Compartment syndrome of the hand following iatrogenic intra-arterial administration of epinephrine during cardiopulmonary resuscitation

Abstract

A 26-year-old woman developed acute compartment syndrome (ACS) of her right hand secondary to reperfusion syndrome. She suffered an out-of-hospital cardiac arrest following a pregabalin overdose. Attending paramedics mistakenly gave intra-arterial epinephrine into her right brachial artery. On resolution of her brachial artery spasm, she developed a reperfusion injury to her right hand and subsequently ACS. A four-incision fasciotomy with carpal tunnel decompression was performed and was successful in reversing focal ischaemia and an irreversible functional deficit. This case demonstrates an unusual case of hand ACS secondary to temporary limb ischaemia and reperfusion syndrome following iatrogenic intra-arterial epinephrine administration. We also summarise the current available literature on ACS of the hand including the aetiology, treatment and use of an intracompartmental monitor.

Background

Acute compartment syndrome (ACS) is an emergency in which intracompartmental pressure can lead to tissue hypoperfusion and irreversible tissue damage if left untreated. The diagnosis is made based on the associated signs and symptoms including pain out of proportion to the injury, pain on passive stretch of muscles in the affected compartment, swelling and in the late stages, sensorimotor deficit and loss of peripheral pulse.¹ Intracompartmental pressure measurements can be used in times of uncertainty to help guide the decision regarding performing fasciotomies.² ACS is most commonly seen in the leg and forearm following trauma³ and is rarely seen in the hand. However, it can lead to devastating loss of function if missed or managed ineffectively. There is uncertainty regarding the spectrum of aetiologies causing hand ACS and how this typically presents.

In this case report we present an unusual case of hand ACS which had good outcomes following four-incision fasciotomies and carpal tunnel decompression. We also summarise the current available literature on ACS of the hand including the aetiology, treatment and use of an intracompartmental monitor. The patient gave informed consent for submission and publication of the data.

Case presentation

A 26-year-old woman with a history of asthma, and borderline personality disorder suffered an out-of-hospital cardiac arrest following an overdose of pregabalin. Paramedics were summoned at noon when her partner first noticed her to be unresponsive and snoring. Initial cardiac tracing showed pulseless electrical activity and cardiopulmonary resuscitation was commenced. No direct-current shocks were given. A cannula was placed into her right antecubital fossa (ACF) and 2 mg of epinephrine and 400 µg of naloxone were administered. She had approximately 20 min of down time followed by spontaneous return of circulation and was with a Glasgow Coma Scale 3 on arrival into the emergency room. She was intubated and ventilated and a right internal jugular central venous catheter and left femoral arterial line were sited. Her background included five previous paracetamol overdoses, alcohol consumption of 6–8 units per day and smoking 1 g of cannabis and 10 cigarettes per day. She had no known allergies.

Approximately 6 hours later, it was noted that her hand had delayed capillary refill and was pale, cold. Peripheral pulses were intact. Doppler ultrasound revealed triphasic flow through the brachial, radial and ulnar arteries. The right ACF cannula was removed with high pressure, arterial flow from the puncture site noted and compression bandaging required to stem the bleeding. No further surgical review was planned at this stage and she was transferred to the intensive care unit (ICU).

Investigations

The patient required norepinephrine to maintain a mean arterial pressure of >65 mm Hg. Her initial acute kidney injury began to improve in the ICU including a reduction in her potassium from 6.2 mmol/L to 2.5 mmol/L, however her lactate remained high (5.9 mmol/L). Her initial creatine kinase in the emergency room was 7500 U/L which increased to 47 000 U/L the following day and the nurses noted the patient’s hand appeared blue and mottled. Radial and ulnar pulses were still palpable. At 07:00, the orthopaedic registrar was called to review the patient. The hand was cyanotic and cool to touch (figure 1A, B). There was a firm, fullness to the thenar and hypothenar eminences and the dorsum of the hand. A clinical diagnosis of ACS was made, and the patient was immediately transferred to the operating room for urgent fasciotomies. The decision to decompress was with the knowledge the hand was not displaying these features at 23:00 the night before; a time less than 12 hours. No further studies were obtained.

Figure 1.

(A, B) Focal hand ischaemia prior to emergency fasciotomies.

Treatment

Fasciotomies were performed over the thenar and hypothenar eminences as well as on the dorsum of the hand in line with the index and ring finger metacarpals (figure 2A, B). A carpal tunnel release was also performed. There was significant muscle bulging out of the thenar and hypothenar eminences however the muscle looked healthy. There was gross oedema over the muscle bellies within the dorsal incision and the muscle appeared slightly discoloured however, it appeared alive. The carpal tunnel incision was closed. Immediate improvement in the colour and capillary refill time of the patient’s hand was noted. The hand was dressed, and the patient moved back to ICU. They returned to theatre 24 hours later for debridement of some muscle necrosis of the dorsum of the hand. The patient was brought back to theatre a third time, 72 hours post-fasciotomies, for closure of the wounds except the most radial of the dorsal wounds. This healed by secondary intention.

Figure 2.

(A, B) Fasciotomy wounds 48 hours following surgery.

Outcome and follow-up

The hand was pain-free on discharge from hospital with some residual intrinsic tightness and grip strength of medical research council grade 4+. The patient was referred for outpatient hand therapy following discharge and the deficits had resolved when reviewed in the clinic at 3 months following surgery. The patient was followed up in a telephone clinic at 9 months post-surgery and was actively looking for employment and did not have any concerns regarding her current hand function.

Discussion

This case demonstrates an unusual case of ACS of the hand secondary to a reperfusion injury after relaxation of a brachial artery spasm which was caused by intra-arterial epinephrine during resuscitation. Ideally, fasciotomies would have been performed sooner however, this case highlights the rarity of hand ACS which few physicians or surgeons have encountered in their practice. It is for this reason that we have reviewed the current available literature reporting on hand ACS, and this can be seen in table 1.

Table 1.

The aetiology, age and treatment of compartment syndrome of the hand in the current literature. If more than two cases were included the age was represented as the mean and range

Author	Year	No. of cases	Aetiology	Age	Treatment	Isolated compartment	Compartment monitor
Abidin and Jalaluddin9	2008	1	Henoch-Schönlein purpura	9	Fasciotomy	No	No
Abdul-Hamid10	1987	1	Exertional	Unknown	Fasciotomy	First dorsal interosseous	Unknown
Basaran et al11	2009	1	Human bite	41	Fasciotomy	Not specified	No
Belzunegui et al12	2011	1	Extravasation of contrast	50	Fasciotomy	No	No
Chokshi et al13	1998	1	Reflex sympathetic dystrophy	40	Fasciotomy	No	Yes
Cosker et al14	2004	1	Suction	68	Fasciotomy	Not specified	Yes
D'Asero et al15	2010	1	Extravasation of contrast	80	Fasciotomy	Not specified	No
de Blacam et al16	2012	1	Crush	56	Fasciotomy	No	No
Del Piñal et al7	2002	11	Closed crush injury	35 (20–57)	Fasciotomy	Varied	No
Dolan et al17	2012	1	Metacarpal fractures	44	Fasciotomy	No	No
Dwyer et al18	2017	1	Exertional	44	Fasciotomy	Not specified	Yes
Funk et al4	1999	2	Intra-arterial drug	24, 28	Fasciotomy	Not specified	No
Gainor19	1984	1	Flexor digitorum superficialis rupture	Unknown	Unknown	Not specified	Not specified
Gallagher and Ruiter20	2015	1	Spontaneous arterial haemorrhage	70	Fasciotomy	Not specified	No
Horlocker and Bishop21	1995	1	Brachial artery cannulation	16	Fasciotomy	Not specified	Yes
Hung et al22	1988	1	Necrotising fasciitis	52	Amputation	Not specified	No
Jue et al23	2017	1	Transradial cardiac catheterisation	64	Fasciotomy	Thenar	Yes
Kies et al8	2004	79	Multiple causes	43	Fasciotomy	Not specified	Not specified
Lee et al24	2012	1	Exertional	34	Fasciotomy	Thenar	Yes
Malik et al25	2011	1	Hereditary angioedema	13	Fasciotomy	No	No
Martin and Treharne26	2016	1	Birth	1 month	Fasciotomy	No	No
Mehta et al27	2018	1	Crush	44	Amputation	No	No
Mull et al28	2015	1	McArdle disease	40	Fasciotomy	Volar only	Yes
Neth29	2019	1	Unknown	67	Fasciotomy	Thenar	Yes
Onal et al30	2015	1	Radial artery cannulation	67	Amputation	Not specified	No
Orta et al5	2018	1	Exertional	30	Incobotulinum A toxin	First dorsal interosseous	No
Ouellette and Kelly6	1996	19	Intravenous injections (11), gunshot (2), crush (3), arterial line complication (2), postoperative wrist arthrodesis (1)	Unknown (0–67)	Fasciotomy	Mixed	Yes
Pentz et al31	2018	1	Protein S deficiency	48	Fasciotomy	No	Yes
Petratos et al32	2011	1	Wasp sting	6	Fasciotomy	No	No
Phillips et al33	1986	1	Exertional	21	Fasciotomy	First dorsal interosseous	Yes
Quigley et al34	1981	1	Extravasation of intravenous fluid	25	Fasciotomy	No	No
Reichman35	2016	1	Carpal fracture/dislocation	37	Fasciotomy	No	Yes
Rios-Alba and Ahn36	2015	1	Elastic bandage	11 months	Fasciotomy	No	Yes
Sawyer et al37	2010	1	Wasp sting	5	Fasciotomy	No	Yes
Seiler et al38	1996	1	Extravasation of intravenous fluid	44	Fasciotomy	Not specified	Yes
Selek et al39	2007	1	Extravasation of contrast	70	Fasciotomy	Dorsal only	No
Sharma et al40	2013	1	Crush	38	Fasciotomy	Not specified	No
Shin et al41	1996	1	Pool suction	19 months, 24 months	Fasciotomy	No	Varied
Silveri et al42	1997	1	Rupture of transverse carpal ligament	Unknown	Fasciotomy	No	Not specified
Söderberg43	1996	2	Exertional	32, 20	Fasciotomy	No	Yes
Song et al44	2015	1	Transradial cardiac catheterisation	84	Spontaneous rupture	Dorsal only	No
Stavrakakis et al45	2018	1	Extravasation of contrast	72	Fasciotomy	No	No
Stein et al46	2003	1	Extravasation of contrast	51	Unknown	Not specified	Not specified
Styf et al47	1987	4	Exertional	29 (20–39)	Fasciotomy	First dorsal interosseous	Yes
Sveen et al48	2018	1	Restrictive splint	17 months	Fasciotomy	No	No
Talbot and Rogers49	2011	2	Extravasation of intravenous fluid	10 months	Fasciotomy	No	Yes
Tanagho et al50	2015	1	Systemic sclerosis	Unknown	Fasciotomy	Not specified	No
Tetreault et al51	2018	1	Birth	Neonate	Fasciotomy	Not specified	Not specified
Thomas et al52	1994	1	Thrombolysis	35	Fasciotomy	No	No
Tucker and Josty53	2005	1	Snake bite	42	Fasciotomy	Thenar	Yes
Varacallo et al54	2018	1	Propofol extravasation	52	Fasciotomy	No	Yes
Venditto et al55	2017	1	Paediatric hereditary angioedema	13	Fasciotomy	No	Yes
Werman et al56	2013	2	First metacarpophalangeal joint fracture/dislocation	16, 26	Fasciotomy	Thenar (in one case)	Yes (in one case)
Whatling and Galland57	1999	1	Post-brachial embolectomy	72	Fasciotomy	Thenar, first dorsal interosseous	No
Wirth et al58	2008	2	HIV-induced vasculitis	41, 49	Fasciotomy	No	Yes
Yurdakul et al59	2014	1	Extravasation of contrast	60	Fasciotomy	Dorsal only	No

This is the first case to describe ACS of the hand secondary to intra-arterial epinephrine during resuscitation and explore the theory of reperfusion syndrome. Funk et al reported two cases of hand ACS following injection of heroin into the radial and brachial artery.⁴ Both cases made full recoveries following fasciotomies. It is well documented that intra-arterial epinephrine into a peripheral limb leads to vascular spasm. At the level of the brachial artery, no collateral blood is available to supply distal perfusion to the limb. In the case presented, this ischaemic period may have been up to 6 hours followed by spontaneous reperfusion.

A review of the literature demonstrated causes for hand ACS are most frequently attributed to extravasation of intravenous fluid, contrast or medication from the venous vasculature of the hand. Trauma was a common aetiology and this included metacarpal fractures, a fracture/dislocation of the carpus and crush injuries to the hand. Interestingly, a number of case reports of exertional compartment syndrome of the hand have been reported. These typically affect the first dorsal interosseous but have also been reported in the thenar eminence. The diagnosis of exertional hand compartment syndrome can be susceptible to delay secondary to its rarity and unfamiliarity with clinicians. Treatment typically included fasciotomies however, one case in the literature was successfully treated with Incobutulinum A toxin.⁵

Included in the literature review were three larger case series. The first was performed by Ouellette and Kelly⁶ and reported a series of 19 patients with hand ACS of which 11 were caused by extravasation of intravenous fluid, 3 were crush injuries, 2 gunshot wounds, 2 arterial line complications and 1 following wrist arthrodesis. Del Piñal et al⁷ retrospectively reviewed 11 cases of hand ACS secondary to closed crush injuries over a 5-year period. They found the injury to be sustained entirely by men involved with manual labour. Six had the ‘generalised form’ affecting all compartments, three had the ‘localised form’ affecting the thenar and first web space muscles, two cases also affected the second web space and two cases were the atypical form which affected the second and third web spaces and the hypothenar eminence. Following treatment 9 of the 11 patients returned to manual labour. The final study by Kies et al⁸ included five cases over a 15-year period sustained following operative procedures where the mechanism was thought to be secondary to crushing of the hand with the draw sheets when the patient was positioned.

Learning points.

• This case demonstrates an unusual cause for acute compartment syndrome (ACS) of the hand following reperfusion syndrome secondary to brachial artery spasm and a requirement for high degrees of clinical suspicion when reviewing patients with suspected acute ischaemia of the hand.

• Four compartment fasciotomies and carpal tunnel release can be a successful treatment option if performed in a relatively timely manner.

• The current literature would suggest that the most common causes of hand ACS are secondary to extravasation of intravenous fluids and crush injuries.