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Characteristics of crush syndrome caused by prolonged limb compression longer than 24 h in the Sichuan earthquake
  1. Zhou Chunguang1,
  2. Chen Rigao1,
  3. Huang Fuguo1,
  4. Tu Chongqi1,
  5. Song Yueming1,
  6. Wang Guanglin1,
  7. Zhang Hui1,
  8. Pei Fuxing1,
  9. Kang Yan2,
  10. Liang Peng2,
  11. Fu Ping3,
  12. Tao Ye3
  1. 1Department of Orthopaedics, West China Hospital of Sichuan University, Chengdu, China
  2. 2Intensive Care Unit, West China Hospital of Sichuan University, Chengdu, China
  3. 3Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
  1. Correspondence to Huang Fuguo, Department of Orthopaedics, Guoxue Road 37#, Chengdu Sichuan 610041, China; huangfuguo79{at}tom.com

Abstract

Background To assess the characteristics, treatment and outcome of patients with crush syndrome caused by prolonged limb compression longer than 24 h in the Sichuan earthquake.

Methods Following the Sichuan earthquake, 2728 patients were transferred to the West China Hospital of Sichuan University and 157 of those were admitted to the intensive care unit. The medical records of nine severe crush syndrome patients were retrospectively reviewed.

Results The major associated injuries were in the lower extremities. Renal failure and oliguria developed in all patients. Creatine kinase peaked in all patients. Hyperkalaemia was seen in five patients, and six patients developed acidosis. All patients had amputations; five had two limbs amputated. One patient underwent fasciotomy. Adult respiratory distress syndrome developed in four patients and required mechanical ventilation. All patients underwent haemodialysis. Multiple organ failure and sepsis developed in eight patients, but no patients died.

Conclusions Crush syndrome caused by extremely long compression has high rates of renal failure, multiple organ failure, sepsis and amputation. Early transportation and immediate intensive care therapy would have improved the outcome and survival rate.

  • Crush syndrome
  • earthquake
  • emergency care systems, intensive care

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Clinical course and pathology of crush syndrome were described in detail by Bywaters and Beall.1 Since then, several cases have been reported as the result of disastrous incidents such as bombing during war, mine accidents, train accidents and earthquakes.2–5

Crush syndrome is the systemic manifestation of muscle cell damage resulting from pressure or crushing. It is characterised by hypovolemic shock, hyperkalemia, acute kidney failure and muscle necrosis.1 2

Crush syndrome is typically encountered in war zones, in mining disasters, after earthquakes, and in industrial and traffic accidents.6 The severity of the condition is related to the magnitude and duration of the compressing force, and the bulk of muscle affected. In patients with crush syndrome, kidney failure develops shortly after muscle compression.3 Early extrication and administration of intravenous fluid if possible, before or immediately after the release of compressed limbs are crucially important in preventing kidney failure.7 8 Mortality for crush syndrome associated with acute kidney failure remains high, despite major advances in critical care.

Difficulties with communication and transportation in the wake of disasters often prevent early extrication and therapeutic interventions. An earthquake on May 12, 2008, in Sichuan, China, killed about 70 000 people. Survivors extricated from the rubble who had sustained crush syndrome and kidney failure were ultimately transported to hospitals in Sichuan. In this study, the profiles, treatment and outcome of nine patients are described, who were buried under rubble for longer than 24 h then transported to the West China Hospital of Sichuan University.

Methods

At least 69 000 people died and 300 000 people were injured after the Sichuan earthquake. Two-thousand seven-hundred and twenty-eight patients were transferred to the West China Hospital of Sichuan University. One hundred and fifty-seven patients were admitted to the intensive care unit (ICU) and nine of those developed severe crush syndrome. All of the nine patients had been buried under their houses, which collapsed in the earthquake, for longer than 24 h. Crush syndrome was diagnosed when the following criteria were met: 1. compressed limbs eventually become tense and oedematous with compromised vascular circulation, 2. secondary sensory and motor disturbances in the compressed limbs, 3. the revascularization of ischaemic tissue has systemic consequences. This results in myoglobinuria and/or haematuria. The following may be seen: peak creatine kinase >10 000 U/l, oliguria (urine output <400 ml/24 h), elevated blood urea nitrogen (>40 mg/dl), serum creatinine (>2 mg/dl), uric acid (>8 mg/dl), potassium (>6 mg/dl), or phosphorus (>8 mg/dl) and a decreased serum calcium (<8 mg/dl).9

All patients were admitted to the nearest hospitals and then transferred to the West China Hospital of Sichuan University for advanced care treatment, because intensive care therapy and haemodialysis were not available at the local hospitals. All nine patients were given intravenous fluid after arriving at the local hospitals, although exact fluid volumes were not noted.

Blood tests, arterial blood gas analysis, chest radiography, clinical and neurological examination were performed on admission to the ICU. Pneumothorax, haemothorax or rib fractures were diagnosed using chest radiography. Complete blood cell counts and biochemistry tests were performed daily. Urine output was measured hourly. Samples of blood, urine and wound were sent for microbiological examination. In hyperkalaemic patients (K+ 6> mEq/l), glucose and insulin were administered and haemodialysis was performed.

Results

Five patients were men and four were women, with an average age of 22.4 years (SD 8.3, range 16–35). Average duration of burial was 38.8 h (SD 15.2, range 24–72). Average time from injury to fluid was 40.9 h (SD 15.8, range 26–72). Average time from injury to arrival at the ICU was 81.6 h (SD 23.9, range 48–120, table 1).

Table 1

Patient characteristics

All patients sustained major injuries that were localised in the lower extremities. Other injuries included to upper extremities in one patient, pelvis in one patient and on the chest in one patient. One patient had rib fractures. Fasciotomy operations were performed on one patient. All patients underwent limb amputations; five patients had two limbs amputated and four had one limb amputated. The main reason for amputation was infection and muscle necrosis, although one patient had amputation because of primary injury and limb ischaemia (table 2).

Table 2

Interventions and complications

Table 3 summarises the laboratory findings. All nine patients developed renal failure and oliguria. Six patients developed acidosis. Myoglobinuria was detected in four patients. Creatine kinase peaked in all patients and the maximum level was 278 000 IU/l. Serum creatinine concentrations peaked in all patients and the maximum level was 15.4 mg/dl on admission to the ICU. Hyperkalaemia was seen in five patients and the maximum value was 7.2 mmol/l, and elevated T waves on ECG were present in three patients. Three patients underwent emergency haemodialysis. Renal failure was treated with haemodialysis and alkalinisation was attempted in all patients. Serum potassium and creatinine were corrected to normal concentrations within days of ICU care.

Table 3

Laboratory findings

Adult respiratory distress syndrome (ARDS) developed in four patients and required mechanical ventilation. Two patients received non-invasive mechanical ventilation, whereas the others received invasive mechanical ventilation. The mean time on mechanical ventilation was 183.5 h. Seven patients had liver function damage in different extents, and one patient required an operation because of hepatorrhexis (Table 2). Eight patients had sepsis and wound infection. Microbiological investigation revealed Pseudomonas, Escherichia coli, Enterobacter cloacae, Proteus and Acinetobacter in wounds, and Enterobacter, Enterobacter Cloacae and Staphylococcus in blood.

All patients survived.

Discussions

Rescue

It is widely accepted that the timing of emergency search and rescue operations is critical in earthquake situations. In the Marmara earthquake, the first rescue teams arrived on site 6 h after the shock. Experience shows that people extricated after 6 h have a low probability of survival.10 11

Previous reports have detailed variable times for people being trapped, from 1 to 72 h.12 13 However, the relationship between the time trapped or time from rescue to admission to the hospital, and the severity of crush syndrome or the prognosis has not been analysed. Hitoshi et al reported that there was no correlation between time trapped and severity of crush syndrome.14 They also demonstrated that those with more severe injury were not necessarily trapped longer. But, in a study of 18 crush syndrome patients whose times trapped were 1.3–72 h, Demirkiran et al reported that the mortality and renal failure was higher in those whose times trapped were longer than 24 h.12 In this study, the times trapped were 24–72 h. All patients developed renal failure and received limb amputations. Eight patients developed multiple organ failure. The patients were severely injured and required ICU therapy.

Mortality

The mortality from crush syndrome sustained in earthquakes ranges from 13% to 25% when renal failure develops. The occurrence of acute renal failure (ARF) decreases the survival of the patients, even with renal replacement therapy.15 When ARF occurs in patients with multiple organ failure, especially with severe hypotension or ARDS, the mortality rate ranges from 50% to 80%.16 It has also been reported that patients who need ICU therapy have a high mortality rate.17

In this study, the patients were severely injured with eight patients developing multiple organ failure, but it was very interesting that no patients died. The favourable patient factor was young age, which may allow for recovery from severe injury. It is possible that most of the older victims died immediately during the earthquake, as this age group may be more prone to both trauma and death during disasters18; hence, they do not appear in the present study.

Complications

Hyperkalaemia can appear within hours of rescue because of rhabdomyolysis, and a common reason for death.19 One of the present patients had cardiac arrest because of hyperkalaemia, although he recovered after timely treatment. Of the many available conservative therapeutic options, only K+ binders were considered safe enough to be administered, given the situation in which appropriate supervision was often lacking. In addition, it should be taken into account that most other methods only cause a temporary K+ shift into the cellular pool, which is soon followed by a return in the opposite direction. It can be argued that the potential to remove potassium using intestinal binders might be minimal compared with the immense potassium load from the necrotic muscle cells. A more aggressive protocol should be carried out after admission.

In this study, eight patients developed sepsis. Kantarci reported that fasciotomy was a significant predisposing factor for development of sepsis.5 Only one patient underwent fasciotomy, but the sepsis rate was significantly high. It was perhaps related to the delayed union of wound and multiple organ impairment. Delayed union of wounds was observed in all patients, and may lead to local infection and sepsis. The presence or development of ARDS in four patients is perhaps related to sepsis syndrome, oxygen toxicity, and too much transfusion.

Interventions

Complications of crush syndrome can be prevented by very early and vigorous treatment. Renal failure is the most serious complication of crush syndrome.20 Fluid replacement with isotonic saline should start at the site of extrication. Intravenous fluid infusion, particularly rapid infusion of isotonic saline solution, has been recommended as a prophylactic treatment against the development of ARF.8 21 In fact, the quantity of fluid given has been the subject of much debate over the years.8 22 It may be affected by the availability of resources in a mass casualty situation, but once in hospital, the only logical way to achieve optimal fluid balance is via dynamic pressure or flow-based monitoring.

In the patients studied, intravenous fluid infusion had been started after arrival at the nearest local hospital. Despite that, all patients developed renal failure when they arrived at the ICU. Whether a delay in treatment, or the longer duration of burial led to renal failure that cannot be reversed by fluid replacement needs to be further investigated.

Fasciotomy had been performed in one patient because of compartment syndrome. There is debate about performing fasciotomy; some authors suggest its use to prevent the muscle necrosis,23 whereas others disagree because fasciotomy encourages wound infection.8 Thus, it is difficult to recommend fasciotomy as the first choice treatment in crush syndrome patients.

Better et al suggested that crush injury and limb ischaemia are primary contributors to the need for limb amputation.8 In this study all nine patients had limb amputations. Oda et al reported that fasciotomy may have prevented circulatory disturbances, and, in their study, no patient needed limb amputation and no skin lacerations, fractures, or muscle necrosis were detected in the affected limbs despite the severe muscle damage.13 Situations were different in the present cases. All patients had been buried under rubble for more than 24 h, and the affected sites were necrotic and infected on admission. Five patients underwent amputation of both legs because of extensive necrosis and infection.

Conclusions

Crush syndrome caused by extremely long compression has high rates of renal failure, multiple organ failure, sepsis and amputation. Early transportation and immediate intensive care therapy would have improved the outcome and survival rate.

References

Footnotes

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the local morality and ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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