Category Archives: Complications

Complications

Gluteal Compartment Syndrome

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Compartment syndromes can occur virtually anywhere a muscle group is surrounded by relatively unforgiving soft tissue. In trauma, these classically involve the calf, forearm, and occasionally the thigh compartments. But they are occur unsuspected in the less common areas they can easily be missed, leading to significant morbidity, disability, and even death.

The gluteal compartment syndrome is one of those uncommon occurrences. Actually, it’s extremely rare, with less than 50 cases documented in the English literature. It is typically seen in patients who are impaired in some manner (drugs, alcohol, stroke) and are unable to move. If they lie in such a way that significant pressure is exerted on the buttock, the full syndrome can develop.

Typical symptoms include swelling, firmness, and pain in the buttock. Neurologic findings are fairly common. Paresthesias can develop late, and pressure on the sciatic nerve can ultimately begin to cause a sciatic palsy.

As with most compartment syndromes, the diagnosis is usually made solely on physical exam. However, in patients with more body fat it may not be as apparent. A pressure monitor can be inserted directly into the fleshiest part of the buttock, and elevated pressures (approaching or exceeding 30 torr) clinches the diagnosis.

The mainstays of treatment are surgical release and physiologic support, primarily for rhabdomyolysis and secondary renal injury. There are two types of incision that may be used. The classic straight line, shown on the right below, is simple but significantly disfiguring. The question mark incision on the left is kinder and gentler, but more challenging to perform properly.

Bottom line: Compartment syndromes can occur in any enclosed muscle group, which is just about all of them. Always be suspicious if your patient has unexplained elevations of CK, especially if they have tight muscle groups or deep pain in hard to access muscles. Err on the side of checking pressures and releasing those compartments in order to minimize morbidity and ultimate disability.

Reference: Gluteal compartment syndrome: a case report. Cases J. 2:190, 2009.

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Complications, Procedures

Air Embolism From an Intraosseous (IO) Line

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IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!

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Complications

Bullet In The Disk Space: Big Deal Or Not?

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In an earlier post, I reviewed the problems with lead poisoning that can occur if a bullet remains in contact with a joint space / synovial fluid, or ends up in the GI tract. But what about if it comes to rest in an intervertebral joint space? They’re dry, right?

The first case report I could find dates back to 1981. A male presented to Parkland Memorial Hospital 12 years after a gunshot to the abdomen in which the bullet lodged in a disk space. He was treated for a GI bleed, but was also noted to have many signs and symptoms of high lead levels. These included irritability, anemia, headache, lethargy, muscle weakness and confusion. A blue line was noted on the gums. X-ray of the lumbar spine showed the bullet fragment in the center of the disk space, and a cystic mass in the prevertebral area that appeared radiodense as well. Blood lead levels were elevated. The patient underwent diskectomy, resection of the mass, chelation therapy, and recovered.

Another case report from 2010 was similar in many ways. The patient was young, had a gunshot 5 years previously, and presented with symptoms of lead poisoning. The appearance of the bullet in the disk space was similar to the last case, in that the bullet could be seen within it, and there appeared to be additional radiopaque material surrounding it. It almost looked like lead was flowing out of the bullet into the disk. This case was also treated with surgical removal and chelation with a successful result.

A literature review was conducted 15 years ago that examined other case reports of bullets in the spine. Over a 25-year period 238 patients were identified with this injury. Only 12 had bullets or fragments in the disk space. All were tested for plumbism, and only one was positive. He underwent diskectomy and resection with resolution of the high lead levels.

Bottom line: We know that a bullet in contact with synovial fluid is bad, with rapid leaching of lead into the circulation. There are also suggestions that lead in contact with CSF can cause a similar problem. However, the intervertebral disk space is usually considered to be “dry” and doesn’t usually cause a problem.

However, patients with a bullet in this location should be cautioned that they do have a small risk of developing lead poisoning. They should be tested about six months post-injury to see if lead levels are on the rise. They should also be cautioned to report the development of new back pain. Structural disruption by the bullet may slowly lead to anatomic changes that result in chronic pain. And be very suspicious if there is radiopaque material in the disk space in addition to the bullet itself!

References:

  1. Acute lead intoxication from a bullet in the intervertebral disk space. JBJS 63A(7):1180-1182, 1981.
  2. Lead Poisoning by Intradiscal Firearm Bullet. Spine 35(4):E140-E143, 2010.
  3. Long-Term Clinical Manifestations of Retained Bullet
    Fragments Within the Intervertebral Disk Space. J Spinal Disord Tech 17(2):108-111, 2004.

 

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Abstracts, Complications

Best of AAST #8: Complications After Trauma Laparotomy

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With the introduction of damage control laparotomy (DCL) in the early 1990s, the trauma literature has focused on the nuances of this procedure. A significant amout of research has looked at patient selection, techniques, optimum time to closure, and complications afterwards. Studies on the single-look trauma laparotomy (STL) seem to have fallen behind. When compared to DCL, it seems to have relatively few complications.

But is that really so? A paper from the 1980s showed a nearly 50% complication rate after STL, but this included some trivial things like atelectasis which padded the numbers. A group at Scripps Mercy in San Diego looked at long-term complications after  STL in a state-wide California database. They were able to identify patients who underwent STL who were then readmitted for complications at a later date. They studied this data over an 8-year period.

Here are the factoids:

  • A total of 2,113 patients had a STL during the study period
  • One third (712) were readmitted at least once, with a median time to first readmission of 110 days
  • 30% of these patients had a surgery-related complication:
    • bowel obstruction 18%
    • infection 9%
    • incisional hernia 7%
  • Mechanism of injury was not related to development of complications

Bottom line: More than 10% of patients undergoing single-look trauma laparotomy develop significant complications. This is much higher than the complication rate seen after typical general surgical procedures. The difference between these groups and the reasons are not clear. Additional work must be done to tease out the risk factors, and our patients should be counseled on these potential complications and when to return for evaluation. Finally, the trauma surgeon should always use their best judgment to avoid an unnecessary trauma laparotomy.

Reference: Long-term outcomes after single-look trauma laparotomy: a large population-based study. Session IV Paper 14, AAST 2018.

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Complications

Tracheostomy After Anterior Cervical Fusion: Can It Be Too Soon?

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Early tracheostomy is generally accepted to be a good thing in critically injured patients. A number of papers have shown that it decreases ventilator days and hence ICU and hospital days,  and also reduces pneumonia rates, sedation requirements, and saves quite a bit of money.

However, there has been one problematic group in whom critical care surgeons are often forbidden to do an early trach: patients with a recent anterior cervical fusion. These patients typically have unstable cervical fractures, with or without a concomitant spinal cord injury. The spine surgeons argue that doing a trach “too soon” leads to a higher infectious complication rate due to the proximity of the trach to their anterior surgical wound.

But is this really true? The trauma/critical care program at Thomas Jefferson University in Philadelphia looked at their experience. They are a federally sponsored spinal cord injury center, and have a vast experience compared to most trauma centers. They reviewed their experience over a 16 year period. Typically, they performed all of their tracheostomies within 10 days, so they arbitrarily defined “early” as within 4 days, and “late” as > 5 days after the cervical procedure.

Here are the factoids:

  • A total of 98 patients with tracheostomy after anterior fusion were included in the study, some of whom also underwent a concomitant posterior fusion
  • 39 cases were “early”, within 4 days of the anterior fusion procedure, and 59 were “late”
  • Average time to fusion in the early group was 2 days, and 10 days in the late group
  • There were no wound infections in the early group
  • There were 5 wound infections in the late group, and 4 of them involved the posterior fusion site(!)
  • The only infection of the anterior fusion site occurred in a late patient who suffered an esophageal perforation from the fusion hardware

Bottom line: Although the numbers are still small after 15 years of data, it’s probably the best we will ever get! It is clear that an anterior fusion wound is safe in these procedures. I am at a loss as to why the posterior fusion wounds tend to get infected, though. But the next time your spine surgeons balk about doing an early trach in one of their anterior fusion, show them this paper!

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