Under Pressure: Abdominal Compartment Syndrome

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Picture of Mohamed Hagahmed, MD, EMT-P
Mohamed Hagahmed, MD, EMT-P
Mohamed is an Emergency Medicine Physician and EMS director. His main areas of interest are Critical Care, Ultrasound, Prehospital Resuscitation, and Medical Education. Find him on Twitter @HagahmedMD

The Pre-brief

Abdominal Compartment Syndrome (ACS) can lead to increased mortality if it’s not promptly recognized and correctly managed. As ED boarding of critically ill patients is becoming more common in most U.S. EDs, clinicians are at risk of missing this life-threatening diagnosis.1

What is the pathogenesis?

  • While intra-abdominal hypertension (IAH) results from intra-abdominal pressures (IAP) readings >12 mmHg, ACS is defined as increased intra-abdominal pressure>20 mmHg with evidence of end-organ damage.2
  • The rise in intra-abdominal pressure causes decreased blood flow to vital organ systems (renal, hepatic, and GI).
  • Diaphragmatic mobility decreases resulting in hypoventilation, hypercapnia, and hypoxia.
  • Decreased preload results in decreased cardiac output and, therefore, hypotension.1

Which patient is at high risk for ACS?

  • ‘Too much in the belly’: Ascites, tumors, hemoperitoneum.
  • ‘Lazy belly’: Ileus, gastroparesis.
  • ‘Noncompliant belly’: obesity, post-surgical scars, severe burns, large pleural effusions decreasing thoracic compliance.

What are some clinical and lab findings?

  • Severe abdominal pain and abdominal distention. However, patients can arrive at the ED, confused or intubated.
  • Dyspnea and respiratory acidosis
  • In the ventilated patient, high-pressure alarms with low lung volumes and tachypnea
  • Multi-organ failure manifesting as elevated lactate, rising LFTs, creatinine, and decreased urine output.2


How to manage ACS?

  • Early detection and prompt intervention are vital in preventing complications
  • Diagnosis is confirmed by measuring bladder pressure
  • Involve your surgical colleagues early when the suspicion is high so that patients can undergo emergent laparotomy
  • Aim for abdominal perfusion pressure> 60 mmHg (Abdominal perfusion pressure= Mean Arterial Pressure (MAP)- Intra-abdominal Pressure (IAP)) by doing the following:2
    • Provide adequate analgesia and control agitation.
    • Place patients in the supine position as much as possible.
    • Avoid aggressive fluid resuscitation and start a vasopressor early.
    • In intubated patients, maintain a low PEEP and plateau pressure if possible. Consider short-term paralytics.
    • Provide intra-abdominal decompression by inserting nasogastric/rectal tubes when indicated
    • Perform paracentesis for patients with ascites
    • Perform escharotomy for patients with severe abdominal burns


  1. Gottlieb M, Koyfman A, Long B. Evaluation and Management of Abdominal Compartment Syndrome in the Emergency Department. J Emerg Med. 2020;58(1):43-53. doi:10.1016/j.jemermed.2019.09.046. PMID: 31753758.
  2. Sosa G, Gandham N, Landeras V, Calimag AP, Lerma E. Abdominal compartment syndrome. Dis Mon. 2019;65(1):5-19. doi:10.1016/j.disamonth.2018.04.003. PMID: 30454823.


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