“Found Down” Compartment Syndrome

Abstract

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.

Pressure Necrosis Requiring Fasciotomy After Kratom Overdose

“…[6][7][8][9][10] In a case series of 30 patients found down after opioid overdose, the authors suggested poor function on presentation did not improve despite fasciotomy. 11 Our case suggests the sedative effects of Kratom because of its action on the mu-receptor resulted in a similar case of pressure necrosis and compartment syndrome. The respiratory depression that can occur in overdose is thought to be due to partial mu-agonist activity.…”

“…Rhabdomyolysis is not generally associated with Kratom use, but there are numerous reports of opioids, sedative-hypnotics, ethanol, and carbon monoxide resulting in prolonged periods of immobilization with rhabdomyolysis caused by pressure necrosis 6–10 . In a case series of 30 patients found down after opioid overdose, the authors suggested poor function on presentation did not improve despite fasciotomy 11 . Our case suggests the sedative effects of Kratom because of its action on the mu-receptor resulted in a similar case of pressure necrosis and compartment syndrome.…”

Combined Upper Extremity and Gluteal Compartment Syndrome Following Illicit Drug Abuse: A Retrospective Case Series

“…2 In the United States, prolonged immobilization after alcohol or opioid abuse is a common etiology of compartment syndrome. [3][4][5][6][7] In our cases, we have found that other illicit substances such as benzodiazepines, amphetamines and synthetic cannabinoids, which are less commonly described with compartment syndrome can also cause this presentation.…”

“…Depressants, including alcohol and heroin, have been described in the literature in multiple case reports as direct causes of obtundation and immobility leading to compartment syndrome. [3][4][5][6][7] Other substances such as synthetic cannabinoids or K2 have been less frequently described as being associated with compartment syndrome. In one study from Turkey, Ergul et al describes six cases in which synthetic cannabinoids were directly linked to cases of renal failure, rhabdomyolysis and compartment syndrome.…”

Substance-Related Found-Down Compartment Syndrome: A Systematic Review

“…Although AECS is often caused by trauma, nontraumatic causes for compartment syndrome are becoming more common and possibly linked to the increase in substance use disorders. 1 Approximately 20.3 million Americans are reported to have a substance use disorder. 2 It is estimated that 14.8 million people suffer from alcohol use disorder and 8.1 million have illicit drug use disorder.…”