More than 40 thousand people lost their lives and more than 100 thousand people were injured in the earthquakes of magnitude 7.7 and 7.6, which occurred at 4:17 and 13:24 on February 6 in Kahramanmaras, affecting 10 provinces, which are the biggest natural disaster in the history of the Republic.
In natural disasters such as large earthquakes, 3 to 20 percent of mass casualties occur with injuries caused by building collapse and compression, while Crush syndrome is the second leading cause of death in earthquakes after direct trauma. Other causes of death include dust inhalation, traumatic asphyxia, Decapitation or multiple organ injuries. cases that have shown survival up to 14 days along with high mortality in cases of being under a dent lasting longer than 24 hours are available in the literature.
Crush syndrome is the systemic consequences of rhabdomyolysis caused by a crush injury that can lead to organ dysfunction (Mainly acute kidney injury) or death.
During the historical earthquakes and the London Blitz bombings of 1941, the term “smiling death” was used for the depiction of the dead being pulled out of destroyed buildings. The cause is Crush Syndrome! Sudden cardiac arrest secondary to ventricular fibrillation as a result of potassium, phosphorus and myoglobin discharge from the crushed injury areas that remain under the dent…
I have tried to compile the approach and treatment recommendations for Crush Syndrome for you. I hope we will not experience a repeat of a similar disaster…
Recommendations
The development of ABH associated with Crush Syndrome
High levels of myoglobin in plasma secondary to hypovolemia and rhabdomyolysis for various reasons can lead to acute kidney injury (ABH), directly causing acute tubular necrosis (ATN). ABH associated with rhabdomyolysis due to crush injury is an important cause of morbidity and mortality in natural or human-caused disasters.
So what should we do in this case;
Before and during the rescue; In order to prevent crush-related ABH, it is recommended to start intravenous (IV) fluid replacement before and during the rescue of the casualty, if possible. In mass disasters, it is recommended to give isotonic saline (Serum Physiological-SF) instead of isotonic alkaline solution. Although the exact ratio has not been determined by controlled studies, it is recommended to give 1 L/h SF initially, to reduce the application speed to 500 mL/h to prevent volume loading after 2 liters are given (Algorithm). Fluid escape into the third cavity in the area of November muscle injury may deepen hypovolemia. Therefore, in patients with rhabdomyolysis, a large amount of fluid (up to 20 liters) may be needed to provide and maintain diuresis.
Children similarly need early and aggressive fluid resuscitation. Intravenous fluid should be given at a rate of 15-20 mL/kg/hour while the injured person is still under the wreckage. If the extraction takes longer than two hours, the rate of liquid delivery should be reduced to 10 mL/kg/h or below. If fluid cannot be given before removal, fluid resuscitation should be started as soon as possible after removal.
before and during recovery, the International Society of Nephrology (ISN) and the Renal Disaster Relief Task Force (RDRTF) agree on the application of isotonic saline instead of isotonic bicarbonate (alkaline liquid), because saline solutions are easier to find in major disasters and their effectiveness for fluid replacement has been proven. If possible, the addition of 5% dextrose to isotonic saline is recommended, as it provides the advantage of providing calories and alleviating hyperkalemia.
More than 70 percent of the total body potassium is found in November, and therefore severe hyperkalemia is often observed in patients with crush injuries. Therefore, the use of potassium-containing solutions ( such as Lactated Ringer ) should be avoided.
After Rescue; If IV fluid was not given before removal from the wreckage, IV isotonic saline at a rate of 1000 mL/h for adults should be started as soon as possible after rescue (algorithm). The patient should be evaluated regularly and urine output should be monitored for at least 6 hours while 3 to 6 Liters of fluid are given. After being removed from the debris and urine output is visible, if alkalosis has been excluded, isotonic saline can be converted into alkaline solution.
The use of bicarbonate; Bicarbonate may be useful in cases of metabolic acidosis and hyperkalemia by preventing the renal tubular accumulation of myoglobin and uric acid. As long as there are no symptomatic signs of alkalosis, alkaline solutions can be applied (urine pH> 6.5). Despite these potential benefits, there is no clear clinical evidence that alkaline diuresis is more effective than saline diuresis in preventing ABH, no direct comparative studies have been conducted. It should also be borne in mind that excessive alkalization will have disadvantages such as calcium phosphate accumulation, deepening of hypocalcemia and volume loading.
(Preparation; 50 mEq of sodium bicarbonate is added to 1 liter of isotonic saline – Usually a total of 200-300 mEq of bicarbonate can be given on the first day, unless the patient is alkaline)
Fluid and monitoring strategy; the optimal composition and delivery rate of IV fluids are unknown. If there are no signs of fluid overload after recovery and the patient can be monitored closely, we administer intravenous crystalloid at a rate of 500 mL/hour on the first day. We closely monitor serum bicarbonate, calcium and serum and urine pH. If alkalemia or symptomatic hypocalcemia develops, we cut off the alkaline solution. Most isotonic solutions for liquid replacement contain potassium (e.g. Ringer’s lactate). Due to the risk of life-threatening hyperkalemia, such fluids are contraindicated in patients at risk of crush syndrome. The expected electrolyte disturbances are hyperkalemia and hypocalcemia.
Mannitol use; The use of mannitol to prevent ABH in crush injury is controversial; mannitol may be useful in rhabdomyolysis patients, but has the potential to cause harm. Mannitol may be a useful adjunct to intravenous crystalloid in patients with urinary outflow with traumatic rhabdomyolysis, provided that close monitoring is possible.
Mannitol is contraindicated in patients with oligo-anuria.
If the urine output is sufficient (defined as >20 mL/hour), 50 mL of 20 percent mannitol (1 to 2 g/kg per day [total 120 g], given at a rate of 5 g per hour) can be added.
Calcium; Calcium supplementation is indicated only for symptomatic hypocalcemia or severe hyperkalemia.
Target urine output; Intravenous fluid administration should be adjusted to keep urine output at about 200 to 300 mL/hour. If the goal of urine output is achieved, it is recommended to continue fluid therapy until myoglobinuria disappears (clinically or biochemically).
Total fluid target; Fluid treatment should be planned individually. In order to prevent volume loading, aggressive fluid therapy should be avoided in chaotic catastrophic conditions, where it is impossible to monitor patients properly, in the field, it is recommended to give fluids up to a maximum of 6 liters per day to these patients. Caution should be exercised in the elderly, those with a history of heart failure, and anuric patients.
Apart from dialysis; maintaining fluid and electrolyte balance and tissue perfusion, there is no specific treatment when the patient develops ABH. Dialysis is indicated in conditions such as excessive volume loading, hyperkalemia, severe acidemia and uremia. Recurrent hemodialysis (two to three times a day) may be indicated due to the mortal course of resistant hyperkalemia.
IV Fluid Protocol Algorithm for Crush Injuries:
Doç. Dr. Nazlı Görmeli Kurt
Ankara Bilkent Şehir Hastanesi
Acil Tıp Kliniği