Crush syndrome.

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  • 挫滅症候群

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Crush syndrome with acute renal failure has been identified as a major medical complication occurring in individuals trapped under the debris resulting from earthquakes, bombings and other disasters. This article reviews the historical aspect, epidemiology, pathophysiology, diagnosis and critical care management of crush syndrome. The crush syndrome is characterized by hypovolemic shock and hyperkalemia, followed by acute renal failure. Traumatic rhabdomyolysis induced by ischemia reperfusion injury plays a crucial role, although the pathophysiology is not fully understood. Initially, prolonged limb compression may cause stretch myopathy as well as ischemic injury. Immediately following limb decompression, re-establishment of the microcirculation produces an adverse effect; reperfusion injury leads to further ischemia, muscle swelling and myonecrosis, thereby producing an acute compartment syndrome. In association with these local events during limb compression/decompression, a massive loss of extracellular fluid into the injured muscles and solutes leaking out of damaged muscles cause systemic deterioration. Chief among the manifestations of this deterioration are hypovolemia and hyperkalemia which, synergistically, increase the risk of early death, metabolic acidosis, shock, coagulopathy and acute renal failure (ARF). A history of prolonged limb compression due to being trapped under heavy objects and a physical finding of limb paralysis following extrication should suggest the diagnosis of crush syndrome. The treatment consists of aggressive volume replacement followed by forced diuresis therapy. Early volume replacement, preferably started at the rescue site, may combat shock and correct the hyperkalemia. If myoglobinuric ARF has occurred, a solute load should not be given, and regular hemodialysis (HD) is indicated. The surgical management of injuries to the limbs remains controversial, since fasciotomy for compartment syndrome may create inlets for purulent infection. A great number of patients with crush syndrome are recognized among the heavy casualties following disaster situations and require immediate critical care in a major medical facility. This paper also refers to medical planning, including preparedness and responses to disasters that cause crush syndrome.

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