TRAUMA/CASE REPORT Bilateral Compartment Syndrome as a Result of Inferior Vena Cava Filter Thrombosis Hamid Shokoohi, MD, MPH Jeffrey Smith, MD, MPH Andrew Holmes, MD Bruce Abell, MD From the Department of Emergency Medicine (Shokoohi, Smith), Department of Orthopedic Surgery (Holmes), and Trauma and Surgical Critical Care (Abell), The George Washington University, Washington, DC. A 54-year-old man with an inferior vena cava filter in situ presented to the emergency department (ED) by emergency medical services, with acute onset of severe abdominal, lower back, and leg pain. He had fallen from a ladder 3 days before admission. An abdominal computed tomography scan revealed a large retroperitoneal hematoma and evidence of occlusive thrombus in the inferior vena cava, extending beyond the inferior vena cava filter. The occluded inferior vena cava filter caused increased venous pressures and compartment syndrome in the lower extremities. Measurement of compartment pressures in the ED revealed increased pressures exceeding 60 mm Hg in both calves and 75 mm Hg in the thighs. The patient underwent bilateral fasciotomies of the lower extremities within 3 hours. Postoperatively, he developed extensive tissue necrosis and gangrene, requiring bilateral above-the-knee amputations, and acute renal failure associated with severe rhabdomyolysis, requiring hemodialysis. This case highlights the importance of prompt recognition and treatment of inferior vena cava filter thrombosis. [Ann Emerg Med. 2008;52:104-107.] 0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2007.08.017 CASE REPORT The patient was a 54-year-old man who presented to the emergency department (ED) by emergency medical services, with acute onset of severe abdominal, lower back, and bilateral leg pain, numbness, and tightness, beginning 30 minutes before arrival. He reported falling approximately 5 feet from a ladder 3 days before ED admission. Immediately after the fall, he was evaluated at an urgent care center. In that visit, he had bilateral lower back pain and tenderness, without evidence of radiculopathy. He did not have abdominal pain, and the abdominal examination result was reported to be unremarkable. He had a normal lumbar spine radiograph result and was treated symptomatically for soft tissue injuries. His medical history was significant for left posterior globe melanoma and pulmonary embolism. He received a Greenfield inferior vena cava filter 3 years before presentation to prevent recurrence of pulmonary embolism. He stopped taking an anticoagulant after 2 years of thromboembolic-free events. On presentation, the patient was alert but extremely agitated because of pain. His vital signs on admission were as follows: blood pressure 85/60 mm Hg, pulse 96 beats/min, respiration 22 breaths/min, temperature 36.8°C (98.2°F), and oxygen saturation 98%. Cardiac examination revealed normal heart sounds and no murmur. Lung examination result was unremarkable. His abdomen was moderately tender, without distention or peritoneal signs. No ecchymosis, abrasions, redness, or tenderness was observed in the upper back and lumbosacral areas. His lower extremities were edematous and tense, with ecchymosis observed around the right ankle. He had palpable femoral pulses, but dorsalis pedis pulses in both feet could be appreciated only with a Doppler. Strength was 4 of 5, and sensation was diminished in both lower extremities. Laboratory values included the following: WBC count, 5.7103/L, with 76% neutrophils; hemoglobin, 11.3 g/dL; hematocrit, 33.6%; platelets, 88103/L; and a normal chemistry panel result, including a creatinine level of 1.2 mg/ dL. His coagulation values and cardiac enzyme levels were normal. In the ED, he had a total creatine kinase level of 285 U/L, which increased to a value of 7,988 U/L in the next 18 hours. The first lactate value was reported as 12.5 mmol/L 8 hours after ED admission. Urinalysis result was normal. After aggressive volume resuscitation with normal saline solution and considering acute vascular events and intra- abdominal trauma-related injuries as differential diagnoses, a computed tomography (CT) scan with a vascular dissection protocol was obtained. The CT scan revealed no evidence of aneurysm or dissection, but a large left retroperitoneal hematoma without evidence of external compression on inferior 104 Annals of Emergency Medicine Volume , .  : August 