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Compartment syndrome in a schizophrenic patient
- VS Murthy Burra (10 January 2009)
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VS Murthy Burra, Consultant Anaesthetist Royal Liverpool University Hospitals, Liverpool
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Editor – I read with interest the recent review article on ‘Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis’.1 I agree with the conclusion that a high index of clinical suspicion, ongoing assessment of patients, and compartment pressure measurement are essential for early diagnosis of compartment syndrome, I would like to add an atypical presentation of compartment syndrome in a chronic schizophrenic patient, which we have already published in detail.2 A known 57 year old schizophrenic man presented to the emergency department with a closed tibial fracture. His regular medications included oral benzhexol 5 mg 8 hourly, haloperidol 5 mg 8 hourly, nitrazepam 2.5 mg once a day and a fortnightly injection of depot fluphenazine 100 mg. He denied any other illness. Examination of the injured limb revealed swelling around the proximal tibia with normal distal sensation and circulation. Although, he was not complaining of pain, he was given pethidine 50 mg intramuscularly to facilitate application of an above-knee plaster of Paris back slab for splinting. His clinical records showed that a further dose of co-codamol (30 mg codeine phosphate and 500 mg paracetamol) was taken that night. On the following morning, examination of the leg revealed a tense and swollen calf, with fracture blisters and intact distal pulses. In spite of this clinical appearance, the patient remained remarkably comfortable and did not have stretch pain. Compartmental pressures, measured under general anaesthesia using an arterial transducer, were 52 mm Hg in the anterior compartment, and 64 mm Hg in the superficial posterior compartment (arterial diastolic pressure: 80 mm Hg). Fasciotomies of all four compartments were carried out and the fracture was fixed appropriately. His intra-operative and postoperative analgesic requirements were meagre. Increasing pain, unresponsive to analgesics, is an early warning of excessive intracompartmental pressures; the absence of this cardinal symptom in our patient could have led to a delay in the diagnosis of compartment syndrome, with its consequent morbidity. According to Kudoh et al, patients with schizophrenia are known to have a higher tolerance to pain with significantly lower postoperative Visual Analogue Pain Scores when compared to normal patients.3 The lack of pain in schizophrenics on treatment with phenothiazines could be due to the opioid agonist activity of this group of drugs.3 However, recent research also suggests that this phenomenon could be due to reduced function of the N-methyl D-aspartate receptor complexes.5 Our case illustrates the need for frequent clinical examination (6th hourly – instead of 24 hourly), in addition to a high index of clinical suspicion, and continuous intracompartmental pressure monitoring in such patients and may serve as a useful reminder. BVS Murthy Liverpool, UK Email: Burra.Murthy@rlbuht.nhs.uk 1. Mar GJ, Barrington MJ, McGuirk BR. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth 2009; 102: 3-11. 2. BVS Murthy, B Narayan, S Nayagam. Reduced perception of pain in schizophrenia: its relevance to the clinical diagnosis of compartment syndrome. Injury 2004; 35: 1192-1193. 3. Kudoh A, Ishihara H, Matsuki A. Current perception thresholds and postoperative pain in schizophrenic patients. Reg Anesth Pain Med 2000; 25(5): 475-479. 4. Maltbie AA, Cavenar JO Jr, Sullivan JL, Hammett EB, Zung WW. Analgesia and haloperidol: A hypothesis. J Clin Psych 1979; 40: 323-326. 5. Olney JW, Farber NB. NMDA Antagonists as neurotherapeutic drugs, psychotogens, neurotoxins and research tools for studying schizophrenia. Neuropsychopharmacology 1995; 13(4): 335-345. Conflict of Interest:None declared |
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