First-aid treatments of crush injuries after earthquake: 2 special cases
Crush injuries a”>Case Report
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American Journal of Emergency Medicine
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First-aid treatments of crush injuries after earthquake: 2 special cases?
Abstract
Hyperkalemia and acute renal failure are the Life-threatening complications of crush injuries. Vigilant prehospital emergency care is vital to reduce the complications. We report and discuss 2 cases diagnosed as crush syndrome after earthquake, in order to illustrate the value of prehospital application of tourniquets to prevent hyperkalemia accompanying extremity crush injuries. The victim in case 1 died of hyperkalemia shortly after extrication without tourniquet. The pre- hospital tourniquet had been used to avoid uncontrollable hemorrhage and release of toxic metabolites into the circulation in case 2. Providers need to be fully aware of the risk of hyperkalemia in the field for patients with crush syndrome. Tourniquet application is strongly recommended in the prehospital setting for severe crush injuries.
Hyperkalemia and acute renal failure are life-threatening compli- cations of crush injuries, and vigilant prehospital emergency care is vital to reduce these complications. We report and discuss 2 special patients who were diagnosed as having crush syndrome after earthquake, in order to provide valuable information for prehospial injury intervention. The victim in case 1 died of hyperkalemia shortly after extrication without tourniquet. The prehospital tourniquet had been used to avoid uncontrollable hemorrhage and release of toxic metabolites into the circulation in case 2. In conclusion, providers were suggested to be fully aware of the risk of hyperkalemia in the field for patients with crush syndrome. Tourniquet is strongly recommended in the prehospital setting for severe crush injuries.
Crush injuries commonly occur after earthquakes. Some patients die of renal failure and hyperkalemia in the field. Prehospital emergency care, often poorly documented, is highly important to reduce the complications. We report and discuss 2 special cases after crush injuries in the 8.0-magnitude Wenchuan earthquake in 2008, in order to provide valuable information for prehospiatl injury intervention.
A 26-year-old man without medical history was buried under 3 concrete slabs for 73 hours after the earthquake. He was found conscious by rescuers. His electrocardiogram showed supraventricular tachycardia with a heart rate of 121 beats/min, blood pressure of 135/83 mm Hg, and O2 saturation of 97% on room air. lactated Ringer‘s solution was infused at a rate of 500 mL per hour. He drank a lot of water and took some food. After 6 hours of handwork, the rescuers finally extracted him without applying a tourniquet. However, his electrocardiogram showed a heart rate of 104 beats/min, blood pressure of 105/73 mm Hg, and peaked T wave 5 minutes later. This was immediately followed by ventricular
? The value of prehospital tourniquet application with extremity crush injuries after an earthquake.
fibrillation and loss of pulse and consciousness. Cardiopulmonary resuscitation was begun; however, the patient did not recover. The death was possibly due to fatal hyperkalemia.
A 46-year-old woman’s right lower extremity was buried under the rubble for 74 hours after the earthquake. Her medical history was notable for rheumatic heart disease for 10 years. She drank urine and blood from the limb. After using gusset as a tourniquet to prevent bleeding, she cut off her right lower limb with the rubble by herself. She moved out and was found by the volunteers. Then she was transported to the hospital and had received some food and water. On arrival at the hospital, arterial blood gas analysis showed the following: pH = 7.19; HCO- = 17.1 mEq/L; K+ = 0.8 mEq/L; and base excess = - 6 mEq/L. Laboratory tests showed a creatinine level of 627.1 umol/L, a myoAlbumin level of 39 320.5 ng/mL, and a creatine kinase level of 33 452 IU/L. She was diagnosed as having crush syndrome complicated by acute renal failure. In order to prevent infection and promote healing, Surgical debridement was performed under general anesthesia. We administered NaHCO3, calcium gluco- nate, furosemide, and insulin. Three hours later, an Emergent hemodialysis was procedured to treat hyperkalemia. The renal function recovered after 7 days continuous hemodialysis. After 2- month physical and psychological therapy, the patient had been discharged from the hospital without permanent Renal damage.
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Crush syndrome was first described in 1941 during the Second
World War [1]. Hyperkalemia and acute renal failure are the life- threatening complications of crush injuries.
Once the external force is released, the breakdowns of cell walls allow potassium and toxin to release into the circulation and accelerate metabolic derangement. Therefore, the immediate fatal complication is dysrhythmia due to hyperkalemia [2]. In case 1, Prehospital providers were not fully aware of the risk of dysrhyth- mias. Potassium levels should be monitored frequently especially shortly after extrication [3,4].
In case 2, gusset as a tourniquet had prevented uncontrollable hemorrhage and release of cellular contents into the circulation, although no randomized control trails are available to support it. The effectiveness of tourniquet in animal model of crush syndrome would be a further research option.
In conclusion, prehospital providers need to be fully aware of the risk of hyperkalemia in the field for patients with crush syndrome. In case 2, the prehospital tourniquet avoided hemorrhage and release of toxic metabolites into the circulation.
Xia Zhang, MD Department of Anesthesiology School & Hospital of Stomatology China Medical University Shenyang 110002, PR China
0735-6757/(C) 2014
Xiaofeng Bai, MD, PhD Qing Zhou, MD, PhD
Department of Oral and Maxillofacial Surgery School & Hospital of Stomatology
China Medical University, Shenyang 110002, PR China
E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.12.062
References
- Bywaters EG, Beall D. Crush injuries with impairment of renal function. Br Med J 1941;1(4185):427-32.
- Sever MS, Erek E, Vanholder R, et al. Serum potassium in the crush syndrome victims of the Marmara disaster. Clin Nephrol 2003;59(5):326-33.
- Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med 2006;354(10):1052-63.
- Genthon A, Wilcox SR. Crush syndrome: a case report and review of the literature. J Emerg Med 2014;46(2):313-9.