|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
- 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.
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||
Better outcomes in subgroups of younger patients, decompress before clinical signs of herniation.
|Delayed (after 12 h from diagnosis)||Extremities (ECS)||
Discouraged for ECS occurred from > 24 h, better outcomes with non-operative management.
|Brain (refractory elevated ICP)||
No advantage after signs of herniation in stroke patients, some advantage in traumatic brain injury even if herniated over non-surgical management. c
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.
- Artero-venous vascular injuries
- Revascularized acute limb ischemia
|Prophylactic early fasciotomy (at index operation) leads to better outcomes|