Under (compartment) pressure in the intensive care unit: a case report

: Compartment syndrome by itself is an emergency, but when it is combined with acute renal failure (ARF) secondary to exertional and toxin-induced rhabdomyolysis in the setting of methamphetamine use, it takes on a new dimension of complexity. We report the case of a 37-year-old male with no past medical history who was brought in by emergency medical services (EMS) after being found underneath a sink in a hotel room after a weekend of illicit drug use. On admission, the patient had a potassium of 7.7 mmol/L, creatinine of 2.71 mg/dL, and creatinine kinase (CK) of 228,635 U/L with severe agitation and confusion, and required admission to the intensive care unit (ICU). He was also noted to have severe tightness in his left posterior deltoid and triceps on exam, with compartment pressure of 40 mmHg. Immediately after hemodialysis (HD), the patient was taken for an emergent fasciotomy which showed marked duskiness of the muscles but no frank necrosis. After multiple sessions of HD, the patient continued to have markedly elevated CK levels which slowly began decreasing. Unfortunately, he was unable to remain euvolemic after HD and a transthoracic echocardiogram (TTE) showed acute heart failure with a reduced ejection fraction (HFrEF) of 40%. Swelling in his left upper extremity was slow to resolve and required closure with a continuous external tissue expander. After recovery from his multiple comorbidities the patient slowly regained functional capacity of his upper extremity despite the numerous complications. This patient’s lengthy and complicated medical course emphasizes the seriousness of this rare condition, and the cruciality of vigilance to ensure the best possible outcomes in cases of posterior deltoid compartment syndrome.