CT contrast extravasation in children: a single-center experience and systematic review.

BACKGROUND: Extravasation of iodinated contrast material during computed tomography (CT) is a rare complication. A few patients may develop severe complications such as compartment syndrome. OBJECTIVE: The purpose of this study was to retrospectively assess the prevalence, severity, management, and outcome of contrast extravasations in our institution and to perform a comparison to what has been reported in the existing literature. MATERIALS AND METHODS: This is a research ethics board (REB)-approved retrospective study comprising 11 patients who had intravenous contrast-enhanced CT between 2019 and 2022 in a tertiary pediatric center, and experienced extravasation of iodinated contrast as a complication. Age, weight, sex, co-morbidities, angiocatheter size, venous access location, total contrast volume, flow rate, patient's symptoms, severity of injury, and management were collected. For the systematic review, PRISMA guidelines were followed. RESULTS: Only 11 (0.3%) (0.17-0.54 (95%CI)) contrast extravasations occurred in a total of 3638 CTs performed with intravenous contrast during the same period in children. The median age (IQR) was 12.5 (10.0, 15.0) years. In our cohort, 1/11 patients developed compartment syndrome and required fasciotomy. The systematic review assessed 12 articles representing a population of 110 children with extravasations. Pooled prevalence from articles stratified by age was 0.32% (0.06-0.58% (95%CI)). Only three children experienced moderate to severe complications. CONCLUSIONS: We confirm that severe complications of contrast extravasation are rare and can occur at any age. No strong associations were seen with the need for surgical consultation (including age, sex, weight, flow rate, injection site, catheter size, and type of contrast).

Cocaine-induced rhabdomyolysis and compartment syndrome.

A man in his 30s with a history of cocaine and intranasal heroin use presented to the emergency department with severe leg pain and weakness. Physical examination findings were significant for tachycardia, absence of dorsalis pedis pulses, tense and painful calf muscles along with absence of plantar reflexes in bilateral lower extremities. Laboratory investigations were significant for positive urinary drug screen for cocaine, severe rhabdomyolysis and acute kidney injury. Given the absence of dorsalis pedis pulses in bilateral lower extremities and radiological evidence of oedematous changes in calf muscles with perimuscular oedema, a diagnosis of compartment syndrome was made. He was treated with bilateral lower extremity four-compartment fasciotomies and haemodialysis for acute kidney injury. Rhabdomyolysis has been attributed to cocaine use; however, compartment syndrome is a very rare complication, especially in the absence of trauma or prolonged immobilisation.

Compartment syndrome of the hand following iatrogenic intra-arterial administration of epinephrine during cardiopulmonary resuscitation.

A 26-year-old woman developed acute compartment syndrome (ACS) of her right hand secondary to reperfusion syndrome. She suffered an out-of-hospital cardiac arrest following a pregabalin overdose. Attending paramedics mistakenly gave intra-arterial epinephrine into her right brachial artery. On resolution of her brachial artery spasm, she developed a reperfusion injury to her right hand and subsequently ACS. A four-incision fasciotomy with carpal tunnel decompression was performed and was successful in reversing focal ischaemia and an irreversible functional deficit. This case demonstrates an unusual case of hand ACS secondary to temporary limb ischaemia and reperfusion syndrome following iatrogenic intra-arterial epinephrine administration. We also summarise the current available literature on ACS of the hand including the aetiology, treatment and use of an intracompartmental monitor.

Compartment Syndrome of the Hand Induced by Peripherally Extravasated Phenylephrine.

Background: Compartment syndrome of the hand is a rare and devastating complication of peripheral intravenous extravasation. With changes in critical care research, vasoactive medications are now more frequently administered through peripheral lines in the acute setting. Methods: We present the case of a patient diagnosed with compartment syndrome of the hand secondary to phenylephrine extravasation in the setting of hypovolemic shock. Results: The use of fasciotomy compartment release and intraoperative phentolamine resulted in significant improvement in tissue perfusion postoperatively. Conclusion: With incraesed incidence of peripherally administered vasoactive medications, the hand surgeon should be aware of potential complications and treatment of compartment syndrome with urgent fasciotomy and phentolamine administration.

Successful adjunctive treatment of compartment syndrome due to acute isocyanate inhalation using hyperbaric oxygen therapy: case report.

Introduction: Isocyanates are the raw materials that make up all polyurethane products. Isocyanate is a powerful irritant to the mucosal membrane of the respiratory tract, eyes and skin. Pulmonary symptoms, especially occupational asthma, are predominant manifestations of isocyanate toxicity. Case report: We report mental changes and compartment syndrome complicated with rhabdomyolysis as an extraordinary manifestation of acute isocyanate toxicity observed in a patient during the waterproofing of a water tank. A 58-year-old man recovered consciousness after six hours in the emergency department and complained of severe pain in the lower leg. The results of his laboratory test showed that his serum creatine kinase (15,250 IU/L) level had increased. The tissue pressure in both the lower legs had increased to 180 mmHg/170 mmHg (right/left). We performed fasciotomy on the second day of hospitalization. The patient was provided hyperbaric oxygen (HBO2) therapy of 2.0 ATA for 90 minutes twice a day for seven days. His condition gradually improved over five months, and he did not require amputation. He had a mild neurological disorder in his foot and was transferred to a rehabilitation center five months after hospitalization. Conclusion: It is important to note that when working with isocyanate, non-specific complications such as a change in consciousness as well as compartment syndrome with rhabdomyolysis can occur in a confined space or high-temperature environment. In addition, we found that compartment syndrome caused by isocyanate toxicity can be effectively treated with fasciotomy and HBO2 therapy.

Thigh Compartment Syndrome After Thrombolytic Therapy of an Occluded Lower Extremity Bypass Graft.

Compartment syndrome is caused by increased pressure within fascial compartment. We present a unique case of a thigh compartment syndrome that occurred after overnight catheter delivered Tissue plasminogen activator (tPA) thrombolysis of an acutely thrombosis femoral-to above knee popliteal artery Propaten® PTFE (WL Gore & Associates, Flagstaff, AZ) bypass graft. The condition was treated by emergency fasciotomy and the patient recovered uneventfully.

[A case of acute osteofascial compartment syndrome caused by rodenticide poisoning].

Acute osteofascial compartment syndrome is a series of symptoms and signs caused by acute ischemia of muscles and nerves in osteofascial compartment. If it is not treated in time, it can lead to tissue necrosis. It is rare that it is caused by rodenticide poisoning. Such patients are often difficult to diagnose and treat early and have poor prognosis. In May 2018, a patient with acute osteofascial compartment syndrome caused by anticoagulant rodenticide poisoning was admitted to the Twelfth Hospital of Guangzhou City. After systematic treatment, he finally recovered and discharged. The early manifestations of this patient were mainly coagulation dysfunction, and finally acute osteofascial compartment syndrome. 5 days later, the diagnosis was made, and the operation of incision decompression and vacuum sealing drainage (VSD) was performed.

Preinjury Narcotic Use Does Not Affect Treatment for Compartment Syndrome.

OBJECTIVES: To determine the association of preinjury opioid use on incidence of fasciotomy after lower extremity trauma. DESIGN: Retrospective case-control study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: We identified 245 consecutive patients treated with fasciotomy for compartment syndrome of the lower extremity from 2011 to 2016. Of these, 115 were excluded for isolated vascular injury without fracture, age younger than 18 years, out-of-state residence, nontraumatic etiology, and/or incomplete opioid records. Three hundred ninety age- and sex-matched patients with tibial fractures not requiring fasciotomy were selected for comparison. INTERVENTION: Review of demographics, injury characteristics, and opioid prescriptions. MAIN OUTCOME MEASUREMENTS: Rate of preinjury narcotic use. RESULTS: There was no significant difference in chronic opioid use between patients requiring fasciotomy and those who did not (odds ratio = 0.80, 95% confidence interval: 0.43-1.50, P = 0.49). There was no significant difference in average morphine milligram equivalents (MME)/day (66.6 vs. 77.4, P = 0.68). There was no significant difference in active opioid use (odds ratio = 0.76, 95% confidence interval: 0.45-1.29, P = 0.30). There was no significant difference in average MME/day (69.3 vs. 75.6, P = 0.80) for active narcotic users. CONCLUSION: There were no differences in the rate or average MME/day of preinjury opioid use between patients with a tibia fracture treated with or without fasciotomy for compartment syndrome. These results indicate that pre-existing opioid use does not interfere with the accurate diagnosis of compartment syndrome in trauma patients. The diagnosis and treatment of compartment syndrome is not affected by preinjury narcotic use and potential associations with opiate-induced hyperalgesia. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

"Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic.

BACKGROUND: With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome. METHODS: We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups. RESULTS: Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function. CONCLUSIONS: Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Envenomation by a western green mamba (Dendroaspis viridis) - A report of three episodes in Switzerland.

The African elapid snake genus Dendroaspis comprises four species, with D. polylepsis the most dangerous of them. D. viridis is believed to cause stronger neurotoxic symptoms than the potentially least toxic of the genus, D. angusticeps, but seems less toxic compared to either of the D. jamesoni species (D. j. jamesoni(TRAILL 1843) and D. j. kaimosae (Loveridge 1936)). We present three episodes of bites byD. viridis in the same patient, sustained on three different occasions, caused by three different and unrelated snakes. While the first bite remained oligosymptomatic with a slight tightness of the throat and speedy resolution of symptoms without specific therapy, episodes two and three resulted in the patient developing massive local swelling. However, the patient showed only minimal neurologic and systemic symptoms such as tightness of the throat and a tingling sensation of the body. Episode two resolved with fasciotomy after compartment syndrome was diagnosed with a measured intracompartmental pressure of 52 mmHg. In episode three, antivenom was administered with good resolution of symptoms. The clinical courses in this patient were remarkable as he displayed mainly local symptoms after three individual bites by a supposedly neurotoxic snake.

Compartment syndrome secondary to an atraumatic gastrocnemius tear in a patient on NOACs: presentation and complications of treatment.

Acute compartment syndrome is a limb-threatening condition often associated with high-energy injury. We present the case of a man who sustained compartment syndrome secondary to an atraumatic tear in the gastrocnemius muscle and the complications which arose in his treatment due to his being on rivaroxaban.

[Compartment syndrome of the forearm after intra-arterial self-injection : With a mixture of methadone, flunitrazepam, saliva and water]. / Kompartmentsyndrom des Unterarms nach intraarterieller Autoinjektion : Mit einem Gemisch aus Methadon, Flunitrazepam, Speichel und Wasser.

A drug-addicted patient injected himself intra-arterially with a mixture of methadone, flunitrazepam, saliva and water. The resulting compartment syndrome could be treated by fasciotomy and multiple debridement, with which a major amputation could be prevented. The course of the treatment and the resulting functional results are described, as well as a brief overview of the literature and a treatment proposal for similar cases.

The curse of relieving pain.

A 39-year-old woman with a history of chronic back pain due to spinal haemangiomas, multiple malignancies and depression was brought by Emergency medical servicesS to the emergency centre (EC) after being found unresponsive on the bathroom floor. The patient had an exacerbation of her back pain the previous day for which she admitted to taking double her usual dose of oxycodone, in addition to alprazolam, lorazepam, diphenhydramine and a glass of wine. She reported that she lost consciousness and was down for over 8 hours. In the EC, she complained of right forearm pain which was accompanied by mild diffuse soft-tissue swelling and decreased sensation in the right hand. Radial pulse was intact. Creatine kinase was found to be at 4663 U/L. The patient was found to have acute compartment syndrome and underwent emergent forearm fasciotomy. She eventually regained full function of the right arm.

Limb-Threatening Ischemia in a Young Man with Cathinone "Bath Salt" Intoxication: A Case Report.

"Bath salts" are synthetic designer drugs that have stimulant properties and are a growing medical concern. The chemical compounds in the mixtures have an affinity for receptors in the brain resulting in a stimulant effect similar to that seen with methamphetamines and cocaine. Although illegal in Canada, these drugs are widely available online with over 20 synthetic drugs marketed as "bath salts" and used increasingly among recreational drug users. Much of the medical literature regarding these drugs comes from emergency medicine case reports, which outline the acute, severe medical, and psychiatric effects of "bath salt" toxicity. In this report, we outline severe vascular limb compromise, which occurred in a 24-year-old man who took large doses of bath salts obtained online from China. We detail our experience to re-establish perfusion to the limbs, and the morbidities encountered due to the ischemic insult our patient experienced. The duration and clinical presentation of "bath salt" toxicity are frequently complicated by lack of toxicology screens for the agents on board, and lack of any pharmacokinetic evidence surrounding these synthetic compounds. Although "bath salts" are now illegal in Canada, these drugs are widely available online and have become an increasing public health concern that involves significant morbidity and mortality to users. Creating a base of knowledge and front-line experience are the only current tool in combating the diverse detrimental aftermath of these synthetic agents' abuse.

Compartment syndrome in a patient treated with perineural liposomal bupivacaine (Exparel).

Acute compartment syndrome is a condition that may result in sensorimotor deficits and loss of function of the affected limb as a result of ischemic injury. It is considered a surgical emergency and prompt diagnosis and treatment results in more favorable outcomes. The use of regional anesthesia is controversial in patients at risk for compartment syndrome due to concern of its potential to mask symptoms of the condition. A 44-year-old African American male presented to surgery for open reduction and internal fixation of a comminuted distal radius fracture. As part of an off-label, investigator-initiated, and institutional review board-approved study, he received a perineural injection of liposomal bupivacaine (Exparel) around the median, ulnar, and radial nerves at the level of the proximal forearm. The following morning, his initial complaints of numbness and incisional pain progressively evolved into worsening numbness, diffuse discomfort, and pain with passive movement. A diagnosis of compartment syndrome was made and he underwent an emergency fasciotomy. The diagnosis of compartment syndrome requires a high index of suspicion and prompt treatment. This patient's changing pattern of symptoms-rather than his pain complaints alone-resulted in the diagnosis of compartment syndrome treated with emergent fasciotomy in spite of finger numbness that was initially attributed to the liposomal bupivacaine. While the use of liposomal bupivacaine did not preclude the diagnosis of compartment syndrome in our patient, it should be used with caution in patients at risk for compartment syndrome until additional data, particularly regarding block characteristics, are available.