Syndrome of prolonged crushing: causes, symptoms, diagnosis, treatment

The syndrome of prolonged crushing (synonyms: traumatic toxicosis, crash syndrome, crushing syndrome, myoretic syndrome, "liberation" syndrome, Byuothers syndrome) is a specific variant of trauma associated with massive prolonged crushing of soft tissues or compression of the major vascular trunks of the extremities, characterized by severe clinical course and high mortality.

ICD-10 code

• T79.5. Traumatic anuria.
• T79.6. Traumatic ischemia of the muscle.

Epidemiology of the syndrome of prolonged crushing

Meet in 20-30% of cases of emergency destruction of buildings, earthquakes, rock falls and in mines.

[1], [2], [3], [4], [5], [6], [7],

What causes long crush syndrome?

The main factors of the pathogenesis of the syndrome of prolonged crushing are traumatic toxemia, plasma loss and pain stimulation. The first factor arises from the penetration into the channel of the blood of the decomposition products of damaged cells, which causes intravascular coagulation of blood. Plasma loss is the result of a significant swelling of the extremities. The pain factor disrupts the coordination of the processes of excitation and inhibition in the central nervous system.

Prolonged compression leads to ischemia and venous stasis of the entire limb or its segment. Nerve trunks are traumatized. There is a mechanical destruction of tissues with the formation of a large number of toxic products of cell metabolism, primarily myoglobin. Metabolic acidosis in combination with myoglobin leads to intravascular coagulation of blood, while the filtration capacity of the kidneys is blocked. The final stage of this process is acute renal failure, differently expressed in different periods of the disease. Hyperkalemia (up to 7-12 mmol / L), as well as histamine, disintegration products of proteins, creatinine, phosphorus, adenylic acid, etc., are exacerbated by toxemia.

As a result of plasma loss, thickening of the blood develops, massive swelling of damaged tissues appears. Plasma loss can reach up to 30% of the volume of circulating blood.

Symptoms of prolonged crush syndrome

The course of the syndrome of prolonged crushing can be divided into three periods.

I period (initial or early), the first 2 days after release from compression. This time is characterized as a period of local changes and endogenous intoxication. In the clinical picture, the manifestations of traumatic shock predominate: severe pain syndrome, psychoemotional stress, hemodynamic instability, hemoconcentration, creatinemia; in the urine - proteinuria and cylinderuria. After conservative and operative treatment, the patient's condition stabilizes in the form of a short light interval,
after which the patient's condition worsens - the next period develops.

II period - the period of acute renal failure. Lasts from the 3rd to the 8th-12th day. The edema of the injured limb is increasing, the skin appears with blisters, hemorrhages. Hemoconcentration is replaced by hemodilution, anemia increases, diuresis drastically drops up to anuria. Maximum hyperkalemia and hypercreatinemia. Despite intensive therapy, lethality reaches 35%.

III period - recovery, begins with the 3-4-th week. Normalized kidney function, protein and blood electrolytes. Infectious complications come to the fore, possibly the development of sepsis.

Summarizing the experience of monitoring the victims during the earthquake in Armenia, clinicians concluded that the severity of the clinical manifestations of the syndrome of prolonged crushing primarily depends on the degree of compression, the area of the lesion and the presence of concomitant injuries. The combination of a small-length limb compression with bone fractures, craniocerebral trauma, internal injuries dramatically increases the course of traumatic illness and worsens the prognosis.

Classification of the syndrome of prolonged crushing

Depending on the types of compression, compression (positional or direct) and crushing are distinguished.

By localization of the lesion: head (chest, abdomen, pelvis, limbs).

By a combination of soft tissue injuries:

• with damage to internal organs;
• with damage to bones, joints;
• with damage to the main vessels and nerve trunks.

By the severity of the condition:

• light degree - compression up to 4 h;
• middle degree - develops at compression up to 6 h;
• severe form - occurs when the entire limb is squeezed for 7-8 hours; characteristic signs of acute renal failure and hemodynamic disorders;
• extremely severe form - compression of one or both extremities with exposure over 8 h.

For periods of clinical course:

• Compression period;
• post-compression period: early (1-3 days), intermediate (4-18 days) and late.

By combination:

• with burns, frostbites;
• with acute radiation sickness;
• with the defeat of warfare agents.

[8], [9], [10], [11], [12], [13]

Complications of long crush syndrome

The most common complications are:

• On the part of organs and systems of the body - myocardial infarction, pneumonia, pulmonary edema, peritonitis, neuritis, psychopathological reactions, etc .;
• irreversible limb ischemia;
• purulent-septic complications;
• thromboembolic complications.

[14], [15], [16]

Diagnosis of prolonged crush syndrome

Anamnesis

In the initial period - complaints of pain in the area of trauma, weakness, nausea. In severe cases - vomiting, severe headache, possible depression, euphoria, impaired perception, etc.

Toxic period. Complaints remain the same, pains in the lumbar region join.

The period of late complications. Complaints depend on the developed complications.

Examination and physical examination

In the initial period, the skin is pale, in severe cases - gray. AD and CVP are usually reduced, sometimes significantly (blood pressure - 60/30 mm Hg, CVP indices are negative). Identify tachycardia, arrhythmias, possibly the development of asystole. E c l and the injured limb was released without the prior application of the tourniquet, a sharp deterioration in the condition of the victim, a drop in blood pressure, loss of consciousness, involuntary urination and defecation. Locally on the skin are visible abrasions, blisters with serous and hemorrhagic contents. Extremity cold, cyanotic color.

Toxic period. The patient is inhibited, in severe cases, a loss of consciousness occurs. Developed edema, anasarca. Body temperature rises to 40 ° C, with the development of endotoxin shock can be reduced to 35 ° C. Hemodynamics is unstable, blood pressure is often lowered, CVP - significantly elevated (up to 20 cm of water), tachycardia is characteristic (up to 140 per minute). Developed arrhythmias (due to severe hyperkalemia), toxic myocarditis and pulmonary edema. Diarrhea or paralytic intestinal obstruction. Due to necrosis of the renal tubules, a pronounced oliguria, up to the anuria. Locally - foci of necrosis in places of compression, suppuration of wounds and eroded surfaces.

The period of late complications. With adequate and timely treatment, intoxication, symptoms of OPN, cardiovascular insufficiency are significantly reduced. The main problems are various complications (eg, immunodeficiency, sepsis, etc.) and local changes (eg, wound suppuration, atrophy of the viable limb muscles, contractures).

Laboratory and instrumental diagnostics of the syndrome of long crushing

The results of laboratory tests depend on the period of the syndrome of prolonged crushing.

• The initial period is hyperkalemia, metabolic acidosis.
• Toxic period. In the blood - anemia, leukocytosis with a significant shift of the leukocyte formula to the left, hypoproteinemia, hyperkalemia (up to 20 mmol / l), creatinine - up to 800 μmol / l, urea - up to 40 mmol / l, bilirubin - up to 65 μmol / l, transferase activity increased 3 times or more, myoglobin, bacterial toxins (from the area of the lesion and intestine), the disturbance of the coagulating system of blood (up to the development of ICE). Urine is lacquer-red or brown (high content of myoglobin and Hb), expressed albumin and creatinuria.
• The period of late complications. The data of laboratory and instrumental studies depend on the type of developing complications.

[17], [18], [19], [20]

Treatment of the syndrome of prolonged crushing

Indications for hospitalization

All victims are hospitalized.

First aid first aid

After elimination of compression, the limb is bandaged, immobilized, cold applied and pain relief and sedatives are prescribed. If the limb is compressed for more than 10 h and the vitality is doubted, the tourniquet should be applied according to the level of compression.

First aid

The first medical help consists in correction or carrying out of manipulations not performed at the first stage, and adjustment of infusion therapy (regardless of hemodynamic parameters). For the infusion, dextran is desirable [Mol. Weight 30 000-40 000], 5% dextrose solution and 4% sodium bicarbonate solution.

Conservative treatment of the syndrome of prolonged crushing

Treatment of the syndrome of prolonged crushing is complex. Its features depend on the period of the disease. However, it is possible to single out the general principles of conservative treatment.

• Infusion therapy with the infusion of fresh-frozen plasma to 1 l / day, dextran [mol.mass 30 000-40 000], detoxification products (sodium bicarbonate, sodium acetate + sodium chloride). Plasmapheresis with extraction of a procedure for up to 1.5 liters of plasma.
• Hyperbarooxygen therapy to reduce hypoxia of peripheral tissues.
• Early application of an arteriovenous shunt, hemodialysis, hemofiltration - in the period of acute renal failure daily.
• Sorption therapy - povidone inside, locally after operations - coal tissue AUG-M.
• Strict adherence to asepsis and antiseptics.
• Dietary regime - water restriction and exclusion of fruits during acute renal failure.

The specific treatment of the syndrome of prolonged crushing of each patient depends on the stage of care and the clinical period of the syndrome of prolonged crushing.

I period.

Large vein catheterization, determination of the blood group and Rh factor. Infusion-transfusion therapy is not less than 2000 ml / day: fresh frozen plasma 500-700 ml, 5% dextrose solution up to 1000 ml with ascorbic acid, group B vitamins, albumin 5-10% - 200 ml, 4% sodium bicarbonate solution - 400 ml , dextroseprocaine mixture - 400 ml. The number and type of transfusion means are determined by the patient's condition, laboratory parameters and diuresis. A strict account of the allocated urine is mandatory.

Sessions HBO-therapy - 1-2 times a day.

Plasmapheresis is indicated for obvious signs of intoxication, exposure to compression for more than 4 hours, expressed local changes in the damaged limb.

Drug treatment of the syndrome of long crushing:

• furosemide up to 80 mg / day, aminophylline 2.4% 10 ml (stimulation of diuresis);
• heparin sodium for 2.5 thousand under the skin of the abdomen 4 times a day;
• dipyridamole or pentoxifylline, nandrolone once every 4 days;
• cardiovascular drugs, antibiotics (after sowing microflora for sensitivity to antibiotics).

After surgical treatment of the syndrome of prolonged crushing (if conducted), the volume of infusion therapy a day increases to 3000-4000 ml, the composition includes up to 1000 ml of fresh frozen plasma, 500 ml of 10% albumin. HBO-therapy - 2-3 times a day. Detoxification - infusion of sodium bicarbonate to 400 ml, the intake of povidone and activated charcoal. Locally apply carbon cloth AUG-M.

II period. Enter a restriction of fluid intake. Hemodialysis is indicated with a decrease in diuresis to 600 ml / day. Anuria, hyperkalemia more than 6 mmol / l, pulmonary edema or brain swelling are considered emergency indications. With severe hyperhydration, hemophilia is shown for 4-5 hours with a liquid deficit of 1-2 liters.

During the interdialysis period, infusion therapy is performed with the same drugs as in the first period, with a total volume of 1.2-1.5 l / day, and in the presence of surgical interventions - up to 2 l / day.

With timely and adequate treatment, kidney failure is stopped by the 10th-12th day.

III period. Treatment consists in the therapy of local manifestations of the syndrome of prolonged crushing, suppurative complications and prevention of sepsis. Treatment of infectious complications is conducted according to the general laws of purulent surgery.

Surgical treatment of the syndrome of prolonged crushing

General principles of surgical treatment - strict adherence to asepsis and antiseptics, fasciotomy ("lamp incisions"), necrectomy, amputation (according to strict indications).

Surgical treatment of the syndrome of prolonged crushing depends on the state and extent of ischemia of the injured limb.

• I degree - a slight inducible edema. Skin pale, towering over healthy on the border of compression. Conservative treatment is effective, so there is no need for surgical intervention.
• II degree - moderately pronounced edema of tissues and their tension. Skin pale, with areas of cyanosis. There may be bubbles with a transparent yellowish content, beneath them a damp pink surface.
• III degree - pronounced indurative edema and tension of tissues. The skin is cyanotic or "marbled", its temperature is lowered. After 12-24 h there are bubbles with hemorrhagic contents, beneath - a damp dark red surface. Signs of microcirculation disorders progressively increase. Conservative therapy is ineffective, leading to necrosis. Shown are lamp incisions with dissection of the fascial vagina.
• IV degree - moderate edema, the tissues are sharply strained. The skin is cyanotic-purple, cold. Bubbles with hemorrhagic contents, beneath them - a cyanotic-black dry surface. In the future, edema does not increase, which indicates a profound circulatory disturbance. Conservative treatment is ineffective. Wide fasciotomy provides the maximum possible restoration of blood circulation, allows you to limit the necrotic process in the more distal areas, reduces the intensity of absorption of toxic products. In case of subsequent amputation, its level will be much lower.

Estimated period of incapacity for work and forecast

The period of incapacity for work and the forecast depend on the timeliness of the care provided, the extent of the lesion, the features of the long-crush syndrome and individual characteristics (eg, age, presence of severe chronic diseases) of each particular patient.