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Keywords:

  • infection control;
  • nursing care;
  • trauma;
  • wound care

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Relevance to clinical practice
  9. Acknowledgements
  10. Disclosure
  11. Conflict of interest
  12. References

Aims and objectives

To perform a descriptive analysis of crush syndrome patients with extremity injuries, which will be used as a reference for future disasters.

Background

In disasters like earthquake, cooperation among medical workers is very important for the follow-up and treatment of patients. Knowing the complications that may emerge with the crush syndrome is one of the responsibilities of the nurses.

Design

Descriptive analysis.

Methods

The medical records of patients with crush syndrome following the 2011 Van Earthquake were retrospectively reviewed. The results were compared with the current literature.

Results

Of the 46 patients with crush syndrome who had extreme trauma, 26 (57%) were men, 20 (43%) were women, and the average age was 38·9 ± 12·5. Fasciotomy was performed in 21 of the patients due to progressive compartment syndromes. Amputations were performed in seven patients who had previously undergone a fasciotomy. Sepsis was observed in seven patients, wound infection in 18, pericardial effusion in three and pleural effusion in two. Additionally, femoral fracture was observed in one patient, tibial fractures in five, haemothorax in three, abdominal traumas in seven and pulmonary embolism in one.

Conclusion

Wound care and antibiotic treatment are important to prevent infections in crush injury. In addition to this, dehydration and electrocardiography changes in hyperkalaemia are observed in crush syndrome. Nurses have significant responsibilities to follow up these observations and their implications.

Relevance to clinical practice

The results of this study may provide the basis for developing strategies in future for optimising attempts to rescue and the nurse care planning of survivors with crush injuries and crush syndrome after earthquakes.

What does this paper contribute to the wider global clinical community?

This article offers:

  • Assistance to nursing care in patients with crush injury or crush syndrome after natural disasters.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Relevance to clinical practice
  9. Acknowledgements
  10. Disclosure
  11. Conflict of interest
  12. References

Crush injury is defined as compression of extremities and other body parts. Muscle swelling and/or neurological disturbances are observed in the affected parts of body (Fig. 1). Crush injuries are most commonly seen in lower extremities (74%), followed by upper extremities (10%) and other parts of body (9%). Crush syndrome is a localised crush injury with systemic manifestations. These systemic effects are caused by traumatic rhabdomyolysis (destruction of skeletal muscle) and release of potentially toxic muscle cell components and electrolytes into the circulation (Michaelson 1992, Centers of Disease Control & Prevention 2009).

image

Figure 1. A crush injury of upper extremity.

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Crush syndrome following great disasters is a common problem. The term ‘crush syndrome’ describes the problems that arise as a result of rhabdomyolysis caused by trauma (Vanholder et al. 2000, Huerta-Alardin et al. 2005, Zhang 2012). Hypovolemic shock, acute renal failure (ARF), hyperpotassemia, cardiac arrhythmias and infections can be included among these problems (Ward 1988, MacLean & Barret 1993, Abassi et al. 1998).

In disasters like earthquake, cooperation within the health team is very important for the follow-up and treatment of patients. Knowing the complications that may emerge with the crush syndrome is one of the responsibilities of the nurses. In this study, we perform a descriptive analysis of the patients registered at the Van Region Education and Research Hospital following the 2011 Van Earthquake and present their treatment methods and outcomes.

Materials and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Relevance to clinical practice
  9. Acknowledgements
  10. Disclosure
  11. Conflict of interest
  12. References

This study was approved by the local institutional ethical review board. This study retrospectively investigated the hospital records of patients with crush syndrome admitted to the Van Research and Education Hospital following the 23 October 2011 Van Earthquake. Within the first seven days after the earthquake, patient information was obtained from the hospital records, that is, between 23 October–30 October 2011. A total of 1582 patients registered at the hospital following the earthquake. Patients with crush syndrome were found out. Inclusion criteria were as follows: (1) patients with crush injury that caused crush syndrome, (2) patients whose cause of the crush injury was the 2011 Van Earthquake and (3) patients aged above 18 and below 70. Exclusion criteria were as follows: (1) patients who had crush syndrome because of the reasons other than crush injury and (2) patients aged below 18 and above 70.

The demographic data of the patients with crush syndrome were recorded. The patients were followed up clinically, complete blood count was noted, biochemical tests were performed and bleeding parameters were recorded. The affected extremities of the patients were noted, and fasciotomies and amputations performed were recorded according to the extremities involved. The Mangled Extremity Severity Score (MESS) of the patients was determined at registration (Table 1) (Slauterback et al. 1994, Sever et al. 2006). MESS may be used to decide whether to carry out amputation in patients with injuries related to limb. A score of ≥7 points indicates the need for amputation (Johansen et al. 1990). Following the crush injury, MESS of patients with ARF and those treated with haemodialysis were determined. Moreover, additional problems of patients were recorded, and a descriptive analysis was performed for patients with crush syndrome.

Table 1. Mangled Extremity Severity Score (MESS)
TypesCharacteristicsInjuryScore
1Low energyStab; simple fracture; pistol gunshot wound1
2Medium energyOpen or multiple fractures, dislocation2
3High energyHigh-speed RTA or rifle GSW3
4Very high energyHigh-speed trauma; gross contamination4
Shock
1Normotensive transientlyBP stable0
2Hypotensive transientlyBP unstable and field but responsive to fluid1
3Persistent hypotensionIn operating room2
Ischaemia group
1NonePulsatile, no signs of ischaemia0
2MildDiminished pulses without signs of ischaemia1
3ModerateNo pulse by doppler, sluggish cap refill, paraesthesia, diminished motor activity2
4AdvancedPulseless, cool, paralysed numb without cap refill 13
Age (years)
1<30 0
2>30–50 1
3>50 2

Statistical analysis

Age, sex and MESS of patients and number of patients with ARF were recorded. The number of patients with crush injury, crush syndrome and compartment syndrome was determined. Continuous variables were expressed as means ± standard deviation, and categorical variables were expressed as numbers and percentages.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Relevance to clinical practice
  9. Acknowledgements
  10. Disclosure
  11. Conflict of interest
  12. References

Crush syndrome with extremity trauma was diagnosed in 46 of 1582 patients (2·91%). Of all the patients with extremity traumas, 26 were men, 20 were women, and the average age was 38·9 ± 12·5 (18–64 years) (Fig. 2). The average of the MESS of 46 patients was 7·6 ± 1·9 (5–12). Seven patients who had a MESS >7 underwent fasciotomy. Eleven patients (23·9%) with crush syndrome died. Fasciotomy was performed in 21 of the patients due to progressive compartment syndromes. Lower-extremity fasciotomy was performed in 17 of the patients, upper-extremity fasciotomy in two and both in two. Amputations were performed in seven patients who had previously undergone a fasciotomy. The laboratory findings, additional problems of patients and medical interventions are shown in Table 2.

Table 2. Laboratory findings, additional problems of patients and medical interventions
CaseAffected limbFasciotomyAmputationAcute renal failureMaximum serum K+ (mmol/l)HaemodialysisAdditional problem
  1. R, right; L, left; AT, abdominal trauma.

1Lower (L)6·1
2Lower (R)6·7
3Lower (L+R)Lower (L+R)+6·6Pregnancy
4Lower (R), Upper (R)Lower (R) + Upper (R)+7·3+
5Lower (L+R)Lower (L+R)+7·1+Sepsis
6Lower (L)+6·2
7Lower (R)+5·7Pericardial effusion
8Lower (L+R)Lower (L+R)+7·1+Sepsis
9Lower (R)Lower (R)Lower (R)+6·1
10Lower (R)+6·8+
11Lower (L)+6·2+
12Lower (L+R), Upper (R)Lower (R) and Upper (R)Lower (R)+6·5+Sepsis, AT
13Lower (R)6·1Pneumothorax
14Lower (R)6·3Pericardial effusion
15Lower (L+R)+6·1+
16Lower (L+R)Lower (L+R)Lower (R)+6·4Sepsis, pericardial effusion
17Lower (L)+6·3Femur fracture, pulmonary embolism
18Lower (L+R)Lower (L+R)Lower (L+R)+5·6
19Lower (L)  +5·7
20Upper (R)Upper (R) 5·9
21Lower (L+R)Lower (L+R)Lower (L)+6·3+AT
22Upper (L)Upper (L) 6·4
23Lower (L+R)  +6·2+Tibia fracture, sepsis
24Lower (L+R)Lower (L+R)Lower (L+R)+6·1+Tibia fracture, sepsis
25Lower (R)  +7·2Cardiac arrhythmia
26Lower (L+R)Lower (L+R) +6·8+Sepsis, AT, tibia fracture
27Lower (L) +6·3
28Lower (L+R)Lower (L+R)Lower (R)+6·6+
29Lower (L+R) +7·1+
30Lower (L)Lower (L)6·4
31Upper (R)+6·6AT
32Lower (R)5·4
33Lower (L)6·0Haemothorax, AT
34Lower (R)6·3Haemothorax, AT
35Lower (R)6·2
36Lower (L+R)Lower (L+R)5·7
37Lower (R)Lower (R)5·1
38Lower (L+R)5·3Pericardial effusion
39Lower (L)Lower (L)6·6
40Lower (L+R)+6·0+
41Lower (L+R), Upper (R)+6·1+Tibia fracture
42Lower (R)Lower (R)+7·2Haemothorax, AT
43Lower (R)6·6
44Lower (L+R)Lower (L+R)+6·9+Tibia fracture
45Lower (L)Lower (L)6·7
46Lower (L)6·1Pericardial effusion
image

Figure 2. Distribution of patients according to age and gender.

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Acute renal failure had progressed in 28 of the patients (60·9%) with crush syndromes, and 16 of the patients (34·7%) were haemodialysed. The average serum potassium value was determined to be 6·32 ± 0·5 mmol/dl (5·1–7·3 mmol/dl).

Sepsis was observed in seven patients, wound infection in 18, pericardial effusion in three and pleural effusion in two (Table 3). No statistically significant difference was found for complication development with regard to age and gender (p > 0·05). Additionally, femoral fracture was observed in one patient, tibial fractures in five, haemothorax in three, abdominal traumas in seven and pulmonary embolism in one.

Table 3. Distribution of complications in patients with crush syndrome
Complications n %
Hyperpotassemia46100
Wound infection2860·9
Acute renal failure1839·1
Compartment syndrome1634·8
Sepsis715.
Pericardial effusion36·5
Pleural effusion24·3

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Relevance to clinical practice
  9. Acknowledgements
  10. Disclosure
  11. Conflict of interest
  12. References

In the literature, there are few studies with detailed data on patients with crush syndrome. Data of only 30 patients affected by 1990 Iran earthquake were completely described, in which there were 13,888 casualties and 43,390 injuries (Atef et al. 1994). Hospital records for the 385 patients with crush syndrome and accompanying ARF following the 1988 Armenian earthquake are incomplete (Richards et al. 1989, Tattersall et al. 1990, Armenian 1997). In regard to the Hanshin–Awaji earthquake, only incomplete hospital records of 372 patients with crush syndrome were available (Oda et al. 1997). In our study, the data of patients with crush syndrome were carefully recorded.

In our study, only 6·5% of the patients with crush syndrome were aged 60 and above and the age range of the patients is similar to those in previous studies on earthquake disasters. The reason for the less number of older people brought to the hospital is thought to result from the fact that they die under the rubble before being brought to the hospital (Tanida 1996, Frink et al. 2010).

The indication for a fasciotomy is problematic among patients with crush syndrome. While some authors believe that fasciotomies should be performed because they prevent muscle necrosis, others think fasciotomies should be avoided because they increase the chance of infections (Rush et al. 1989, Frink et al. 2010, Gormeli et al. 2012). In our series, fasciotomy indications include swelling accompanied by bullae in the extremities, ecchymosis, pain in the extremity, faintness, cold, lack of pulse in the extremity, paralysis, myoglobinuria resulting in rhabdomyolysis due to intracompartmental pressure and an intracompartmental pressure >40 mmHg. Measuring the intracompartmental pressure is recommended in the literature for the diagnosis of compartment syndromes (Elliott & Johnstone 2003). However, in our study, measuring the intracompartmental pressure was not possible because usually, large numbers of patients were affected in earthquakes. So, 21 patients who met the above criteria and seven patients who had a MESS >7 underwent a fasciotomy. Patients who underwent a fasciotomy were sent to hospitals in other cities because their wound site care would otherwise be inadequate and because of the problems resulting from the large number of patients admitted for haemodialysis.

There are no standard criteria for decisions to perform an amputation in the early stages of treatment of any of the limbs. A MESS of seven points as a reason for amputation does not appear suitable when assessing injuries to the major vessels in any of the limbs. It is generally accepted that amputation can be performed to control bleeding, to remove the limb that is the source of infection and to avoid crush syndrome (Togawa et al. 2006). The rate of amputation after a fasciotomy ranges between 11–38·7% in the literature (Duman et al. 2003, Li et al. 2009, Safari et al. 2011, Guner et al. 2013). In our study, the rate of amputation after a fasciotomy was 25%. Fasciotomy is an important predisposing cause in cases developing sepsis (Rush et al. 1989, Sever et al. 2006, Gormeli et al. 2012). In the present study, six of the patients who developed sepsis underwent a fasciotomy.

Hyperkalaemia is a condition that occurs in patients with crush syndrome over a period of hours and results in death due to cardiac arrest if it is not relieved quickly (Greenberg 1998, Parham et al. 2006). One patient died as a result of a cardiac arrest related to hyperkalaemia (Patient no. 25, Table 2). The serum potassium value of that patient was 7·2 mmol/dl, and some changes were observed related to hyperkalaemia in the electrocardiography (ECG). Abdominal traumas with crush syndrome were observed in 6·4% of the patients in the Marmara earthquake and in 4·3% of the patients in the Hanshin–Awaji earthquake (Oda et al. 1997, Erek et al. 2002). The rate of abdominal traumas with crush syndrome among our patients was 13%.

In patients with crush injury, rhabdomyolysis is one of the leading causes of ARF. Other causes of ARF are dehydration and sepsis. ARF developed in 28 (1·7%) of the 1582 patients registered at our hospital after the 2011 Van Earthquake. This rate was 2·7% in the Marmara earthquake, 3·3% in the Hanshin–Awaji earthquake and 0·5% in the Iran earthquake (Atef et al. 1994, Oda et al. 1997, Erek et al. 2002). These lower rates in the Iran earthquake and 2011 Van Earthquake may be related to the fact that there are fewer high-rise buildings in these regions compared with other regions. Moreover, the fact that the 2011 Van Earthquake occurred in the daytime and that people were not in the buildings may be additional reasons for the less number of people trapped under the rubble.

The rate of death among patients with crush syndrome was 40% in the Iran earthquake, 24·7% in the Hanshin–Awaji earthquake and 15·2% in the Marmara earthquake (Atef et al. 1994, Oda et al. 1997, Erek et al. 2002). In our study, the rate of death of patients with crush syndrome was 23·9% (11 patients). Among the patients died, hyperpotassemia was observed in 11 patients, ARF in 5 and cardiac arrhythmia in 1. It appears that the most frequent cause of death was cardiac arrest due to hyperpotassemia and sepsis. We believe that the death rates in crush syndrome can be minimised by transferring patients to the intensive care units to observe ARF follow-up findings and by regular wound care to prevent sepsis development from infection.

The rate of haemodialysis in cases of ARF ranged between 20–60%. Sixteen of the patients with crush syndrome (57·1%) who developed ARF were haemodialysed (Wheeler et al. 1986, Corwin et al. 1987, Better & Stein 1990, Turney et al. 1990, Chertow et al. 1999). The rate of death can increase up to 80% among haemodialysed patients in cases of multiple-organ failure, sepsis and cardiovascular and pulmonary problems. Of all 16 patients who were haemodialysed in our hospital, 5 (31·2%) died as a result of concurrent additional problems. O those five, there were two cases of sepsis alone, one abdominal trauma with sepsis, one abdominal trauma and tibial fracture with sepsis and one abdominal trauma alone. Moreover, all these patients underwent a fasciotomy.

Crush syndrome following a great disaster such as an earthquake is an important problem. Hyperkalaemia, ARF and compartment syndrome which may accompany crush syndrome aggravate the clinical situation. Fasciotomy and amputation can be life-saving when appropriately indicated; however, following these procedures, patients should be monitored for infection and sepsis.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Relevance to clinical practice
  9. Acknowledgements
  10. Disclosure
  11. Conflict of interest
  12. References

In this study, we found that ARF is the most important complication in patients with crush syndrome. In addition, sepsis and wound infection are other frequently seen complications. Dehydration and ECG changes in hyperkalaemia should also be given due attention in the diagnosis of ARF. Wound care and antibiotic treatment are important to prevent infections. Nurses have significant responsibilities to follow up these observations and their implications.

Relevance to clinical practice

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Relevance to clinical practice
  9. Acknowledgements
  10. Disclosure
  11. Conflict of interest
  12. References

The results of this study may provide the basis for developing strategies in future for optimising attempts to rescue and the nurse care planning of survivors with crush injuries and crush syndromes after earthquakes.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Relevance to clinical practice
  9. Acknowledgements
  10. Disclosure
  11. Conflict of interest
  12. References

I would like to thank the Dr. Savas Guner and Dr. Gokay Gormeli, who supported data collection.

Disclosure

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Relevance to clinical practice
  9. Acknowledgements
  10. Disclosure
  11. Conflict of interest
  12. References

The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Relevance to clinical practice
  9. Acknowledgements
  10. Disclosure
  11. Conflict of interest
  12. References
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