CrushCrush SyndromeSyndrome TraumaTrauma RoundsRounds JanJan 26,26, 20092009 SamaraSamara Zavalkoff,Zavalkoff, MDCM,MDCM, FRCP(C)FRCP(C) OutlineOutline

►►TerminologyTerminology ►►HistoricalHistorical descriptionsdescriptions ►►PathophysiologyPathophysiology ►►FeaturesFeatures ofof crushcrush syndromesyndrome .. ,Shock, electrolyteelectrolyte problems,problems, renalrenal dysfunction,dysfunction, compartmentcompartment syndrome,syndrome, etcetc ►►ManagementManagement ►►OutcomesOutcomes ObjectivesObjectives

AtAt thethe endend ofof thisthis session,session, thethe learnerlearner willwill bebe ableable to:to: ►►DefineDefine andand describedescribe thethe pathophysiologypathophysiology ofof crushcrush syndromesyndrome ►►DescribeDescribe thethe featuresfeatures ofof crushcrush syndromesyndrome ►►OutlineOutline aa managementmanagement planplan forfor aa patientpatient withwith crushcrush syndromesyndrome TerminologyTerminology

►►CrushCrush syndromesyndrome ►►TraumaticTraumatic RhabdomyolysisRhabdomyolysis ►►BywaterBywater’’ss syndromesyndrome

Definition:Definition: .. SevereSevere systemicsystemic manifestationmanifestation ofof traumatrauma andand ischemiaischemia involvinginvolving softsoft tissues,tissues, principallyprincipally skeletalskeletal muscle,muscle, duedue toto prolongedprolonged severesevere crushing.crushing. TerminologyTerminology

Criteria?Criteria? ►►CrushingCrushing injuryinjury toto skeletalskeletal musclemuscle ►►SensorySensory andand motormotor disturbancesdisturbances toto thethe compressedcompressed limbslimbs --swollenswollen andand tensetense ►►MyoglobinuriaMyoglobinuria and/orand/or hemoglobinuriahemoglobinuria ►►PeakPeak CKCK >1000>1000 U/LU/L ►►RenalRenal problemsproblems ((oligouriaoligouria,, renalrenal failure)failure) SettingsSettings

. Severe beatings . Multistory building . Improper operative collapse positioning ►Up to 40% incidence . Alcohol, drug . War intoxication intoxication . Earthquakes immobilization ►eg Mamara . MVAs . MVAs earthquake, 1999 . Pneumatic antishock . Pneumatic antishock . Landslides garment (PASG) . Electrical . Prolonged seizures . Mine collapses EarlyEarly descriptionsdescriptions

.. WW1:WW1: Dr.Dr. MyerMyer Betz:Betz: ““musclemuscle pain,pain, weaknessweakness andand brownbrown urineurine”” (1910)(1910) .. WW2:WW2: Dr.Dr. EricEric BywatersBywaters afterafter thethe LondonLondon blitz,blitz, BMJBMJ 1941.1941. ““crushcrush injuryinjury”” EarlyEarly descriptionsdescriptions

►►1941,1941, BywatersBywaters:: .. “…“…inin thethe renalrenal tubules,tubules, degenerativedegenerative changeschanges andand castscasts containingcontaining brownbrown pigmentpigment”” ►►1943,1943, BywatersBywaters andand SteadStead .. identifiedidentified myoglobinmyoglobin asas thethe brownbrown pigmentpigment .. SuggestedSuggested Rx=Rx= ►heat to the loins ►volume ►alkalinization of urine ►caffeine for diuresis OurOur casecase

►►1818 monthmonth oldold femalefemale ►►GrandmotherGrandmother pushingpushing herher inin herher strollerstroller ►►GrandmotherGrandmother isis hithit byby thethe busbus mirrormirror ►►ChildChild fallsfalls fromfrom strollerstroller ►►BusBus runsruns overover herher legslegs ►►UrgencesUrgences SantSantéé transfertransfer toto MCHMCH OurOur casecase ►►WhatWhat dodo youyou prepare?prepare?

►►WhoWho dodo youyou call?call?

►►WhatWhat dodo youyou do?do? EpidemiologyEpidemiology

►►Earthquakes:Earthquakes: >> 22--5%5% buriedburied inin rubblerubble ►►UpUp toto 50%50% ofof MamaraMamara victimsvictims developeddeveloped crushcrush syndromesyndrome (Donmez et al, Iskit et al, 2001) PathophysiologyPathophysiology

►►LysisLysis ofof skeletalskeletal musclesmuscles andand releaserelease ofof cellularcellular contentscontents (K,(K, P04,P04, myoglobinmyoglobin)) ►►MechanicalMechanical stressstress opensopens CaCa channelschannels withwith anan influxinflux inin Na,Na, Ca,Ca, fluidfluid andand neutrophilsneutrophils ►►MainMain issueissue isis musclemuscle reperfusionreperfusion withwith systemicsystemic effectseffects ofof thethe toxinstoxins PathophysiologyPathophysiology

Release , K, P04, urate Water, Na influx ↑permeability R H Vascular compromise A Anaerobic metabolism B D O

Malinoski, et al. 2004 PathophysiologyPathophysiology:: reperfusionreperfusion CrushCrush TimeTime

►►>1h>1h likelylikely toto resultresult inin crushcrush syndromesyndrome ►►ReportedReported afterafter 2020 minutesminutes ►►CanCan toleratetolerate upup toto 2h2h warmwarm ischemiaischemia ►►44--66 hourshours anatomical,anatomical, functionalfunctional changeschanges ►►>6>6 hourshours musclemuscle necrosisnecrosis ClinicalClinical EvaluationEvaluation

►►HistoryHistory .. SAMPLESAMPLE HxHx .. EstimatedEstimated crushcrush timetime ►►PhysicalPhysical ExamExam .. ExternalExternal signssigns ofof traumatrauma .. CompartmentCompartment syndromesyndrome (more(more later):later): temperature,temperature, colour,colour, pulses,pulses, motor,motor, sensorysensory FeaturesFeatures ofof CrushCrush SyndromeSyndrome

►►ShockShock ►►ElectrolyteElectrolyte disturbancesdisturbances ►►RenalRenal FailureFailure ►►CompartmentCompartment SyndromesSyndromes ►►OtherOther ShockShock

►►#1#1 causecause ofof deathdeath dayday 00--44 ►►CapillaryCapillary leakleak volumevolume lossloss .. UpUp toto 12L12L intointo thethe involvedinvolved extremitiesextremities (A.(A. Blalock)Blalock) .. GlobalGlobal 33rd spacingspacing CaseCase scenarioscenario

►►AA 1515 yearyear oldold malemale extractedextracted fromfrom hishis collapsedcollapsed apartmentapartment buildingbuilding ►►HeHe waswas trappedtrapped forfor 66 hourshours ►►DecreasedDecreased levellevel ofof consciousnessconsciousness andand unableunable toto protectprotect hishis airwayairway ►►YouYou dodo aa rapidrapid sequencesequence intubationintubation CaseCase scenarioscenario

►►TheThe monitormonitor alarmsalarms andand youyou see:see:

WHAT HAPPENED? ElectrolyteElectrolyte ProblemsProblems

► HyperkalemiaHyperkalemia . Largest stores of K in . #2 cause of death (D1-4) ► HyperphosphotemiaHyperphosphotemia . Worsens hypocalemia ► HypocalcemiaHypocalcemia Tumour lysis- like . Influx of ca into muscle tissue

► RecipeRecipe forfor arrhythmiaarrhythmia == acidosisacidosis ++ hyperkalemiahyperkalemia ++ hypocalcemiahypocalcemia RenalRenal failurefailure

►► upup toto 35%35% withwith crushcrush syndromesyndrome RFRF .. DonmezDonmez etet alal,, 2001:2001: 20/4020/40 crushcrush syndrome,syndrome, 7/207/20 (35%)(35%) RF,RF, 4/74/7 dialysisdialysis .. IskitIskit etet al,al, 2001:2001: 15/3315/33 crushcrush syndrome,syndrome, 10/1510/15 RF,RF, 2/102/10 dialysisdialysis

►►33--50%50% associatedassociated mortalitymortality ►►AccountsAccounts forfor 55--7%7% ofof ARFARF inin thethe USAUSA RenalRenal failurefailure

►►PathophysiologyPathophysiology 1)ATN1)ATN fromfrom decreaseddecreased renalrenal perfusionperfusion 2)Myoglobin2)Myoglobin ►Binds Tamm-Horsfell protein and precipitates casts tubule obstruction (worse if aciduria) ►Stimulates free radical formation ►Lipid peroxidation destruction of phospholipid bilayer RenalRenal failurefailure

►►ClinicalClinical presentationpresentation .. TeaTea--colouredcoloured oror ““motormotor oiloil”” urineurine .. PositivePositive urineurine dipdip forfor blood,blood, fewfew RBCRBC onon microscopymicroscopy .. UrineUrine oror serumserum myoglobinmyoglobin CompartmentCompartment SyndromeSyndrome

== elevatedelevated interstitialinterstitial pressurepressure inin aa closedclosed fascialfascial compartmentcompartment (P>30(P>30 mmHg)mmHg) Compartment P > capillary perfusion pressure .. PressurePressure relativerelative toto diastolicdiastolic ►<20-30mmHg consider faciotomy .. VascularVascular compromise,compromise, myoneuralmyoneural damage,damage, tissuetissue hypoxiahypoxia CompartmentCompartment SyndromeSyndrome

.. 55 PsPs ►pain with passive stretch ► ► ► ►pulseless .. ChildrenChildren ↑↑ risk:risk: smallersmaller spaces,spaces, lessless elasticelastic OtherOther problemsproblems

►►DICDIC--releaserelease ofof thromboplastinthromboplastin ►►PulmonaryPulmonary .. DiaphragmDiaphragm weaknessweakness respresp failurefailure .. Fractures,Fractures, pneumo/hemothroaxpneumo/hemothroax,, contusioncontusion .. FatFat embolismembolism .. PneumoniaPneumonia .. ARDSARDS ManagementManagement

UsualUsual traumatrauma RxRx,, plusplus…… ►►AA ►►BB ** avoidavoid succhinylcholinesucchinylcholine ►►CC *early,*early, aggressiveaggressive fluidfluid resuscitationresuscitation ** NoNo RingerRinger’’ss lactatelactate (contains(contains K)K) ** traumatrauma labslabs ++ *CK,*CK, Ca/P04/Mg,Ca/P04/Mg, urineurine dip,dip, serum/urineserum/urine myoglobinmyoglobin,, uricuric acidacid *remove*remove contaminatedcontaminated IVIV lineslines placedplaced inin fieldfield ManagementManagement

►►DD ►►EE *evaluate*evaluate forfor compartmentcompartment syndromesyndrome ►►FF *insert*insert foleyfoley earlyearly toto monitormonitor U/OU/O ManagementManagement-- electrolyteselectrolytes andand arrhythmiaarrhythmia

►►CLOSECLOSE electrolyteelectrolyte monitoring!monitoring! ►►AvoidAvoid givinggiving KK inin IVIV fluidsfluids

►►HypocalcemiaHypocalcemia .. OnlyOnly treattreat forfor hyperkalemiahyperkalemia .. RiskRisk ofof metastaticmetastatic calcificationcalcification ManagementManagement-- electrolyteselectrolytes andand arrhythmiaarrhythmia

►►HyperkalemiaHyperkalemia .. CalciumCalcium ►May be ineffective (binds to P04) ►Metastatic calcifications .. TreatmentsTreatments causingcausing cellularcellular shiftsshifts-- ineffectiveineffective ►Eg / .. MayMay needneed hemodialysishemodialysis earlierearlier ManagementManagement-- renalrenal failurefailure

►►FluidFluid resuscitationresuscitation .. ImproveImprove renalrenal perfusionperfusion pressurepressure .. PreventPrevent contractioncontraction alkalosisalkalosis withwith aciduriaaciduria ►Angiotensin II ►Aldosterone .. BetterBetter etet al.al. 1979:1979: 77 men,men, 77 ARF,ARF, 77 deaths.deaths. 1982:1982: 88 men,men, 77 earlyearly fluids,fluids, 77 nono ARFARF ManagementManagement-- renalrenal failurefailure

► ► AlkalinizationAlkalinization Urine pH Percent . Bicarb +/- acetazolamide precipitated . Improves clearance 6.56.5 44 . Prevents precipitation . Reduces free radicals 5.55.5 2323 . Goal pH >6.5 5.05.0 4646 . Benefit: Rx of  K <5.0<5.0 7373

Gonzalez et al, 2005. ManagementManagement-- renalrenal failurefailure

►►LasixLasix (pros vs cons) ►►MannitolMannitol (pros vs cons) ►►RenalRenal replacementreplacement therapytherapy .. SupportSupport onlyonly .. MyoglobinMyoglobin isis notnot dialysabledialysable ►►NEW!NEW! .. AntioxidantsAntioxidants (glutathione,(glutathione, vitvit E)E) Management:Management: RadicalRadical surgicalsurgical proceduresprocedures ►►CrushCrush SyndromeSyndrome .. FasciotomyFasciotomy doesdoes notnot improveimprove outcomeoutcome (consensus(consensus only)only) .. :Amputation: ►May not change outcome ►Expedite extraction ►►CompartmentCompartment SyndromeSyndrome .. FasciotomyFasciotomy?? AnotherAnother talktalk…… ManagementManagement

►►DICDIC .. UsualUsual managementmanagement ManagementManagement-- PrehospitalPrehospital

►►RemoveRemove compressivecompressive forcesforces ►►RiskRisk toto rescuerescue personnelpersonnel ►►StartStart fluidfluid resuscitationresuscitation duringduring extricationextrication .. PositivePositive effecteffect onon survivalsurvival (Better(Better etet al,al, IsraelIsrael studiesstudies 19791979 andand 1982)1982) .. DonmezDonmez etet al:al: n=40n=40 inin MamaraMamara earthquake,earthquake, 88 gotgot fluidsfluids atat thethe scenescene nonenone developeddeveloped RFRF ►►TransferTransfer toto aa dialysisdialysis--capablecapable facilityfacility ManagementManagement

AnticipateAnticipate andand preventprevent complicationscomplications PreventionPrevention

►►DisasterDisaster planningplanning .. RescueRescue availabilityavailability .. PersonnelPersonnel availabilityavailability .. DialysisDialysis availabilityavailability OutcomesOutcomes OutcomeOutcome

►►CrushCrush timetime DOESDOES NOTNOT predictpredict outcomeoutcome ►►RenalRenal andand cardiaccardiac complications:complications: .. MagnitudeMagnitude ofof pressurepressure .. SizeSize ofof compressedcompressed areaarea ►Rule of thirds (Ringer AG Jn, 2004) analogous to the rule of 9s for CauseCause ofof deathdeath

►►ShockShock #1#1 (day(day 00--4)4) ►►HyperkalemiaHyperkalemia #2#2 (day(day 00--4)4) ►►RenalRenal failurefailure (day(day 33--7)7) ►►InfectionInfection (later)(later)

►►MortalityMortality inin MamaraMamara == 15.2%15.2% ►►MortalityMortality doubledouble otherother traumatrauma patientspatients (Kobe, Japan earthquake) CauseCause ofof death:death: HanshinHanshin--AwajAwaj earthquakeearthquake

Hypovolemia

Oda et al, J Trauma, 1997 PredictorsPredictors ofof PoorPoor OutcomeOutcome

► PeakPeak CKCK levellevel ► LowLow albuminalbumin . Most sensitive marker ► HypotensionHypotension of ARF ► HighHigh KK . >100 000 predicts dialysis, death ► HighHigh bodybody temperaturetemperature . >20 000 monitor ► AmputationsAmputations closely (ICU) ► AbdominalAbdominal oror thoracicthoracic ► OligouriaOligouria traumatrauma ► RaisedRaised CrCr ► LowLow plateletsplatelets BackBack toto ourour casecase ►►WhatWhat dodo youyou prepare?prepare?

►►WhoWho dodo youyou call?call?

►►WhatWhat dodo youyou do?do? TakeTake homehome pointspoints

►►AboveAbove allall else,else, treattreat shockshock earlyearly andand aggressivelyaggressively ►►AnticipateAnticipate otherother problems:problems: .. renalrenal failurefailure .. electrolyteelectrolyte disturbancesdisturbances .. compartmentcompartment syndromesyndrome ►►NeedNeed toto workwork asas anan interdisciplinaryinterdisciplinary teamteam toto achieveachieve goodgood outcomeoutcome SuggestedSuggested readingreading

►►GonzalezGonzalez D.D. CrushCrush Syndrome.Syndrome. CriticalCritical CareCare MedicineMedicine V33(1)V33(1) supp,supp, JanJan 2005,2005, S34S34--41.41.

►►MalinoskiMalinoski D,D, SlaterSlater MM andand MullinsMullins R.R. CrushCrush injuryinjury andand rhabdolyolysisrhabdolyolysis.. CritCrit CareCare ClinClin 2020 (2004)(2004) 171171--192.192.