Table 4 Decompression timing
| Â | 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. | Â | |
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) | Â | 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 | Â | |
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) | Â | 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) | Â | Open chest management. Inability for the patient to tolerate closure of the sternum after the intervention. | Â | |
Extremities - Artero-venous vascular injuries - Revascularized acute limb ischemia | Â | Prophylactic early fasciotomy (at index operation) leads to better outcomes | Â |