Crush Injury

By Che Haniff B Che Hassan

Supervisor Dr Azahari

Overview

Case studyDefinitionsHistoricallyCausesPathophysiologyClinical Management

Case StudyMrs. X45y.o , malay, femalePreviously NKMIWorks as food vendor

c/oAlleged industrial injury by sugarcane machine around 12pm (13/12/13)Trying to carry and pull the sugarcane, suddenly she slipped on her right foot and her left hand landed on the sugarcane machine.Her left hand stuck in the working machine for about 5min until a passerby stopped stopped by and turned off the machine

Post trauma sustained pain and bleeding at left hand

Total amputated at left hand exposing muscle and tendon

Was brought to ED HSNZ immidiately

Done wound irrigation with 3L of waterWas given antibiotic iv cefuroxime 1.5g statIv flagyl 500mg stat

o/eAlert, concious, not tachypneicnot tachycardic

Bp 150/56Pr 92T 37Spo2 100%

Cvs s1s2 drnmLungs clearPa soft, non tender

Examination of left upper limbtotal amputated at metacarpal area of left wristExposing muscle and tendonDistal part only connected by 2 flexor tendonsMinimal bleedingTotal crush on dorsal aspect of left hand

Case Study

Total amputation at metacarpal bones of left wrist with total crushed of distal part

Blood ixHb: 13.6/ Twc 10.8/ Plt 299Busec: 4/132/4.1/100/45PT/APTT: 13.5/27.4

Plan:For left wrist disarticulationFor wound irrigationFor triple abx, iv cefuroxime, iv gentamycin and iv flagylMonitor vs in wardTo notify OT

s/b Mr Hadizi

Explained regarding findings and plan.Distal part was not salvageable and to go for operation. Patient and family understood and

agreed to go for op as plan

Operative recordPost traumatic amputation over carpo-metacarpal point with crush injury of distal part of left handOp: wrist disarticulation of left hand

Op findings:Traumatic amputation over carpo-metacarpal point with crush injury of distal part of left handAmputation done at level of radio carpal jointSoft tissue healthyUnable to close the skin

EBL minimalTorniquet: 35mins

DefinitionDefinition

Definitions

• A crush injury is direct injury resulting from a crush, injury by an object that causes compression of the body. This form of injury is common following a natural disaster or after some form of trauma

• A crushing injury can cause either Compartment Syndrome (CS) or Crush Syndrome

• A crush syndrome is the systemic manifestation of muscle cell damage, resulting from pressure or crushing.-Also known as traumatic rhabdomyolysis

resulting inMuscle Cell Death and Muscle Cell Injury

History

In 1910 Myer-Betz Syndrome, German physician.Triad: Muscle Pain, Weakness, Brown Urine.

World War IIDr Bywaters described patients during London

Bombings (Battle of Britain 1941).Oliguria, pigmented casts, limb oedema, shock and

death.In 1943, in animal models, Bywaters & Stead

identified myoglobin as the offending agent, and formulated the first treatment plan.

History

In 1950 Korean War, dialysis reduces mortality rate from 84% to 53%.

Natural Disasters – Earthquakes1976 Tangshan (near Beijing): 20% of 242,000

deaths due to crush syndrome.1988 Spitak (Armenia)In 1995, British nephrologists introduced the

Disaster Relief Task Force with the goal to prevent acute renal failure.

1999 Marmara (Turkey): 7.2 Richter scale earthquake. 12% hospitalised patients had renal failure, 76% received dialysis, 19% fatality rate.

Causes

Causes - Traumatic

Trauma and compression• building collapse • natural disasters(earthquake)• construction accidents• MVA• Industrial injury

Phatophysiology

Mechanism of Muscle Cell Injury and Death:1. Involvement of a muscle mass2. Prolonged compression3. Vascular compromise

Crush InjuryMuscle ischemia and Necrosis

from Prolonged Pressure(Local effects)

Crush Syndrome (Systemic Effects)

Compartment Syndrome

Fluid Retention in Extremities

(third spacing)

Hypotension

Myoglobinuria

Renal Failure

Metabolic Abnormalities (electrolytes)

Cardiac Arrhythmias

Secondary Complications

Toxins and Their Effects• Amino acids-dysrythmia• Creatine phosphokinase CPK, marker• Free radicals- oxygen reitroed further damage• Histamine-vasodilation, bronchoconstriction• Lysozymes-cell-digesting enzymes• Myoglobin-renal failure• Phosphate and Potassiumhyperkalmia causes

dysrhythmias• Purines (uric acid)-further renal damage

• Revascularization• Fluids trapped in damaged tissue• Oedema of affected limb• Haemoconcentration and shock• Myoglobin, potassium, phosphate enter venous

circulation

Clinical manifestations

· Skin injury –may be subtle.· Swelling –usually a delayed finding.· Paralysis –may cause crush injury to be mistaken

as a spinal cord injury.· Paresthesias, numbness –may mask the degree of

damage.· Pain –often becomes severe upon release.· Pulses –distal pulses may or may not be present.· Myoglobinuria –the urine may become dark red or

brown ,indicating the presence of myoglobin.

Complications

Early (<12hrs)HypovolaemiaHyperkalaemiaHypocalcaemiaCardiac arrhythmiasCardiac arrestCompartment syndrome

Late(12-72hrs)Acute renal failure DICsepsis

Lab findings

CK n 45-260U/LRises within 12hoursPeaks 1-3 daysDeclines 3-5days after cessation of muscle injury

CK-peak

Huerta-Alardin et al :CK>5000U/L serious muscle injury, related to renal failure

Gonzales et al:

>10000U/L related to ARF

Brown et al :2083 trauma ICU admission,85% abn CK (>520)

74 of 382 <5000U/L developed RF(8%) 143 of 1701 >5000U/L developed RF(19%)Renal failure defined peak creatinine >2mg/dl

Other muscle markers

Measuring myoglobin level in serum or urineAppears in urine when plasma concentration

exceeds 1.5mg/dlUrine becomes dark red –brown colour >100mg/dlMyoglobin has short T1/2 (2-3hours)Serum level return to normal after 6-8hours

Lab tests

Raised U&E Hyperkalaemia hypocalcaemia hyperphosphataemia uric acid

Management

Primary Survey

A irway B reathing C irculation D isability E nvironment

Airway

• Suctioning/Mechanical removal • Chin lift/jaw thrust maneuver • Oropharyngeal/Nasopharyngeal airway • Endotracheal intubation • Surgical airway • Tracheostomy

Breathing

• Inspection • Palpation • Percussion • Auscultation

Circulation

• External haemorrhage-direct pressure• Internal haemorrhage-skin colour, pulse, blood pressure • 2 large bore IV lines • Fluid resuscitation

Disability • Level of consciousness-GCS -Eye opening(4) -Best verbal respone(5) -Best motor response(6) • Pupillary response• Movement

Exposure • Head to toe examination

FluidsWhen

if possible before the crush is relievedWhat

isotonic crystalloids are favoured normal saline preferred (consensus meeting crush syndrome 2001-Edinburgh) (R/L have 4 mEq K )

Children 10-20ml/kg/hrUrine output -.50ml/hr -200mls/hrChildren 2mls/kg/hr

CVP –Smith et al suggest fluid bolus until a sustained increase in CVP (>3mmhg after 15 min )

Stop fluids if sign of fluid overload

Alkalinisation using bicarbonate

• Alkalinisation increases the solubility of myoglobin and promotes its excretion .

• Bicarbonate is used to raise the urine pH to 6.5 thereby increasing solubility of Haeme pigments

• prevent renal failure• Correct the acidosis (blood pH0

Mannitol

• protect the kidneys from the effects of rhabdomyolysis

• increases extracellular fluid volume• increases cardiac contractility

Dialysisif patient oliguric, fluid overloaded, consider dialysis

Despite optimal treatment ,daily haemodialysis or haemofiltration may be necessary

Remove urea and potassium

Free radical scavengers and antioxidants• administration of free-radical scavengers used in

the early treatment of crush syndrome to minimize the amount of nephrotoxic material released from the muscle

• Pentoxyphylline is a xanthine derivative used to improve microvascular blood flow. In addition, pentoxyphylline acts to decrease neutrophil adhesion and cytokine release

• Vitamin E , vitamin C , lazaroids (21-aminosteroids) and minerals such as zinc, manganese and selenium all have antioxidant activity and may have a role in the treatment of the patient with rhabdomyolysis

HYPERKALEMIAtreating hyperkalemia· Insulin and glucose.· Calcium –intravenously for life- threatening dysrhythmias .· Beta- 2 agonists – albuterol, metaproterenol sulfate (Alupent),etc.· Potassium - binding resins such as sodium polystyrene sulfonate

WOUND MANAGEMENT

should be cleaned, debrided and covered with sterile dressing

Gustilo Anderson

Hyperbaric Oxygenincreased oxygen transport capacity of the blood

The use of this modality will be limited because of lack of access to hyperbaric chambers.

Traumatic Amputation

• absolute indication for primary amputation is an irreparable vascular injury in an ischemic limb

• Mangled extremity severity score

Compartment syndrome •Defined as an “increased pressure within a confined space that leads to micro-vascular compromise and ultimately to cell death as a result of oxygen starvation”•Acute compartment syndrome can be have disastrous consequences, including paralysis, loss of limb or loss of life

Secondary complication

Increased interstitial pressure in a close fascial compartment leading to microvascular compromise and cellular death

Pressures measuring >30mmhg – surgical assessment

DBP-compartment =< 30 – indication for fasciotomy

Take home message

High index of suspicionOn scene treatment importantAggressive fluid treatmentAdequate monitoring Recognition and early treatment of complications

References

Oda, Jun MD; Tanaka, Hiroshi MD; Analysis of 372 Patients with Crush Syndrome Caused by the Hanshin-Awaji Earthquake,J of trauma:Volume 42(3), March 1997, pp 470-476

Gonzalez, Dario MD ,Crush syndrome,J of critical care:Volume 33(1) Supplement, January 2005, pp S34-S41

Ana L Huerta-Alardín1, Joseph Varon2 and Paul E Marik .Bench-to-bedside review: Rhabdomyolysis – an overview for clinicians; Critical Care 2005, 9:158-169Crush Injury and Crush Syndrome: A Review

Smith, Jason MD; Greaves, Ian Crush Injury and Crush Syndrome: A Review .J of trauma:Volume 54(5) Supplement, May 2003, pp S226-S230

Brown,carlos V MD:Rhee,Peter MD ;Preventing Renal Failure in Patients with Rhabdomyolysis: Do Bicarbonate and Mannitol Make a difference . J of Trauma :Vol 56 ,June2004,pp1191-1196

A practical approach to anaesthesia for emergency surgery

Thank You