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F. Fevzi Ersoy Professor of Medicine and Nephrology , Akdeniz University Medical School Antalya

THE CRUSH SYNDROME: A nephrological overview. F. Fevzi Ersoy Professor of Medicine and Nephrology , Akdeniz University Medical School Antalya. Definition of acute renal injury/Acute renal failure: Renal functional deterioration within 48 hours:.

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F. Fevzi Ersoy Professor of Medicine and Nephrology , Akdeniz University Medical School Antalya

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  1. THE CRUSH SYNDROME: A nephrologicaloverview F. Fevzi Ersoy Professor of MedicineandNephrology, Akdeniz UniversityMedicalSchool Antalya

  2. Definition of acute renal injury/Acute renal failure:Renal functional deterioration within 48 hours: • Serum Cr ≥ 0.3 mg/dl increase or • Serum Cr ≥ % 50 increase (1.5Xbasal) or • Decrease in urinary volume: (Urinary volume <0.5 ml/kg/hour for 6 hours or longer)

  3. GFR Criteria Urine volume criteria Scr increase x 1.5 or GFR decrease > % 25 UrinVol < 0.5 ml/kg/hour x 6 hour Risk High sensitivity Scr increase x 2 or GFR decrease > % 50 UrinVol < 0.5 ml/kg/hour x 12 hour Injury Scr increase x 3 or GFR decrease > % 75 or Scre≥4 mg/dl Acute increase≥0.5 mg/dl UrinVol < 0.3 ml/kg/hour x 24 hours or anuriaX12 hours Failure Permenant failure = Total loss of renal function > 4 weeks Loss High specificity ESRD>3 months ESRD

  4. Timeline in AcuteTubulerNecrosisInducedAcuteRenalFailure kreatininmol/L Sürekli diyaliz tedavisi Üre hacmiL/gün time / days 1. Renal injury(minutes-days) 2. Oliguria/Anuria total loss of renal function(Up to 6 weeks) 3. Poliüria (1-2 weeks) 4.Renal recovery(A few months) Zöllner, Innere Medizin, modified

  5. ACUTE TUBULAR NECROSIS ATN ISCHEMIC HEMORRHAGES HYPOVOLEMIA HYPOTENSION CARDIAC ARREST NEPHROTOXIC ATN RADYOCONTRAST USE NEPHROTOXIC DRUGSMYOGLOBINE HEMOGLOBINE ETHYLEN GLYCOL ETC. CRUSH SYNDROME !

  6. BACKGROUND ETIOLOGY of RHABDOMYOLYSIS Non-traumatic Traumatic • Metabolic myopathies • Drugsandtoxins • Infections • Electrolyte abnormalities • Endocrine disorders • Polymyositis, dermatomyositis • Traffic or working accidents • Prolongedimmobilization • Vessel clamping • Strainful exercise of muscles • Electrical current • Hyperthermia • Disasters Brumback et al. Pediatr Clin N Am 1992 Vanholder et al. JASN 2000

  7. “CRUSH” SYNDROME • Hypovolemic shock + hyperpotasemia + renal failure + infections + heart failure + muscle trauma + muscle edema etc.. =CRUSH SYNDROME. • Occurs 2-5 % of overall trauma cases. • If an apartment building crashes 80% of the inhabitants die, 40% of the rest develop CRUSH SYNDROME.

  8. BACKGROUND TERMINOLOGY- I Crush: injury due to pressure between opposing elements Crush syndrome:systemic manifestations caused by rhabdomyolysis as a result of crush • MEDICAL • Hypovolemic shock • ARF • Hyperkalemia • Heart failure • Respiratory failure • Infections • SURGICAL • Local findings of trauma • Compartment syndrome A complex clinical picture!

  9. BACKGROUND PATHOGENESIS of TRAUMATIC RHABDOMYOLYSIS • Pressure-inducedincrease in capillarypermeability  musclecelledema (compartmentsyndrome) • Impaired muscle perfusion / reperfusion injury TRIGGERING EVENT: Increase in cytosolic Ca++ Activation of intracellular proteolytic enzymes RHABDOMYOLYSIS Better OS, Stein JH. NEJM, 1990; Zager Kidney Int, 1996 Zager. Kidney Int 1996

  10. I. DETERIORATION IN RENAL PERFUSION A.HYPOVOLEMIA, HYPOTENSION (COMPARTMENT BSYNDROME) NO B. INCREASE IN VASOCONSTRICTOR CYTOKINES AII, CATECHOLAMINES, AVP, NO IV. OTHER FACTORS REPERFUSION FREE RADICALS DIC Na-K-ATP’ase  CYTOSOLIC Ca  RABDOMYOLYSIS III. INTRATUBULAR OBSTRUCTION MYOGLOBIN CASTS HEMATINE CRYSTALS URIC ACID CRYSTALS II. DIRECT TOXIC EFFECT OF MYOGLOBINE ON TUBULAR EPITHELIA DIRECT EFFECT IS NOT OF PRIMARY IMPORTANCE, DEHYDRATATION AND ACIDOSIS AUGMENTS DIRECT TOXIC EFFECT.

  11. GLOBAL SEISMIC HAZARD MAP EARTHQUAKES: A WORLWIDE PROBLEM

  12. AREAS IN RED SHOW 1. DEGREE RISK OF SEVERE EARTHQUAKES !

  13. North Anatolian Fault

  14. 17 Ağustos 1999 Saat: 03:01 Kandilli İstasyonu Vertikal amplitüd kayıtları

  15. MARMARA EARTHQUAKE • Deathtoll: 17,480 • Injured: 43,953

  16.  80% die instantly  10% minor injuries  10% major injuries Crush syndrome 2nd most frequent cause of deaths (following direct effect of trauma) “R E N A L D I S A S T E R” Ron et al. Arch Intern Med 1984 Ukai. Ren Fail 1997

  17. RENAL DISASTER !

  18. CRUSH SYNDROME Inearthquakes: (followingthedirecteffect of trauma) IS THE MOST FREQUENT CAUSE OF DEATH!

  19. BACKGROUND The Marmara Earthquake The Hanshin-Awaji (Kobe) Earthquake Pts. with ARF: 202 Pts. requiringDx.:123 Pts. with renal prob.: 639 Pts. requiringDx.: 477 The largest“renal disaster” documented so far ! Sever et al. Kidney Int 2001 Oda et al. J Trauma 1997

  20. CLINICAL FINDINGS IN CS SURGICAL (Travma ile ilgili) MEDICAL (Crushsyndrome andcomplicationscomp.) • Compartmentsyndrome • Thoraxtrauma • Abdominaltrauma • Othertraumas • (Skull, spine, pelvis) • Hypovolemıcshock • Acuterenalfailure • Hyperpotasemia • Heartfailure • Pulmonaryfailure • Infections

  21. Death/injuredratio in earthquakes is:  1/3 • Not alltraumacasesdeveloperhabdomyolysis ! • Not allrhabdomyolysiscasesdevelopescrushsyndrome • (30-50%) ! • Not allcrushsyndomecasesdevelopeacuterenalfailure 2 -5 % of overalltraumacases developescrushsyndrome Marmara Earthquake: 1.5% (639/43,953)

  22. CLINICAL FINDINGS ON ADMISSION MEAN BLOOD PRESSURE Died: 88±21 mmHg Survived: 95 ±17 mm Hg (p=0.004) • Urınevolume in first 24hs • Died: 563±965 • Survived: 761 ±1131 ml/gün (p=0.017) • Mean body temperature • Died: 37.5 ± 1.0°C • Survived: 37.1 ± 0.7°C (p=0.027) Hypotensive, oliguricandhypertermicpatients pose a greaterprobabilityfordeathand thereforeshould be followedclosely!

  23. CLINICAL FINDINGS IN THE DISASTER FIELD • Crush syndrome may develope even in lightly injured victims Checkurinevolumeandcolor!

  24. TRAUMA PATTERN ON ADMISSION p<0.0001 p<0.0001 P=0.19 • Multivariate analysis for mortality risk: • Thoracic (p=0.001, RR=2.8) • Abdominal (p<0.0014, RR=3.8) Victims with thoracic / abdominal trauma should be referred from the field as soon as possible Sever et al. NDT 2002

  25. Most important rule in renal triage: • Rescued patients should be checked for their urinary output with or without using Foley catheters, cases with dark and low volume of urine pose a greater risk for developing acute renal failure and should be transferred to larger medical centers with nephrology departments.

  26. CLINICAL FINDINGS TRAUMA PATTERN – RISK OF CRUSH SYNDROME Even mildly injured victims carry the risk of crush syndrome Discharged patients should frequently check the color of their urine ! Sever et al. NDT 2002

  27. Laboratory findings in CS Laboratory: Dark brown granular or tubuli epithel containing cellular casts,

  28. LaboratoryFindings at Admission Sever et al. NDT 2002

  29. LABORATORY FINDINGS ON ADMISSION Hct: Died: (%32.3 ± 9.8) Survived:%35.5 ± 9.1 (p=0.028) Platelets: Died:143.344± 80.383/mm3 Survived: 192.557± 141.398 /mm3 (p<0.001 Calcium: Died:8.5±1.1 mg/dl Survived:8.9±0.9 mg/dl (p=0.039) Albumine: Died:2.3 ± 0.7 mg/dl Survived:2.6 ± 0.7mg/dl (p=0.003) Potassium: Died:6.0 ± 1.7 mEq/L Survived:5.3 ± 1.2 mEq/L (p=0.001) Closefollowup is crucialforthepatientswith lowhct, platelets, calcium, albumineandhighpotassium!

  30. HYPERKALEMIA-DEATH RELATIONSHIP IN EARTHQUAKE-RELATED DEATH CASES HyperkalemiaarrythmiasDEATH Hypocalcemia arrythmias “Mostfrequentcause of earthquakerelateddeaths is directeffect of trauma.” On theotherhandmostrescuedpatientsdie because of hyperkalemia. Collins, 1991; Better, 1993; Noji, 1992; Oda, 1997

  31. CLINICAL FINDINGS THE MARMARA EARTHQUAKE – SERUM POTASSIUM ON ADMISSION Mean: 5.3±1.3 ( 2.4 – 13.3) mmol/L Many patients died at the disaster field or within the first hours of admission to hospitals due to fatal hyperkalemia! Sever et al. Clin Nephrol 2003

  32. CLINICAL FINDINGS ECG should be taken as soon as possibleat admission to hospitals Sever et al. Clin Nephrol 2003

  33. MEDICAL INTERVENTIONS AT THE DISASTER FIELD – I - • Rescued victims who are seemingly well, can get worse • or even die as soon as extrication RESCUE DEATH • Severe metabolic acidosis • Fatal hyperkalemia • Rescue teams must include health care providers Noji. Crit Care Clin 1992

  34. HYPERPOTASEMIA DURING HOSPITAL STAY 40 PATIENTS ADMITTED AFTER FIRST WEEK In 8 pts. K > 6.5 mEq/L K > 7.5 mEq/L In 4 pts. K > 8 mEq/L In 3 pts Especially in heavily traumatized, male patients: • Serum K should be checked 3-4 timesdaily! • Extensivecareforlowpotassiumdiet ! • Drugswithpotential risk forinducing • hyperkalemiashould be limited !

  35. TREATMENT IN THE DISASTER FIELD / RISK of HYPERKALEMIA • Manyvictimslosttheirlivesduetohyperkalemia Needforempiricaltreatmentforhyperkalemia • Somepatientswerehypokalemic! Empiricaltreatmentfor Heavilytraumatized, malevictims ! Knochel. West J Med1976 Sever et al. NDT 2002

  36. AGE The Marmara earthquake: 31.714.7 (3.5 months – 90 years) Sever et al. Kidney Int 2001

  37. Marmara Tıp Fak.: 35±13 s. • Uludağ Tıp Fak.: 18±5 s. (İskit, 2001) (Dönmez, 2001)

  38. TIME UNDER RUBBLE (Hours) • Rescue operations within first 2 days are extremely important!

  39. MEDICAL INTERVENTIONS AT THE DISASTER FIELD – I - EARLY FLUID ADMINISTRATION IS OF VITAL IMPORTANCE ! (1 L / hr saline) Better and Stein. NEJM 1990

  40. MEDICAL INTERVENTIONS AT THE DISASTER FIELD – II 3. Checktheamount of urine (Urination, Foley). 4. Fluidadministration in case of hypovolemia; follow urinaryoutput. 5. If no urinaryoutput, fluidoutput+ 1000-1500 ml. 6. Neverusepotassiumcontainingfluidsempirically

  41. THERAPEUTIC INTERVENTIONS MEDICAL INTERVENTIONS AT THE DISASTER FIELD –III Marmara E.: Many patients (35/352=%10) were receiving K+ containing solutions at admission This was certainly a malpractice: Resulted in many patient deaths?? K+ containing solutions should NEVER be administered empirically ! KADALEX ISOLYTE ISOLYTE-M

  42. MEDICAL INTERVENTIONS AT THE DISASTER FIELD –IV- • AftertherescueMannitol-alkaline solution • {1000 cc %0.045 NaCl/5%Dextrose+ • 4 amps NaHCO3 and 50 ml 20%Mannitol} • Adequateurineresponse + mannitol  8 - 12 L/day • Less aggressively (4-6 L/day) in disasters • CVP measurements Better and Stein. NEJM, 1990 Vanholder et al. Kidney Int. 2000

  43. Compartment syndrome • Compartment = spacerestricted bytherigidfasciaesurrounding themuscles • Increasedpressure (>0-15 mmHg) in thecompartments due to traumatic tissue swellingresults in muscleinjuryandnecrosis Compartment syndrome= muscle tamponade)

  44. A SECOND RISE IN CPK = COMPARTMENT SYNDROME If hydrostatic pressure inside the compartment exceeds 40 mm Hg and remains there for more than 8 hours, fasciotomy is indicated.

  45. FASCIOTOMIES Ifnecessary: • Preferstayingsupportive • Greatcare on woundcare • Objectivecriteria? • Regulardressingchanges Culture in case of infection • Debridment in infectedwounds

  46. THERAPEUTIC INTERVENTIONS THE MARMARA EARTHQUAKE 397 fasciotomies in 323 patients (p<0.001) Sever et al. Nephron 2002

  47. FLUID RESUSCITATION Mean fluid volume: 51091711 ml/day Died vs Survived: NS Dialysis (+): 5407  1623ml/day (p=0.01) Dialysis (-) : 3825  1539 ml/day In order to estimate the necessary amount of fluid: CVP measurement as soon as possible

  48. OTHER MEDICAL TREATMENTS Antibiotics: 347Heparine: 82 Diuretics: 36Other: 89 • Indications for broad spectrum antibiotics? • Dopamine use: Is it effective?

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