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Table 4 Decompression timing

From: Timing of surgical intervention for compartment syndrome in different body region: systematic review of the literature

  Body district Risk Treatment Clinical presentation
Immediate Eye Sight-threatening Lateral canthotomy and cantholysis Eye pain, visual loss, diplopia and reduced mobility of the eyeball.
At ophthalmologic examination: eyebrow proptosis, eyelid ecchymosis, ophthalmoplegia, papilledema, and pulsation of the central retinal artery
Thorax
Tension pneumothorax
Cardiac arrest Decompression:
- Chest tube thoracostomy
- Lateral (mini)-thoracotomy
- Needle decompression
Chest pain, dyspnea, respiratory distress, tachypnea, hypoxia and/or increased oxygen requirements, increased respiratory effort and contralateral respiratory excursions, tachycardia Hyper-tympanic sound and reduction or abolition of respiratory sounds in the affected side.
Absence of pleural gliding at ultrasound in the affected side.
Mediastinum
Cardiac tamponade
Cardiac arrest Pericardial opening and evacuation:
- Needle pericardial evacuation
- Sub-xiphoidal pericardial window
- Left-side thoracotomy
- Clam-shell thoracotomy
Low arterial blood pressure, distended neck veins, and distant, muffled heart sounds, hemodynamic instability, shortness of breath.
Pericardial free fluid at ultrasound.
Early (within 3–12 h from diagnosis) Extremities (ECS) Muscles necrosis Fasciotomy 6 p’s: pain, pallor, poikilothermia, paresthesia, paralysis, and pulselessness. Pain: generally, out of proportion and exacerbated by passive stretching of the involved muscles.
Abdomen (ACSa) Multiorgan dysfunction syndrome Decompressive laparotomy within 3/6 h from the diagnosis if step-up maximal medical management failed (separate considerations for severe acute pancreatitis and after burns). b Intra-abdominal hypertension with a new onset organ dysfunction.
Brain (refractory elevated ICP) Brain herniation Decompressive craniotomy.
Better outcomes in subgroups of younger patients, decompress before clinical signs of herniation.
 
Delayed (after 12 h from diagnosis) Extremities (ECS)   Fasciotomy.
Discouraged for ECS occurred from > 24 h, better outcomes with non-operative management.
 
Brain (refractory elevated ICP)   Decompressive craniotomy.
No advantage after signs of herniation in stroke patients, some advantage in traumatic brain injury even if herniated over non-surgical management. c
 
Prophylactic Brain
Primary decompressive craniotomy
No ICP driven, generally utilized in TBI (also in ischemic and hemorrhagic strokes) and associated, in the acute phase, with the removal of post-traumatic intracranial hematomas
Brain herniation (presenting at the end of surgical intervention or to prevent it)   At the end of surgical intervention:
- Swollen brain (impossible to reposition the bone)
- Suspicion of brain swelling in next h
Thorax-mediastinum (after cardiac surgery)   Open chest management.
Inability for the patient to tolerate closure of the sternum after the intervention.
 
Extremities
- Artero-venous vascular injuries
- Revascularized acute limb ischemia
  Prophylactic early fasciotomy (at index operation) leads to better outcomes  
  1. aAbdominal pressure > 20 plus signs of organ failure
  2. bConsider decompressive laparotomy within 1 h for ACS developed after burn injury secondary to aggressive resuscitation
  3. cAll benefit was lost in decompressive craniotomy performed after 48 h (Hamlet trial)
  4. No benefit was seen in trials while the median time of decompression was 38 h