Crush syndrome

Classification according to ICD-10
T79	Certain early complications of trauma, not elsewhere classified
T79.5	Traumatic anuria
-	Crush syndrome kidney failure after crushing
S77	Bruising of the hip and thigh
ICD-10 online (WHO version 2019)

The crush syndrome , also called compression syndrome (formerly also called squeezing or crushing syndrome and Bywaterss disease ), is a clinical picture caused by extensive skeletal muscle necrosis with subsequent fulminant liver and kidney failure due to rhabdomyolysis . These necroses usually occur as a result of compression injuries after earthquakes or other accidents with concrete slabs, wall parts or the like.

The crushing is a compression injury with muscle swelling and / or neurologic impairment in the injured limb, while the crush syndrome , a crushing with subsequent systemic disease is.

The injuries are typically found in the lower extremities (74%), upper extremities (10%) and trunk (9%). Primary causes are explosions (as a tertiary cause of injury), earthquakes or other environmental disasters as well as construction accidents .

Crush injuries are a major challenge in disaster medicine . In contrast to classic trauma medicine, in which permissive hypotension is sought, this concentrates on prior volume administration, so-called "fluid loading". The blood is thus thinned before liberation in order to be able to absorb the burden of the returning metabolites . The field amputation should be mentioned as the most drastic measure, with which this backflow can of course be directly prevented.

Pathophysiology

The British doctor Eric Bywaters described the crush syndrome in 1941 in patients who were injured during the German air raid on London Blitz . The big problem arises from the restored blood flow after releasing the bruise, which leads to the so-called reperfusion trauma . It is believed that the resuming blood flow releases the breakdown products of the muscle cells - myoglobin , potassium and phosphorus - as products of rhabdomyolysis , which in turn trigger acute kidney failure ( crush kidney ). Furthermore, the rapid increase in potassium in particular can lead to hyperkalemia with the resulting cardiac arrhythmias . If a patient is not medically prepared for the liberation with volume, preferably a potassium-free infusion and binding of the affected extremity, the risk of so-called "smiling death" increases. The name comes from the fact that these patients are practically symptom-free before liberation (if treated with analgesics) and then suddenly die, still laughing.

The Japanese doctor Seigo Minami recorded the crush syndrome way earlier than Eric Bywaters . This after he examined three soldiers who died of kidney failure in the First World War. He found that the renal changes were due to tubular necrosis, which was also found in survivors with major muscle damage.

therapy

Unfortunately, the current recommendations for therapy differ widely. While in Great Britain it is recommended to use a tourniquet in the pre- hospital setting for a compression period of 15 minutes or more, the Australian Resuscitation Council recommends releasing the pressure as soon as possible without a tourniquet and monitoring vital parameters. At St John Ambulance Australia , they are also instructed to do so.

Preclinical

As already mentioned, permissive hypotension is not appropriate for this clinical picture. Especially in the case of crushing that lasted longer than four hours, volume overload should take place before liberation and , if possible, sodium hydrogen carbonate should be administered. The EMS algorithm from San Francisco from 2002 calls for a bolus of 2 liters of infusion solution followed by 500 ml / h to be administered to an adult . Children and patients with a cardiac history or known renal insufficiency are excluded. If there is no possibility of prophylactic fluid overload, the extremity should be ligated with a tourniquet.

emergency department

In the first phase, the patient must be protected from hypotension , renal insufficiency , acidosis , hyperkalemia, and hypocalcaemia . Even supposedly stable patients must be monitored with an ECG, as their condition can change quickly. Open wounds should be treated surgically, with debridement, antibiotics and tetanus protection.

The infusion should continue to run at up to 1.5 liters per hour to definitely prevent hypotension. If necessary, the diuresis should be kept to at least 300 ml / h by means of diuretics . The blood electrolytes should still be checked regularly using blood gas analysis .

literature

• Joseph C. Blessing: Concise Dictionary of Modern Medicine . McGraw-Hill, New York 2006, ISBN 88-386-3917-5 .
• MS Sever, R. Vanholder, N. Lameire: Management of crush-related injuries after disasters . In: N. Engl. J. Med. Band 354 , no. 10 , 2006, p. 1052-1063 , doi : 10.1056 / NEJMra054329 , PMID 16525142 .

Web links

• Life or Limb: What happens when your leg gets trapped under a building?

Individual evidence

1. ↑ Joachim Frey : Parenchymatous kidney changes. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid. 1961, pp. 951-963, here: pp. 958 f.
2. ↑ H. Schubothe: Traumatic-ischemic muscle necrosis with myoglobinuria and renal insufficiency (crush syndrome, Bywaters disease). In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. 1961, p. 1161.
3. ↑ Blast Injuries: Crush Injuries & Crush Syndrome. (No longer available online.) Centers for Disease Control , archived from the original on January 21, 2015 ; accessed on January 21, 2015 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.  
4. ↑ Bywater's syndrome on whonamedit.com: last accessed on April 4, 2014.
5. ↑ EG Bywaters, D. Beall: Crush injuries with impairment of renal function . In: Br Med J . tape 1 , no. 4185 , 1941, pp. 427-432 , doi : 10.1136 / bmj.1.4185.427 , PMID 20783577 , PMC 2161734 (free full text).
6. ^ Nancy Caroline: Nancy Caroline's Emergency Care in the Streets: Trauma Medical . 6th edition. Vol. 2, 2007, ISBN 978-0-7637-4239-3 , pp. 19-13 ( online ).
7. ↑ Seigo Minami: About kidney changes after burial . In: Virchows Arch. Patho. Anat. Band 245 , no. 1 , 1923, pp. 247 , doi : 10.1007 / BF01992107 .
8. ^ JE Schmidt: Medical discoveries - Who and when. Thomas, Springfield 1959, p. 115.
9. ↑ Morton's medical bibliography - An annotated check-list of texts illustrating History of medicine. (Garrison-Morton). Solar Press, Aldershot 1911, p. 654.
10. ^ Emergency Management of a Crushed Victim. (PDF) (No longer available online.) Australian Resuscitation Council, March 2001, archived from the original on October 6, 2011 ; Retrieved July 20, 2011 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.  
11. ↑ Crush Syndrome. (PDF) San Francisco Emergency Medical Services Agency, July 1, 2002, archived from the original on October 28, 2011 ; Retrieved January 21, 2015 (Protocol: # P-101). 

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