of antioxidants assistant treatment of extremities crush syndrome (CS)in order to find new therapy. METHODS: Twenty-one male patients (aged from 24 to 48 years, mean 36 years) were treated with the next antioxidants in early stage: (1) 20% Mannitol 250 ml intravenous drip in 30 minutes (one time per 6 to 8 h). (2) Sodium aescinate 20 mg, Salvia Miltiorrhiza 20 ml were dissolved respectively in isotonic saline or 5% glucose 200 ml and dripped by intravenous drip (50 to 60 drips per minute). The drugs were used for 5 to 7 days (one time per day). Basifying urine, keeping the negative liquid balance and electrolyte balance, preventing infection and hold out treatment were done. When the pressure of muscular osteofascial compartment was more than 30 mmHg, deep fasia was cut to decompress timely and the above- mentioned drugs were continuously applied for patients. RESULTS: Myoglobin urine of 21 cases died out after 2 to 3 days, of them, 13 cases were performed to decompress. After open decompression, 2 cases suffered from amputation because of long time of ischemia, 2 cases took place slight dysfunction of lower limbs, one hand had ischemia muscular contracture in 1 case and one foot down-vertical in 1 case. After followed-up of 8 months to 1 year, according to the function standard, the result were excellent in 8 cases, good in 7 cases, fair in 2 cases, poor in 4 cases. The excellent and good rate was about 71.4% (15/21). CONCLUSION: After extremities crushed for long time, application of antioxidents as early as possible can decrease significantly the incidence and invalidity rate of CS. Tratamiento de sindrome aplastamiento con antioxidantes. 21 masc, 1. manitol 20%, 2. eoscinato sodico, 5 a 7 dias OD. 30mmhg fasciotomia. Resultados: mioglobina disminuye en 2 a 3 dias. Conclusion: El uso de antioxidantes en etapas tempranas disminuye la contractura postisquemica.
  20. 20. Compartment syndrome of the leg in the coagulopathic, end-stage liver disease patient: Fasciotomy is not the best answer. Int J Surg. 2008 Dec;6(6):e31-3. Epub 2006 Nov 1. PMID: 19059130 [PubMed - in process]. Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA. BACKGROUND: Compartment syndrome of the leg secondary to spontaneous bleeding has been described in coagulopathic patients. Correction of the coagulopathy and emergency fasciotomy is the recommended treatment. We present a cirrhotic patient with a short life expectancy who developed compartment syndrome of the leg secondary to spontaneous bleeding. This patient underwent fasciotomy of the leg and subsequently developed persistent postoperative bleeding and required repeated transfusions of blood and blood products. The patient eventually expired in the hospital 1 month after surgery. RESULTS: Compartment syndrome of the leg occurring in patients with coagulopathy secondary to cirrhosis is very difficult to manage. Coagulopathy in these patients is hard to correct and constant bleeding from fasciotomy site is a major complication mandating frequent transfusions of blood and blood products. The complications of fasciotomy in these patients may outweigh the complications of untreated fasciotomy, particularly in patients with a short life expectancy. CONCLUSIONS: Fasciotomy is not always the best treatment for compartment syndrome of the leg. In certain patients, particularly in the coagulopathic, end-stage cirrhotic patient with a short life expectancy who is not a candidate for liver transplantation, fasciotomy is not indicated. Fasciotomy should be used selectively, if at all, in patient population with end-stage and terminal diseases. SC en pac con coagulopatía por enfemedad teminal hepática, la Fasc no es la mejor respuesta. Corregir cuagulopatia y fasc de emergencia es el trat recomendado. Pac cirrosis hepatica terminal desarrolla SC por sangramiento espontaneo. Se realiza fasc y requiere post múltiples transfusiones. Pac fallece al mes de cirugia. Resultados: fasc en estos pac sobrepesan las complic de no realizar fasc.
  21. 21. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth. 2009 Jan;102(1):3-11. Epub 2008 Nov 19. PMID: 19022795 [PubMed - indexed for MEDLINE]. Department of Anaesthesia, St Vincent's Hospital, Melbourne, PO Box 2900, Fitzroy, 3065 VIC, Australia. gjpmar@yahoo.com.au Acute compartment syndrome can cause significant disability if not treated early, but the diagnosis is challenging. This systematic review examines whether modern acute pain management techniques contribute to delayed diagnosis. A total of 28 case reports and case series were identified which referred to the influence of analgesic technique on the diagnosis of compartment syndrome, of which 23 discussed epidural analgesia. In 32 of 35 patients, classic signs and symptoms of compartment syndrome were present in the presence of epidural analgesia, including 18 patients with documented breakthrough pain. There were no randomized controlled trials or outcome-based comparative trials available to include in the review. Pain is often described as the cardinal symptom of compartment syndrome, but many authors consider it unreliable. Physical examination is also unreliable for diagnosis. There is no convincing evidence that patient-controlled analgesia opioids or regional analgesia delay the diagnosis of compartment syndrome provided patients are adequately monitored. Regardless of the type of analgesia used, a high index of clinical suspicion, ongoing assessment of patients, and compartment pressure measurement are essential for early diagnosis. SCA en pierna y el efecto de analgesia postoperatoria en el diagnostico. Pac bajo analgesia epidural se diagnostica un SC con examen clinico no siendo el dolor el sintoma principal. Realizando un buen ex. Clinico y teniendo presente la sospecha de un SC y midiendo la presion compartimental se diagnostica SCA
  22. 22. Pathology and diagnostic options of lower limb compartment syndrome Clin Hemorheol Microcirc. 2009;41(1):1-8. PMID: 19136736 [PubMed - in process]. Department of General and Vascular Surgery, Faculty of Medicine, University of Pécs, Pécs, Hungary. Background: The indication of surgical treatment in lower limb compartment syndrome mostly depends on the clinical signs which can be often uncertain, resulting in delayed insufficient intervention. Aim: The aim of the study was to evaluate the progression of compartment syndrome by measuring of intracompartmental pressure and monitoring of decreased tissular oxygenation, indicating an insufficient secondary microcirculation. Materials and methods: 16 patients were examined in our study (12 males, 4 females, mean age: 62.7+/-9.5 years), who underwent acute lower limb revascularization surgery for a critical (lasting more than 4 hours) limb ischemia. The indications were: 5 iliac artery embolizations and 11 femoral artery occlusions. After revascularization, on the second postoperative day, we detected significant lower limb edema and swelling of several grade. To monitor the elevated intracompartmental pressure (ICP) and to evaluate the extremital circulation, we used KODIAG pressure meter and the tissular oxygen saturation (StO2) was measured by near-infrared-spectroscopy. Results: In 12 cases the ICP exceeded the critical 40 mmHg. In these patients the average StO2 was 50-53%, in spite of complete recanalization. In these cases we made urgent, semi-open fasciotomy. In 4 cases, where the clinical aspect showed compartment syndrome, the measured parameters did not indicate a surgical intervention (ICP: 25-35 mmHg, StO2: around normal).Summary: A novel approach in our examination is that, besides empirical therapeutic guidelines generally applied in clinical practice, we established an objective, parameter-based ("evidence based medicine") surgical indication strategy for the lower limb compartment syndrome. Our parameter results produced by the above pressure and saturation measurements help the clinicians to decide between conservative and operative treatment of the disease. Patologia y Opcion diagnostica de SC en piernas. Objetivo: evaluar progresion de SC midiendo presion intracompartimental y monitoreo de disminucion de oxigenacion tisular, indicando microcirculacion deficiente secundaria. 16 pac revascularizacion (2 dia PO). Resultados: 12 casos ICP >40mmhg – StO2 50 – 53% se realiza fasciotomia. 4 casos ICP 25 – 35 mmhg – StO2 normal. Conclusion: el uso de ICP y medida de saturacion ayuda a la decision quirurgica.
  23. 23. Arato, E. y cols. Pathology and diagnostic options of lower limb compartment syndrome. Clin Hemorheol Microcirc. 2009;41(1):1-8. PMID: 19136736 [PubMed - in process]. Department of General and Vascular Surgery, Faculty of Medicine, University of Pécs, Pécs, Hungary. 2009. Bucholz, R. y cols. Rockwood y Green, Fracturas en el Adulto. Editorial MARBAN. Philadelphia, USA. 2003. Caceres, E. y cols. Manual SECOT de cirugia ortopedica y traumatologia. Editorial Panamericana, Espana, 2004. Fitzgerald, R. y cols. Ortopedia. Editorial Panamericana. St. Louis Missouri, USA. 2004. Fu, CG. Treatment for crush syndrome of extremities with antioxidants. Zhongguo Gu Shang. 2008 Feb;21(2):109- 10. PMID: 19105470 [PubMed - in process] Department of Orthopaedics, Coal General Hospital of Henan Province, Zhengzhou 450002, Henan, China. Mar, GJ. y cols. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth. 2009 Jan;102(1):3-11. Epub 2008 Nov 19. PMID: 19022795 [PubMed - indexed for MEDLINE]. Department of Anaesthesia, St Vincent's Hospital, Melbourne, PO Box 2900, Fitzroy, 3065 VIC, Australia. gjpmar@yahoo.com.au. 2009. Mendoza, A. y Manzo, H. Síndrome compartimental en extremidades. Conceptos actuales. Compartment syndrome in the extremities. Current concepts. Servicio de Cirugía General. Hospital General Balbuena. DDF. México. Cirujano General Vol. 25 Núm. 4 – 2003. Milanchi, S. y cols. Compartment syndrome of the leg in the coagulopathic, end-stage liver disease patient: Fasciotomy is not the best answer. Int J Surg. 2008 Dec;6(6):e31-3. Epub 2006 Nov 1. PMID: 19059130 [PubMed - in process]. Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA. 2008. SINDROME COMPARTIMENTAL REFERENCIAS
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Sindrome compartimental

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