MED-NERD

Crush Syndrome

Introduction:

Historical view:

-In 1909, Crush syndrome (CS) was first described in Italy during the Messina earthquake.

-In 1941, during the World War II, victims from bombed buildings that presented with swollen limbs, dark urine, hypovolemic shock, and renal failure, died later due to kidney failure despite being in a good condition upon rescue. This was reported by Bywaters and Beall during the World War II and crush syndrome was described clinically. Later on, the disorder was known as Bywaters’ syndrome.

-In August 1999, the Great Marmara earthquake occurred in north western Turkey leaving thousands of crush injury patients.

-The latest disaster that was the Turkey-Syria earthquake that occurred in February 2023.

-A variety of disorders were identified by Mubarak et al including compartment syndrome and crush syndrome.

-Hyperbaric oxygen therapy became essential in treatment of crush syndrome about 30 years ago.

-In the European Continent, haemodialysis became a primary modality of treatment of crush syndrome.

-The current concern is about early detection of crush syndrome considering fluid regimen and renal replacement therapy (RRT).

-The clinical aspect and the pathogenesis of crush syndrome have become clear over years due increasing the report of crush syndrome cases in natural disasters like earthquakes and other global conflicts that increased the information about and the interest in crush syndrome.

N.B:

It is important to differentiate between the following terms:

-Crush injury >> is something heavy causing a direct physical crushing of the muscles leading to injury of the affected muscles.

-Crush syndrome (or rhabdomyolysis) >> is an injury of the skeletal muscles leading to disruption of muscle cells, release of its contents into the blood causing metabolic and electrolyte disturbances.

-Compartment syndrome >> occurs when the tension within the muscle compartment rapidly rises leading to metabolic changes.

-Compression syndrome >> is an indirect injury of the muscles through simple and slow compression of a group of muscles causing ischemia and release of the muscle contents into the circulation.

Crush syndrome:

Crush syndrome (also known as traumatic rhabdomyolysis, Bywaters’ syndrome), is a systemic disorder due to high-degree crush injury or traumatic compression, whether direct or indirect, leading to long-term crushing of the muscle (extremities or torso or other parts of the body) with compression and destruction of striated muscle cells. When the compressive forces become removed, swelling and injury of muscles with necrosis and neurologic dysfunction in the affected parts may occur. The damage is whether due to the primary direct effect of the trauma or the ischemia that occurred as a result of the compression. Due to restoration of blood, the cell contents such as phosphate, urate, potassium, nephrotoxicity myoglobin (Mb), and other contents are released into the circulation leading to myoglobinuria, acute kidney injury (AKI), electrolyte disturbance (hyperkalaemia and hypocalcaemia), metabolic disturbance (acidosis), arrhythmias, Adult Respiratory Distress Syndrome (ARDS) as a result of the inflammatory response, Disseminated Intravascular Coagulation (DIC) due to the released thromboplastin, hypovolemic shock, and multiple organ dysfunction syndrome (MODS) and eventually death. Compartment syndrome can also occur in Crush syndrome. The body parts affected in crush syndrome include lower extremities (74%), upper extremities (10%), and trunk (9%).

Crush syndrome is a life-threatening condition and is the second leading cause of death in earthquakes, following direct trauma. The incidence of crush syndrome is about 2-15% with nearly 50% developing acute renal failure and over 50% that require fasciotomy. About 50% of the renal failure patients require dialysis. The diagnosis and the treatment are difficult due to inability to reach the areas of disasters and provide the treatment early with difficulties in communication and transportation. The treatment is mainly focused on the management of circulatory shock, arrhythmias, and kidney failure. This is achieved by early fluid resuscitation, forced diuresis, and renal replacement therapy (RRT) (haemodialysis, peritoneal dialysis, haemodiafiltration, haemofiltration, and eventually kidney transplantation). Removing the myoglobin until repair of kidney function is performed through hemodialysis or continuous venovenous haemofiltration (CVVHF). Despite the treatment modalities, a wide range of patients develop systemic inflammatory response syndrome (SIRS) later on that eventually progresses into multiple organ failure (MOF) and death.

Crush syndrome may occur in non-traumatic conditions with impaired consciousness such as prolonged immobilization, burns, stroke, coma, and electrical injury. In prolonged immobilization under anaesthesia, the weight of body part alone without relief with increased local pressure may be one of the causes of rhabdomyolysis and compartment syndrome.

In comatosed, postoperative, and intoxicated patients with prolonged immobilization which is a condition known as "Gluteal compartment syndrome" may also lead to crush syndrome.

References:

(1)Li N, Wang X, Wang P, Fan H, Hou S, Gong Y. Emerging medical therapies in crush syndrome - progress report from basic sciences and potential future avenues.
https://pubmed.ncbi.nlm.nih.gov/32662306/

(2)Rajagopalan S. Crush Injuries and the Crush Syndrome. Med J Armed Forces India. 2010 Oct;66(4):317-20.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919827/

(3)Emily Lovallo, Alex Koyfman, Mark Foran,
Crush syndrome, African Journal of Emergency, Medicine,Volume 2, Issue 3, 2012, Pages 117-123, ISSN 2211-419X.
https://www.sciencedirect.com/science/article/pii/S2211419X12000675

(4) Stanley Oiseth, Lindsay Jones, Evelin Maza, crush syndrome, lecturio.
https://www.lecturio.com/concepts/crush-syndrome/

(5)Laura N Haines, MD, FACSJay J Doucet, MD,.FRCSC, FACS Severe crush injury in adults
https://www.uptodate.com/contents/severe-crush-injury-in-adults#topicContent

(6)Crush Injury and Crush Syndrome, American College of Emergency Physicians.
https://www.acep.org/imports/clinical-and-practice-management/resources/ems-and-disaster-preparedness/disaster-preparedness-grant-projects/cdc---blast-injury/cdc-blast-injury-fact-sheets/crush-injury-and-crush-syndrome

(7)Demirkiran O, Dikmen Y, Utku T, et al, Crush syndrome patients after the Marmara earthquake
Emergency Medicine Journal 2003;20:247-250.
https://emj.bmj.com/content/20/3/247