Crush syndrome following unconsciousness: need for urgent orthopaedic referral

Traumatic Rhabdomyolysis: Crush Syndrome, Compartment Syndrome, and the 'Found Down' Patient

Traumatic rhabdomyolysis is a systemic manifestation of muscle injury and can occur from various traumatic etiologies, including crush syndrome (CrshS) and compartment syndrome (CS). Although historically described in natural disaster survivors trapped under collapsed structures, the frequency of CrshS has increased in the setting of 'found down' patients from opioid overdoses. Signs and symptoms of the injured limb in CrshS may range from pressure-induced skin changes to neurologic deficits and paralysis. Although its pathophysiology differs from CS, severe injuries may lead to an associated CS. Identifying CS in a patient with CrshS can be difficult but is important to distinguish because it affects treatment. The degree of muscle damage, viability of the remaining muscular compartment, and presence of elevated compartment pressures dictate the need for surgical intervention in the form of fasciotomy. Surgical outcomes from CrshS and delayed CS result in similar high morbidity and surgical complications. This review defines and classifies the types of traumatic rhabdomyolysis and summarizes the outcomes to facilitate timely diagnosis and appropriate management for this population to reduce morbidity associated with these conditions.

Destructive disasters, trauma, crush syndrome, and beyond

Orthopedic injuries, especially fractures of long bones as well as multiple fractures and comminuted fractures, are very common after destructive disasters (e.g., earthquakes, wars, and hurricanes). Another frequent problem is traumatic rhabdomyolysis, which may result in crush syndrome, the second most frequent cause of death after direct traumatic impact following earthquakes. To improve outcomes, interventions should be initiated even before extrication of the victims, which include maintenance of airway patency and spine stabilization, stopping traumatic bleeding by any means, and initiating fluid resuscitation. On-site amputations have been extensively debated to liberate the victims if the release of trapped limbs is impossible. Early after the rescue, a primary survey and triage are performed, a fluid resuscitation policy is planned, complications are treated, the wounds are decontaminated, and the victim is transported to specialized hospitals. A triage and primary survey are also performed at admission to the hospitals, which are followed by a secondary survey, physical, laboratory, and imaging examinations. Washing and cleaning of the soft-tissue injuries and debridement in open, necrotic wounds are vital. Applications of fasciotomies and amputations are controversial since they are associated with both benefits and serious complications; therefore, clear indications should be defined. Crush syndrome has been described as the presence of systemic manifestations following traumatic rhabdomyolysis, the most important component of which is acute kidney injury that may contribute to fatal hyperkalemia. The overall mortality rate is around 20% in crushed patients, which underlines the importance of prevention. Treatment includes maintaining of fluid electrolyte and acid-base balance, application of dialysis, and also prevention and treatment of complications. The principles and practices in disaster medicine may differ from those applied in routine practice; therefore, organizing repeated training courses may be helpful to provide the most effective healthcare and to save as many lives as possible after mass disasters.

Gluteal compartment syndrome: A systematic review and meta-analysis

INTRODUCTION

Gluteal compartment syndrome is a rare but devastating condition with limited characterization in the literature. The purpose of our systematic review, case series, and meta-analysis is to synthesize the current literature and provide recommendations on how to prevent gluteal compartment syndrome, identify at-risk patients, and avoid delays in diagnosis and treatment.

METHODS

International Classification of Disease codes were used to identify patients at our institution. PubMed, MEDLINE, and the Cochrane Library were searched to identify case reports between 1972 and March 1st, 2018. Cases were analyzed based on demographics, etiology, presentation, symptoms, diagnosis, treatment, and outcomes.

RESULTS

139 cases - 13 from our institution and 126 previously published - were included. The most common etiologies were postoperative (41%), prolonged immobilization secondary to substance abuse or loss of consciousness (35%) and trauma (19%). 89% were male, mean age was 45 years (range, 16-74), and mean body mass index was 41 kg/m². Rhabdomyolysis and sciatic neuropathy were identified in 94% and 74% of patients, respectively. Fasciotomy was performed in 80% of patients. Overall, 93% of patients survived. However, 41% of patients suffered prolonged neurologic dysfunction. In patients with an initial neurologic deficit, there was a higher rate of permanent neurological deficit in patients treated medically than those treated surgically (12/14 vs 29/61, p=0.0153), but no statistical difference in mortality (0/14 vs 4/61, p=1). In patients without initial neurologic deficit, there were no statistical differences in rates of permanent neurological deficit (0/7 vs 2/20, p=1) or mortality (0/7 vs 3/20, p=0.545) between those receiving medical or surgical treatment.

DISCUSSION

Gluteal compartment syndrome is an orthopaedic emergency that may be more prevalent and associated with higher morbidity and mortality than previously recognized. Risk factors may include prolonged surgical duration, immobilization secondary to substance abuse, and pelvic trauma. Intraoperative precautions and postoperative surveillance are recommended in obese patients undergoing prolonged procedures. Fasciotomies improve neurologic outcomes in patients presenting with an initial neurologic deficit. In patients who are neurologically intact on presentation, medical management with neurologic function surveillance may be the optimal initial treatment. Fasciotomies do not impact mortality. Additionally, a treatment algorithm is provided.

Pressure Necrosis Requiring Fasciotomy After Kratom Overdose

INTRODUCTION

Kratom (Mitragyna speciosa) is a popular plant-based extract that has dose-dependent stimulatory and sedative effects. It has been used for self-treatment of opioid withdrawal and can result in seizures, hepatotoxicity, and infectious complications from bacterial contamination. Reports of morbidity and mortality associated with Kratom may be confounded by coingestants. We report a case of severe rhabdomyolysis and pressure necrosis leading to fasciotomy in a patient who was using Kratom.

CASE REPORT

A 31-year-old male with substance use presented to the emergency department after loss of consciousness for 6 hours after smoking Kratom. He was found to have rhabdomyolysis, acute renal and hepatic injury, and electrolyte disturbances. No ethanol was detected, and urine drug screen was negative. Over the next 3 hours, the patient developed signs of compartment syndrome and he was transferred to the operating room for fasciotomy. He required continuous renal replacement therapy for 48 hours and his labs and clinical status improved. He was discharged 18 days later. A serum and urine sample from the first day of presentation were analyzed for mitragynine and 7-hydroxymitragynine using an Ultra Performance Liquid Chromatography-Tandem Mass Spectrometer (UPLC-MSMS) method. The serum mitragynine was 5 ng/mL and the urine mitragynine 6 ng/mL.

CONCLUSIONS

Although there are numerous reports of opioids resulting in prolonged periods of immobilization and rhabdomyolysis, this is not commonly reported in Kratom overdoses.This case report highlights the profound sedative effect of Kratom and the potential of pressure necrosis injury resulting in rhabdomyolysis and compartment syndrome requiring fasciotomy.

Substance-Related Found-Down Compartment Syndrome: A Systematic Review

OBJECTIVE

To characterize the patient population with substance-related found-down extremity compartment syndrome (FDECS) and report on their treatment and outcome.

DATA SOURCE

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Articles in English language were identified by searching 3 online databases, EMBASE, PubMed Publisher, and Cochrane Central, in September 2019.

STUDY SELECTION

Studies involving substance-related FDECS were included. Exclusion criteria were as follows: patient age <18 years, not original studies, no full text available, technical reports, traumatic acute extremity compartment syndrome, chronic exertional compartment syndrome, and vascular acute extremity compartment syndrome.

DATA EXTRACTION

There were 61 studies included with 166 cases of FDECS. Two investigators screened and extracted data independently according to a standardized template. Disagreements were addressed by an attempt to reach a consensus, and involvement of a third reviewer. Studies were quality assessed with "Quality Assessment tool for Case Series Studies."

DATA SYNTHESIS

Descriptive statistics were reported using Excel.

CONCLUSION

Substance-related FDECS is often occurring in young adults. Data from this review found that most of the patients were already diagnosed with substance use disorders and/or psychiatric disorders. There should be a high index of suspicion of FDECS in patients presenting after prolonged immobilization.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

"Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic

BACKGROUND

With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome.

METHODS

We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups.

RESULTS

Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function.

CONCLUSIONS

Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Consensus statement on crush injury and crush syndrome

Crush syndrome remains rare in European practice. It is however common in areas of civil disorder and where the normal structures of society have given way to civil war or natural disaster. Western doctors are becoming increasingly involved in such situations and there is no reason to believe that instances due to more conventional causes, such as collapse in the elderly or road traffic accidents, will cease. For all these reasons it is important that clinicians who deal infrequently with crush syndrome have access to appropriate guidelines. This consensus report seeks to provide such advice. It reports the findings of a consensus meeting on crush injury and crush syndrome held in Birmingham on 31 May 2001, and coordinated by the Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh.

Management of crush victims in mass disasters: highlights from recently published recommendations

Crush syndrome is the second most common cause of death after earthquakes (the first most common is direct trauma). Many logistic problems with the treatment of patients with crush syndrome are due to chaotic disaster circumstances; consequently, medical and logistic recommendations on the treatment of crush victims are needed. In a joint initiative of the Renal Disaster Relief Task Force of the International Society of Nephrology and European Renal Best Practice, a work group of nephrologists, intensivists, surgeons, and logisticians with disaster experience or experts in guideline preparation collaborated to provide comprehensive information and recommendations on the management of crush casualties considering their occurrence with "epidemic" dimensions after mass disasters. The result is the monograph "Recommendations for the Management of Crush Victims in Mass Disasters", which may help provide effective health care to disaster victims with renal problems. This article discusses medical and logistic principles of the treatment of crush victims, both at the disaster field and on admission to hospitals, and guidance is described. The importance of early fluid administration even before extrication of the victims and avoidance of potassium-containing solutions during the treatment of crush victims is underlined. Also, the logistic problems in treating crush casualties are emphasized. The most important aspects of the recently published recommendations are highlighted.

Complex extrication and crush injury

An unusual motor vehicle collision case is presented involving a complex, prolonged extrication with crush injury. While crush injury and crush syndrome are often considered to be in the realm of disaster medicine and urban search and rescue, more typical single-patient or few-patient incidents such as industrial accidents and vehicular crashes can involve these clinical entities. All emergency medical services (EMS) personnel should have a basic working familiarity with the operational and clinical issues involved in crush injury and crush syndrome. Crush syndrome is reviewed here from the perspective of prehospital management.

Rhabdomyolysis

Rhabdomyolysis is the disintegration of striated muscles resulting in the release of muscular cell contents into the extracellular fluid. Crush syndrome is systemic manifestations caused by rhabdomyolysis; the most important component of crush syndrome is acute kidney injury. Non-physical and physical causes play a role in the aetiology of rhabdomyolysis. Clinical spectrum varies from asymptomatic elevation in creatine kinase to acute tubular necrosis and multiorgan failure. Myoglobinuria, increased serum creatine kinase level and hyperkalaemia are the most important laboratory parameters. Vigorous hydration with isotonic saline followed by alkaline solutions and mannitol are useful in the treatment of rhabdomyolysis.

Mathematical model describing erythrocyte sedimentation rate. Implications for blood viscosity changes in traumatic shock and crush syndrome

Background

The erythrocyte sedimentation rate (ESR) is a simple and inexpensive laboratory test, which is widespread in clinical practice, for assessing the inflammatory or acute response. This work addresses the theoretical and experimental investigation of sedimentation a single and multiple particles in homogeneous and heterogeneous (multiphase) medium, as it relates to their internal structure (aggregation of solid or deformed particles).

Methods

The equation system has been solved numerically. To choose finite analogs of derivatives we used the schemes of directional differences.

Results

(1) Our model takes into account the influence of the vessel wall on group aggregation of particles in tubes as well as the effects of rotation of particles, the constraint coefficient, and viscosity of a mixture as a function of the volume fraction. (2) This model can describe ESR as a function of the velocity of adhesion of erythrocytes; (3) Determination of the ESR is best conducted at certain time intervals, i.e. in a series of periods not exceeding 5 minutes each; (4) Differential diagnosis of various diseases by means of ESR should be performed using the aforementioned timed measurement of ESR; (5) An increase in blood viscosity during trauma results from an increase in rouleaux formation and the time-course method of ESR will be useful in patients with trauma, in particular, with traumatic shock and crush syndrome.

Conclusion

The mathematical model created in this study used the most fundamental differential equations that have ever been derived to estimate ESR. It may further our understanding of its complex mechanism.

Electrophysiologic evaluation of peripheral nerve injuries in children following the Marmara earthquake

The aim of this study was to investigate the clinical, demographic, and electromyographic (EMG) characteristics of 12 earthquake victims in the pediatric age group and to compare the findings with those of the adult group. Following the 1999 Marmara earthquake, 75 subjects with suspected peripheral nerve injury were referred to our EMG laboratory for evaluation. In the pediatric age group, five patients had a history of short-term temporary trauma and seven had a history of being trapped under the debris for 4 to 10 hours and sustaining long-term trauma. Five patients had developed compartment syndrome and one had developed crush syndrome. The EMG examinations revealed peripheral nerve injury findings in all patients. The brachial plexus was damaged in 2 patients, and 19 peripheral nerves were damaged in 10 patients. Peroneal and posterior tibial nerves were predominantly affected. Regeneration was detected in all of the patients with brachial plexus damage at a mean follow-up of 3.5 months and in 62.5% of patients with peripheral nerve damage at a mean follow-up of 7.7 months. Being buried under the debris, compartment syndrome, peripheral nerve injuries in the lower extremities, and total axonal damage in the first EMG examinations were found to be higher in the pediatric age group. Regeneration findings were found at similar rates in both groups, with the brachial plexus being the most favorable. When it is considered that the regeneration process lasts 15 to 18 months and EMG findings mostly show pathologies in the form of neuropraxia and axonotmesis, we think that the prognosis of our patients will be good.

Compartment syndrome. The silent danger related to patient positioning and surgery

Compartment syndrome affecting the limbs is a well-documented condition and there are cases where it has become evident following surgery undertaken with the patient in the Lloyd Davies position. This article explores the contributory factors and the devastating effect it can have on the patient, and questions whether we practise evidence-based care when patients are undergoing certain types of surgery. It also discusses factors related to abdominal compartment syndrome, a condition usually affecting the critically ill patient.

Acute compartment syndrome in the absence of fracture

OBJECTIVES

To determine if there are differences in demographics, referral patterns, and operative findings between patients with and without a fracture who develop an acute compartment syndrome.

DESIGN

Retrospective cohort.

SETTING

Orthopaedic trauma unit, university teaching hospital.

METHODS

This study examines 164 cases of acute compartment syndrome over an 8-year period. Of these, 13 patients had a diagnosis of crush syndrome and are excluded from this study. The remaining 38 cases with no fracture form the basis for this study.

MAIN OUTCOME MEASURES

Patient demographics, referral patterns, and operative findings were compared for the "fracture" and "no fracture" groups.

RESULTS

Patients who had acute compartment syndrome in the absence of fracture were older (P < 0.05) and had significantly more comorbidities (P < 0.001) than those with a fracture. Cases without a fracture had a significantly greater mean delay to fasciotomy of 12.4 hours (P < 0.05) compared to those with a fracture. At fasciotomy, 20% of patients without a fracture had muscle necrosis requiring debridement compared to 8% for patients with a fracture (P < 0.05).

CONCLUSIONS

This study demonstrates that muscle necrosis is more commonly found in acute compartment syndrome in the absence of a fracture than in those with a fracture. Referral of swollen limbs without fracture for an orthopaedic opinion should not be delayed.

Consensus statement on crush injury and crush syndrome

Crush syndrome remains rare in European practice. It is, however, common in areas of civil disorder and where the normal structures of society have given way to civil war or natural disaster. Western doctors are becoming increasingly involved in such situations and there is no reason to believe that instances due to more conventional causes, such as collapse in the elderly or road traffic accidents will cease. For all these reasons it is important that clinicians who deal infrequently with crush syndrome have access to appropriate guidelines. This consensus report seeks to provide such advice.

Crush syndrome patients after the Marmara earthquake

BACKGROUND

To assess the treatment and outcome of patients with crush injury sustained in the Marmara earthquake.

METHODS

Seven hundred eighty three patients were transferred to a university hospital and 25 of them were admitted to the intensive care unit. The medical records of 18 crush injury patients were retrospectively reviewed.

RESULTS

The major associated injuries were in the lower extremities, upper extremities, and chest. Seven patients underwent fasciotomy and six patients had amputations. Twelve patients required mechanical ventilation. Adult respiratory distress syndrome developed in four patients. Oliguria occurred in eight patients. Hyperkalaemia was seen in six patients and four of them underwent emergency haemodialysis. One patient died because of hyperkalaemia on arrival to the intensive care unit. Renal failure was treated with haemodialysis or haemoperfusion in 13 patients. Five patients died because of multiple organ failure and two patients because of sepsis.

CONCLUSION

Crush syndrome is a life threatening event. The authors believe that early transportation and immediate intensive care therapy would have improved the survival rate.

Crush injury and crush syndrome: a review

Crush injuries and the subsequent systemic manifestations are well described, but there is limited evidence on which to base protocols for optimal management. Given that in most environments such in-juries are relatively rare, there is, however, an undoubted need for such guidelines. This article reviews the currently available evidence and summarizes the treatment options available.

Soft tissue complications of orthopedic emergencies

The emergency physician encounters a diversity of potentially devastating and disabling soft tissue maladies. This article reviews the literature and approach to the compartment syndrome and Volkmann contracture, reflex sympathetic dystrophy and causalgia, fracture blisters, and gas gangrene.

Crush syndrome sustained in the 1995 Kobe, Japan, earthquake; treatment and outcome

STUDY OBJECTIVE

To assess the treatment and outcome of patients with crush syndrome sustained in an earthquake disaster.

METHODS

We conducted a retrospective analysis of eight patients with crush syndrome and subsequent acute kidney failure who were treated in the ICU of a university hospital. All eight patients had been extricated from buildings that collapsed in the 1995 Kobe, Japan, earthquake. Crush injury involved the upper extremities in one patient and the lower extremities in seven. Each patient received intravenous fluid infusion and diuretic drugs and underwent hemodialysis. Emergency fasciotomy was performed in some patients, 17 to 100 hours after extrication.

RESULTS

All patients were conscious and lucid on admission, and blood pressure and heart rate were normal. All the patients demonstrated kidney failure with increased concentrations of serum creatinine (1.9 to 9.6 mg/dL [169 to 852 mumol/L]). Six patients were oliguric. Hyperkalemia (5.6 to 8.8 mEq/L) was present in six patients. We found close correlations between the serum potassium and creatine kinase concentrations, between the serum myoglobin and potassium concentrations, and between the serum myoglobin and creatine kinase concentrations. All the patients were weaned from hemodialysis. The serum creatinine concentration decreased to a normal level within 20 to 52 days of admission in all patients. No patients underwent amputation. Muscle weakness and sensory deficits persisted in all patients 6 months after the earthquake.

CONCLUSION

Our findings support current therapeutic strategies for crush syndrome, despite the long delay to initiation of intensive therapy. All the patients recovered kidney function and were weaned from hemodialysis; none required amputation.

Ecstasy-induced rhabdomyolysis and its role in the development of acute renal failure

Ecstasy (MDMA) is widely used within the dance scene of the 1990s. In this article the growing trend of ecstasy usage among teenagers is considered, in particular, one of its potentially devastating side-effects, rhabdomyolysis. From consideration of the pathophysiology of rhabdomyolysis and its role in the development of acute renal failure, it becomes apparent that preventative measures and prompt treatment can prevent patients developing acute renal failure as a consequence of rhabdomyolysis.

A complication of self-poisoning

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Compartment syndrome as a complication of the prolonged use of the Lloyd-Davies position

Compartment syndrome in the legs is a rare complication of the prolonged use of the lithotomy position. We report two cases of compartment syndrome developing as a complication of the prolonged use of the Lloyd-Davies position. Both patients received combined general and epidural anaesthesia and postoperative epidural analgesia. The diagnosis was delayed in the first case, resulting in the avoidable complications of renal failure and permanent neuromuscular dysfunction.