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

Advancing crush syndrome management: the potent role of Sodium zirconium cyclosilicate in early hyperkalemia intervention and survival enhancement in a rat model

Background: Crush Syndrome (CS), a severe trauma resulting from prolonged muscle compression, is commonly seen in large-scale disasters such as earthquakes. It not only causes localized tissue damage but also triggers electrolyte imbalances, particularly hyperkalemia, increasing the risk of early mortality. This study aims to assess the early intervention effects of Sodium Zirconium Cyclosilicate (SZC) on hyperkalemia in rat CS model. Methods: A rat CS model was established using a self-developed multi-channel intelligent small-animal crush injury platform. Rats in the experimental groups were treated with varying doses of SZC before compression and immediately post-decompression. The efficacy of SZC was evaluated by continuous monitoring of blood potassium levels and survival rates. Serum creatinine (Cre) and blood urea nitrogen (BUN) levels were analyzed, and renal damage was assessed through histopathological examination. Results: SZC treatment significantly reduced blood potassium levels and improved survival rates in rats. Compared to the placebo group, the SZC-treated rats showed a significant decrease in blood potassium levels at 6 and 12 h post-decompression, maintaining lower levels at 24 h. Biochemical analysis indicated no significant impact of SZC on renal function, with no notable differences in Cre and BUN levels between groups. Histopathological findings revealed similar levels of renal damage in both groups. Conclusion: SZC demonstrates significant early intervention effects on hyperkalemia in a rat model of crush injury, effectively improving survival rates without adverse effects on renal function. These results provide a new strategic direction for the clinical treatment of Crush Syndrome and lay the foundation for future clinical applications.

Surgical and critical care management of earthquake musculoskeletal injuries and crush syndrome: A collective review

Earthquakes are unpredictable natural disasters causing massive injuries. We aim to review the surgical management of earthquake musculoskeletal injuries and the critical care of crush syndrome. We searched the English literature in PubMed without time restriction to select relevant papers. Retrieved articles were critically appraised and summarized. Open wounds should be cleaned, debrided, receive antibiotics, receive tetanus toxoid unless vaccinated in the last 5 years, and re-debrided as needed. The lower limb affected 48.5% (21.9%-81.4%) of body regions/patients. Fractures occurred in 31.1% (11.3%-78%) of body regions/patients. The most common surgery was open reduction and internal fixation done in 21% (0%-76.6%), followed by plaster of Paris in 18.2% (2.3%-48.8%), and external fixation in 6.6% (1%-13%) of operations/patients. Open fractures should be treated with external fixation. Internal fixation should not be done until the wound becomes clean and the fractured bones are properly covered with skin, skin graft, or flap. Fasciotomies were done in 15% (2.8%-27.2%), while amputations were done in 3.7% (0.4%-11.5%) of body regions/patients. Principles of treating crush syndrome include: (1) administering proper intravenous fluids to maintain adequate urine output, (2) monitoring and managing hyperkalemia, and (3) considering renal replacement therapy in case of volume overload, severe hyperkalemia, severe acidemia, or severe uremia. Low-quality studies addressed indications for fasciotomy, amputation, and hyperbaric oxygen therapy. Prospective data collection on future medical management of earthquake injuries should be part of future disaster preparedness. We hope that this review will carry the essential knowledge needed for properly managing earthquake musculoskeletal injuries and crush syndrome in hospitalized patients.

February 6th, Kahramanmaraş earthquakes and the disaster management algorithm of adult emergency medicine in Turkey: An experience review

This compilation covers emergency medical management lessons from the February 6th Kahramanmaraş earthquakes. The objective is to review relevant literature on emergency services patient management, focusing on Koenig's 1996 Simple Triage and Rapid Treatment (START) and Secondary Assessment of Victim Endpoint (SAVE) frameworks. Establishing a comprehensive seismic and mass casualty incident (MCI) protocol chain is the goal. The prehospital phase of seismic MCIs treats hypovolemia and gets patients to the nearest hospital. START-A plans to expedite emergency patient triage and pain management. The SAVE algorithm is crucial for the emergency patient secondary assessment. It advises using Glasgow Coma Scale, Mangled Extremity Severity Score, Burn Triage Score, and Safe Quake Score for admission, surgery, transfer, discharge, and outcomes. This compilation emphasizes the importance of using diagnostic tools like bedside blood gas analyzers and ultrasound devices during the assessment process, drawing from 6 February earthquake research. The findings create a solid framework for improving emergency medical response strategies, making them applicable in similar situations.

BREAKING NEW GROUND: STANDARDIZING RAT MODELS FOR CRUSH SYNDROME INVESTIGATIONS

ABSTRACT

Crush syndrome (CS), alternatively termed traumatic rhabdomyolysis, is a paramount posttraumatic complication. Given the infeasibility of conducting direct simulation research in humans, the role of animal models is pivotal. Regrettably, the dearth of standardized animal models persists. The objective of this study was to construct a repeatable standardized rat CS models and, based on this, simulate specific clinical scenarios. Methods: Using a self-developed multichannel intelligent small-animal crush injury platform, we applied a force of 5 kg to the hind limbs of 8-week-old rats (280-300 g), subjecting them to a continuous 12 h compression to establish the CS model. Continuous monitoring was conducted for both the lower limbs and the overall body status. After decompression, biochemical samples were collected at 3, 6, 12, and 24 h. In addition, we created a CS model after resection of the left kidney (UNx-CS), which was conceptualized to simulate a more challenging clinical scenario to investigate the physiological and pathological responses rats with renal insufficiency combined with crush injury. The results were compared with those of the normal CS model group. Results : Our experiments confirm the stability of the crush injury platform. We defined the standardized conditions for modeling and successfully established rats CS model in bulk. After 12 h of compression, only 40% of the rats in the CS group survived for 24 h. Systemically, there was clear evidence of insufficient perfusion, reflecting the progression of CS from localized to generalized. The injured limbs displayed swelling, localized perfusion deficits, and severe pathological alterations. Significant changes were observed in blood biochemical markers: aspartate transaminase, lactate dehydrogenase, K+, creatine kinase, creatinine, and blood urea nitrogen levels rose rapidly after decompression and were significantly higher than the sham group. The kidney demonstrated characteristic pathological changes consistent with established CS diagnostic criteria. Although the UNx-CS rat model did not exhibit significant biochemical differences and pathological scores when compared with the standard CS model, it did yield intriguing results with regard to kidney morphology. The UNx-CS group manifested a higher incidence of cortical and medullary protein casts compared with the NC-CS group. Conclusion: We developed and iteratively refined a novel digital platform, addressing the multiple uncontrollable variables that plagued prior models. This study validated the stability of the platform, defined the standardized conditions for modeling and successfully established the CS model with good repeatability in bulk. In addition, our innovative approach to model a clinically challenging scenario, the UNx-CS rat model. This offers an opportunity to delve deeper into understanding the combined effects of preexisting renal compromise and traumatic injury. In summary, the development of a standardized, reproducible CS model in rats represents a significant milestone in the study of Crush syndrome. This study is of paramount significance as it advances the standardization of the CS model, laying a solid foundation for subsequent studies in related domains, especially in CS-AKI.

Factors predicting kidney replacement therapy in pediatric earthquake victims with crush syndrome in the first week following rescue

Crush syndrome due to traumatic rhabdomyolysis is one of the most significant problems to occur following earthquakes. On February 6, 2023, millions of people in Turkey were affected by two consecutive Kahramanmaraş earthquakes. The present study reports the analysis of clinical and laboratory findings of crush syndrome in pediatric earthquake victims admitted to our hospital from our region where the earthquake had a devastating effect. Clinical and laboratory findings concerning earthquake victims with crush syndrome were analyzed within the first week to determine what factors are predictive of kidney replacement therapy (KRT). The data of patients were retrospectively collected from medical records. A total of 310 children were admitted as earthquake victims to the pediatric emergency department. Ninety-seven (31%) of these patients had crush syndrome. Fifty-three (55%) of those with crush syndrome were female. The mean age was 10.9 ± 4.7 years, and the mean time under the rubble was 30.6 ± 23.8 h. Twenty-two patients (23%) required KRT. Hemodialysis was applied to 16 (73%) of them, and hemodiafiltration was applied to the other six (27%) in the pediatric intensive care unit. Regarding creatine kinase (CK) levels, the area under the receiver operating characteristic (ROC) curve (AUC) for predicting KRT was 0.905 (95% confidence interval [CI] 0.848-0.963; p < 0.001). The optimal cut-off value was 40,000 U/L with a sensitivity of 86% and a specificity of 83%. In terms of the percentage of body area crushed, the AUC for predicting KRT was 0.907 (95% CI 0.838-0.976; p < 0.001). The optimal cut-off value was 30% with a sensitivity of 86% and a specificity of 88%. Multiple logistic regression analysis showed that each 10% increase in body area crushed (OR 4.16, 95% CI 1.58-10.93, p = 0.004) and 1 mg/dl increase in the serum phosphorus level (OR 4.19, 95% CI 1.71-10.28, p = 0.002) were significant risk factors for dialysis treatment.

CONCLUSIONS

Crush syndrome and kidney problems are common following disasters like earthquakes. Clinical and laboratory findings at admission can predict dialysis requirement in earthquake victims. While CK elevation, body area crushed percentage, and increased phosphorus level were predictive of dialysis treatment, time under the rubble was not. Even if the patients were under the rubble for a short time, acute kidney injury (AKI) may develop as a result of severe hypovolemia due to crush injuries, and patients may need KRT.

WHAT IS KNOWN

•Crush syndrome after earthquakes needs to be treated carefully in victims and can cause AKI and mortality when not treated timely and appropriately.

WHAT IS NEW

•CK level elevation, body area crushed percentage, and increased phosphorus level are predictive of dialysis treatment. •The time under the rubble may not be predictive of dialysis requirement.

Disasters and kidney care: pitfalls and solutions

Patients with kidney disease, especially those with kidney failure, are particularly susceptible to the adverse effects of disasters because their survival depends on functional infrastructure, advanced technology, the availability of specific drugs and well-trained medical personnel. The risk of poor outcomes across the entire spectrum of patients with kidney diseases (acute kidney injury, chronic kidney disease and kidney failure on dialysis or with a functioning transplant) increases as a result of disaster-related logistical challenges. Patients who are displaced face even more complex problems owing to additional threats that arise during travel and after reaching their new location. Overall, risks may be mitigated by pre-disaster preparedness and training. Emergency kidney disaster responses depend on the type and severity of the disaster and include medical and/or surgical treatment of injuries, treatment of mental health conditions, appropriate diet and logistical interventions. After a disaster, patients should be evaluated for problems that were not detected during the event, including those that may have developed as a result of the disaster. A retrospective review of the disaster response is vital to prevent future mistakes. Important ethical concerns include fair distribution of limited resources and limiting harm. Patients with kidney disease, their care-givers, health-care providers and authorities should be trained to respond to the medical and logistical problems that occur during disasters to improve outcomes.

Prehospital management of earthquake crush injuries: A collective review

Earthquakes are natural disasters which can destroy the rural and urban infrastructure causing a high toll of injuries and death without advanced notice. We aim to review the prehospital medical management of earthquake crush injuries in the field. PubMed was searched using general terms including rhabdomyolysis, crush injury, and earthquake in English language without time restriction. Selected articles were critically evaluated by three experts in disaster medicine, emergency medicine, and critical care. The medical response to earthquakes includes: (1) search and rescue; (2) triage and initial stabilization; (3) definitive care; and (4) evacuation. Long-term, continuous pressure on muscles causes crush injury. Ischemia-reperfusion injury following the relieving of muscle compression may cause metabolic changes and rhabdomyolysis depending on the time of extrication. Sodium and water enter the cell causing cell swelling and hypovolemia, while potassium and myoglobin are released into the circulation. This may cause sudden cardiac arrest, acute extremity compartment syndrome, and acute kidney injury. Recognizing these conditions and treating them timely and properly in the field will save many patients. Majority of emergency physicians who have worked in the field of the recent Kahramanmaraş 2023, Turkey, earthquakes, have acknowledged their lack of knowledge and experience in managing earthquake crush injuries. We hope that this collective review will cover the essential knowledge needed for properly managing seriously crushed injured patients in the earthquake field.

Progress in the Diagnostic and Predictive Evaluation of Crush Syndrome

Crush syndrome (CS), also known as traumatic rhabdomyolysis, is a syndrome with a wide clinical spectrum; it is caused by external compression, which often occurs in earthquakes, wars, and traffic accidents, especially in large-scale disasters. Crush syndrome is the second leading cause of death after direct trauma in earthquakes. A series of clinical complications caused by crush syndrome, including hyperkalemia, myoglobinuria, and, in particular, acute kidney injury (AKI), is the main cause of death in crush syndrome. The early diagnosis of crush syndrome, the correct evaluation of its severity, and accurate predictions of a poor prognosis can provide personalized suggestions for rescuers to carry out early treatments and reduce mortality. This review summarizes various methods for the diagnostic and predictive evaluation of crush syndrome, including urine dipstick tests for a large number of victims, traditional and emerging biomarkers, imaging-assisted diagnostic methods, and developed evaluation models, with the aim of providing materials for scholars in this research field.

Crush syndrome: a review for prehospital providers and emergency clinicians

INTRODUCTION

Disasters and accidents have occurred with increasing frequency in recent years. Primary disasters have the potential to result in mass casualty events involving crush syndrome (CS) and other serious injuries. Prehospital providers and emergency clinicians stand on the front lines of these patients' evaluation and treatment. However, the bulk of our current knowledge, derived from historical data, has remained unchanged for over ten years. In addition, no evidence-based treatment has been established to date.

OBJECTIVE

This narrative review aims to provide a focused overview of, and update on, CS for both prehospital providers and emergency clinicians.

DISCUSSION

CS is a severe systemic manifestation of trauma and ischemia involving soft tissue, principally skeletal muscle, due to prolonged crushing of tissues. Among earthquake survivors, the reported incidence of CS is 2-15%, and mortality is reported to be up to 48%. Patients with CS can develop cardiac failure, kidney dysfunction, shock, systemic inflammation, and sepsis. In addition, late presentations include life-threatening systemic effects such as hypovolemic shock, hyperkalemia, metabolic acidosis, and disseminated intravascular coagulation. Immediately beginning treatment is the single most important factor in reducing the mortality of disaster-situation CS. In order to reduce complications from CS, early, aggressive resuscitation is recommended in prehospital settings, ideally even before extrication. However, in large-scale natural disasters, it is difficult to diagnose CS, and to reach and start treatments such as continuous administration of massive amounts of fluid, diuresis, and hemodialysis, on time. This may lead to delayed diagnosis of, and high on-site mortality from, CS. To overcome these challenges, new diagnostic and therapeutic modalities in the CS animal model have recently been advanced.

CONCLUSIONS

Patient outcomes can be optimized by ensuring that prehospital providers and emergency clinicians maintain a comprehensive understanding of CS. The field is poised to undergo significant advances in coming years, given recent developments in what is considered possible both technologically and surgically; this only serves to further emphasize the importance of the field, and the need for ongoing research.

Lessons learned during the war in Ukraine: a report from the Renal Disaster Relief Task Force of the ERA

People living with kidney disease are among the most vulnerable at times of natural or man-made disasters. In addition to their unpredictable course, armed conflicts impose a major threat given the disruption of infrastructure, sanitation and access to food, water and medical care. The ongoing war in Ukraine has once more demonstrated the importance of preparedness, organization, coordination and solidarity during disasters. People living with kidney disease face serious challenges given their dependence on life-sustaining treatment, irrespective of whether they remain in the war zone or are displaced internally or externally. This especially affects those requiring kidney replacement therapy, dialysis or transplantation, but also patients with other kidney diseases and the medical staff who care for them. Soon after the war started, the European Renal Association assigned a Renal Disaster Relief Task Force dedicated to support the people living with kidney disease and the nephrology community in Ukraine. This report summarizes the major challenges faced, actions taken and lessons learned by this task force. We anticipate that the experience will help to increase preparedness and mitigate the devastating effects of armed conflicts on the kidney community in the future and propose to establish an international collaboration to extend this effort to other parts of the world facing similar challenges.

Crush injury and syndrome: A review for emergency clinicians

INTRODUCTION

Primary disasters may result in mass casualty events with serious injuries, including crush injury and crush syndrome.

OBJECTIVE

This narrative review provides a focused overview of crush injury and crush syndrome for emergency clinicians.

DISCUSSION

Millions of people worldwide annually face natural or human-made disasters, which may lead to mass casualty events and severe medical issues including crush injury and syndrome. Crush injury is due to direct physical trauma and compression of the human body, most commonly involving the lower extremities. It may result in asphyxia, severe orthopedic injury, compartment syndrome, hypotension, and organ injury (including acute kidney injury). Crush syndrome is the systemic manifestation of severe, traumatic muscle injury. Emergency clinicians are at the forefront of the evaluation and treatment of these patients. Care at the incident scene is essential and focuses on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport. Care at the healthcare facility includes initial stabilization and trauma evaluation as well as treatment of any complication (e.g., compartment syndrome, hyperkalemia, rhabdomyolysis, acute kidney injury).

CONCLUSIONS

Crush injury and crush syndrome are common in natural and human-made disasters. Emergency clinicians must understand the pathophysiology, evaluation, and management of these conditions to optimize patient care.

Management of pediatric dialysis and kidney transplant patients after natural or man-made disasters

Pediatric patients on kidney replacement therapy (KRT) are among the most vulnerable during large-scale disasters, either natural or man-made. Hemodialysis (HD) treatments may be impossible because of structural damage and/or shortage of medical supplies, clean water, electricity, and healthcare professionals. Lack of peritoneal dialysis (PD) solutions and increased risk of infectious/non-infectious complications may make PD therapy challenging. Non-availability of immunosuppressants and increased risk of infections may result in graft loss and deaths of kidney transplant recipients. Measures to mitigate these risks must be considered before, during, and after the disaster including training of staff and patients/caregivers to cope with medical and logistic problems. Soon after a disaster, if the possibility of performing HD or PD is uncertain, patients should be directed to other centers, or the duration and/or number of HD sessions or the PD prescription adapted. In kidney transplant recipients, switching among immunosuppressants should be considered in case of non-availability of the medications. Post-disaster interventions target treating neglected physical and mental problems and also improving social challenges. All problems experienced by pediatric KRT patients living in the affected area are applicable to displaced patients who may also face extra risks during their travel and also at their destination. The need for additional local, national, and international help and support of non-governmental organizations must be anticipated and sought in a timely manner.

Remote ischemic postconditioning protects against crush-induced acute kidney injury via down-regulation of apoptosis and senescence

BACKGROUND

Acute renal failure due to crush syndrome is one of the leading causes of death in disasters. Ischemic Postconditioning (IPC) is a potentially effective strategy to protect against ischemic reperfusion injury, but a few studies noted its protective effect in crush induced acute kidney injury (AKI). Hence, this study investigated the optimal IPC strategy to prevent crush induced AKI and reveal related cellular mechanisms.

METHODS

The right lower extremities of rabbits were constantly compressed for 8 h and then performed five cycles of clamping and releasing the femoral artery and vein before depression using a clip. In terms of the duration of clamping and releasing, the animals were randomly divided into 5 groups, Control, IPC-5sec, IPC-30sec, IPC-1min, and IPC-5min groups; 6 rabbits for each group. Biomarkers of inflammation, renal function, renal tubular injury, and muscular injury, apoptosis, and cellular senescence in kidney were detected.

RESULTS

Six hours after decompression, the levels of Serum Creatine (SCr), Blood Urea Nitrogen (BUN), K+, and Interleukin-6 (IL-6) in IPC-1min and IPC-5min groups were lower than Control, with a statistically significant difference. The morphological study of Periodic Acid-Schiff (PAS) staining demonstrated that 6 h after decompression, IPC-1min can attenuate renal tubular damage renal tubule. Meanwhile, the level of Neutrophil Gelatinase-Associated Lipocalin (NGAL) in circulation in the IPC-30sec, IPC-1min, and IPC-5min groups was significantly decreased compared with the Control group, 2 h after decompression. On the other hand, the levels of serum Creatine Kinase (CK) and Myoglobin (Mb), and the morphological change of muscular damage detected by hematoxylin and eosin (H&E) staining in IPC-1min-treated group were significantly lower than Control group 6 hours after decompression. Further results of the cellular mechanism showed that the apoptotic markers of Terminal deoxynucleotidyl Transferase-mediated dUTP Nick End Labeling (TUNEL) and Caspase3 and the cell senescent markers of senescence-associated β-galactosidase (SA-β-Gal) and nuclear LAMNB1 have changed significantly in the IPC-1min group, compared with the control group.

CONCLUSIONS

Performing 5 cycles of 1-min IPC would be a convenient, time-saving, and effective method to prevent crush-induced AKI by attenuating the release of nephrotoxic substances after decompression and downregulation of the expression of apoptosis and cellular senescence biomarkers.

Earlier continuous renal replacement therapy is associated with reduced mortality in rhabdomyolysis patients

Background

Continuous renal replacement therapy (CRRT) is commonly employed for rhabdomyolysis (RM) patients. However, the optimal initiation timing of CRRT and prognostic factors were not well evaluated for patients with RM. We aimed to investigate the efficacy of CRRT timing on mortality and the risk factors for death in RM patients who received CRRT.

Methods

RM patients who received CRRT between 1 May 2010 and 31 May 2021 in our center were retrospectively included. Univariate and multivariate logistic analyses were performed to identify the risk factors for primary outcome (90-day mortality).

Results

A total of 134 patients were included in our study. The 90-day mortality rate was 38.06%. The median time from CRRT initiation to peak CK occurrence was 4.8 h (IQR −16, 14), 67 patients received CRRT before 4.8 h after peak CK occurrence (early CRRT), and 67 patients received CRRT beyond 4.8 h after peak CK occurrence (late CRRT). Multivariate logistic regression analysis showed that the time from CRRT initiation to the peak CK (per 1 h, OR 1.026, 95% CI 1.004–1.049, p = 0.023), late CRRT (OR 3.082, 95% CI 1.072–8.859, p = 0.037), elevated serum cardiac troponin I (cTnI) (per 1 ng/mL, OR 1.218, 95% CI 1.011–1.468, p = 0.038), older age (per 1 year, OR 1.042, 95% CI 1.003–1.081, p = 0.032), and need of mechanical ventilation support (OR 4.632, 95% CI 1.292–16.61, p = 0.019) were independent risk factors for 90-day mortality.

Conclusions

Earlier CRRT initiation before 4.8 h after peak CK occurrence was associated with lower 90-day patient mortality.

The Role of Alpha-1-Acid Glycoprotein in the Diagnosis and Treatment of Crush Syndrome-Induced Acute Kidney Injury

BACKGROUND

Crush syndrome (CS) is the most common cause of deaths following earthquakes and other disasters. The pathogenesis of CS has yet to be fully elucidated. Thus, clinical choice of ideal drug treatments for CS remains deficient.

METHODS AND RESULTS

In this study, we first evaluated the relation between extrusion force and the severities of CS. Rats were exposed to different extrusion forces: 1 kg, 3 kg, 5 kg, and 8 kg, respectively. Survival rates, crushed muscle tissue edema, serum biochemical parameters, and histopathological staining were used to assess severity. Our results showed that there were no statistical differences in survival rate or changes in thigh circumference among the different extrusion forces groups. However, serum levels of potassium, creatine kinase, blood urea nitrogen, creatinine, and myoglobin were elevated at 12- and 24-h post-decompression in 5 kg and 8 kg groups, compared with 1 kg and 3 kg groups. Histopathological staining demonstrated that the degree of organ damage to kidney, muscle, and lung tissues correlated with increasing extrusion force. We next analyzed changes in serum protein profiles in 3 kg or 5 kg extrusion pressure groups. A total of 76 proteins (20 upregulated, 56 downregulated) were found to be altered at all three time points (0, 12, and 72 h) post-decompression, compared with the control group. Three common upregulated proteins alpha-1-acid glycoprotein (α1-AGP), neutrophil gelatinase-associated lipocalin (NGAL), and Haptoglobin were selected for validation of increased expression. α1-AGP was explored as a treatment for CS-induced acute kidney injury (AKI). Intraperitoneal injection of α1-AGP protected kidneys from CS-induced AKI by regulating TNF-α and IL-6 production, attenuating neutrophil recruitment, and reducing renal cell apoptosis.

CONCLUSION

Our findings demonstrated that the severity of crush injury is causally related to extrusion pressure and increase in blood serum markers. Our identification of the biomarker and treatment candidate, α1-AGP, suggests its implication in predicting the severity of CS and its use as a mediator of CS-induced AKI, respectively.

Guidelines for the acute care of severe limb trauma patients

GOAL

To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre.

DESIGN

A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded.

METHODS

The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations.

CONCLUSIONS

There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.

RIG-I, a novel DAMPs sensor for myoglobin activates NF-κB/caspase-3 signaling in CS-AKI model

BACKGROUND

Acute kidney injury (AKI) is the main life-threatening complication of crush syndrome (CS), and myoglobin is accepted as the main pathogenic factor. The pattern recognition receptor retinoicacid-inducible gene I (RIG-I) has been reported to exert anti-viral effects function in the innate immune response. However, it is not clear whether RIG-I plays a role in CS-AKI. The present research was carried out to explore the role of RIG-I in CS-AKI.

METHODS

Sprague-Dawley rats were randomly divided into two groups: the sham and CS groups (n = 12). After administration of anesthesia, the double hind limbs of rats in the CS group were put under a pressure of 3 kg for 16 h to mimic crush conditions. The rats in both groups were denied access to food and water. Rats were sacrificed at 12 h or 36 h after pressure was relieved. The successful establishment of the CS-AKI model was confirmed by serum biochemical analysis and renal histological examination. In addition, RNA sequencing was performed on rat kidney tissue to identify molecular pathways involved in CS-AKI. Furthermore, NRK-52E cells were treated with 200 μmol/L ferrous myoglobin to mimic CS-AKI at the cellular level. The cells and cell supernatant samples were collected at 6 h or 24 h. Small interfering RNAs (siRNA) was used to knock down RIG-I expression. The relative expression levels of molecules involved in the RIG-I pathway in rat kidney or cells samples were measured by quantitative Real-time PCR (qPCR), Western blotting analysis, and immunohistochemistry (IHC) staining. Tumor necrosis factor-α (TNF-α) was detected by ELISA. Co-Immunoprecipitation (Co-IP) assays were used to detect the interaction between RIG-I and myoglobin.

RESULTS

RNA sequencing of CS-AKI rat kidney tissue revealed that the different expression of RIG-I signaling pathway. qPCR, Western blotting, and IHC assays showed that RIG-I, nuclear factor kappa-B (NF-κB) P65, p-P65, and the apoptotic marker caspase-3 and cleaved caspase-3 were up-regulated in the CS group (P < 0.05). However, the levels of interferon regulatory factor 3 (IRF3), p-IRF3 and the antiviral factor interferon-beta (IFN-β) showed no significant changes between the sham and CS groups. Co-IP assays showed the interaction between RIG-I and myoglobin in the kidneys of the CS group. Depletion of RIG-I could alleviate the myoglobin induced expression of apoptosis-associated molecules via the NF-κB/caspase-3 axis.

CONCLUSION

RIG-I is a novel damage-associated molecular patterns (DAMPs) sensor for myoglobin and participates in the NF-κB/caspase-3 signaling pathway in CS-AKI. In the development of CS-AKI, specific intervention in the RIG-I pathway might be a potential therapeutic strategy for CS-AKI.

Mass Disasters and Burnout in Nephrology Personnel: From Earthquakes and Hurricanes to COVID-19 Pandemic

Mass disasters result in extensive health problems and make health care delivery problematic, as has been the case during the COVID-19 pandemic. Although COVID-19 was initially considered a pulmonary problem, it soon became clear that various other organs were involved. Thus, many care providers, including kidney health personnel, were overwhelmed or developed burnout. This review aims to describe the spectrum of burnout in mass disasters and suggests solutions specifically for nephrology personnel by extending previous experience to the COVID-19 pandemic. Burnout (a psychologic response to work-related stress) is already a frequent part of routine nephrology practice and, not surprisingly, is even more common during mass disasters due to increased workload and specific conditions, in addition to individual factors. Avoiding burnout is essential to prevent psychologic and somatic health problems in personnel as well as malpractice, understaffing, and inadequate health care delivery, all of which increase the health care burden of disasters. Burnout may be prevented by predisaster organizational measures, which include developing an overarching plan and optimizing health care infrastructure, and ad hoc disaster-specific measures that encompass both organizational and individual measures. Organizational measures include increasing safety, decreasing workload and fear of malpractice, optimizing medical staffing and material supplies, motivating personnel, providing mental health support, and enabling flexibility in working circumstances. Individual measures include training on coping with stress and problematic conditions, minimizing the stigma of emotional distress, and maintaining physical health. If these measures fall short, asking for external help is mandatory to avoid an inefficient disaster health care response. Minimizing burnout by applying these measures will improve health care provision, thus saving as many lives as possible.

Emerging medical therapies in crush syndrome - progress report from basic sciences and potential future avenues

Crush injury is a disease that is commonly found in victims of earthquakes, debris flows, mine disasters, explosions, terrorist attacks, local wars, and other accidents. The complications that arise due to the crush injury inflicted on victims give rise to crush syndrome (CS). If not treated in time, the mortality rate of CS is very high. The most important measure that can be taken to reduce mortality in such situations is to immediately start treatment. However, the traditional treatment methods such as fluid resuscitation, diuresis, and hemodialysis are not feasible enough to be carried out at the disaster scene. So there is a need for developing new treatments that are efficient and convenient. Because it is difficult to diagnose in the disaster area and reach the treatment equipment and treat on time. It has become a new research needs to be directed into identifying new medical treatment targets and methods using the etiology and pathophysiological mechanisms of CS. In recent years, a large number of new anti-oxidant and anti-inflammatory drug therapies have been shown to be highly efficacious in CS rat/mouse models. Some of them are expected to become specific drugs for the emergency treatment of a large number of patients who may develop CS in the aftermath of earthquakes, wars, and other disasters in the future. Hence, we have reviewed the latest research on the medical therapy of CS as a source for anyone wishing to pursue research in this direction.

International Conference: "Renal Aspects of Disaster Relief", Ohrid, R. Macedonia, May 24-26, 1996

The International Conference Renal Aspects of Disaster Relief, Ohrid, R. Macedonia, May 24-26, 1996 united doctors and engineers in order to better build settlements, and in case of an earthquake, how to help the injured.Plans have been proposed for the treatment of the injured with fluid and dialysis, as well as how to organize the non-governmental organizations and the population to assist the medical staff in optimizing the treatment of the injured.Members of the Renal Disaster Relief Task Force of the International Society of Nephrology and the European Renal Best Practice were tasked with preparing guidelines for medical staff and the population to address earthquake injuries.

Kidney problems in disaster situations

Mass disasters, particularly earthquakes, cause many medical problems, including kidney problems, but an organized approach to cope with them was initiated only at the end of previous century, subsequent to the Armenian Spitak earthquake in 1988. Originally, interventions were focused on acute kidney injury (AKI) following crush injury and rhabdomyolysis in victims who had been trapped under the debris of collapsed buildings. However, similar problems were also registered in the context of other catastrophic events, especially man-made disasters like wars and torture. Other kidney-related problems, such as the preservation of treatment continuity in chronic kidney disease (CKD), especially in maintenance dialysis patients, deserved attention as well. Specific therapeutic principles apply to disaster-related kidney problems and these may differ from usual day-to-day clinical practice. Those approaches have been formulated in global and specific country-related guidelines and recommendations. It is clear that a well-conceived and organized management of kidney diseases in disasters benefits outcomes. Furthermore, it may be useful if the model and philosophy that were applied over the last three decades could be adapted by broadening the scope of disasters leading to intervention. Actions should be guided and coordinated by a panel of experts steering ad hoc interventions, rather than applying the "old" static model where a single coordinating center instructs and uses volunteers listed long before a potential event occurs.

TAK-242 Attenuates Crush Injury Induced Acute Kidney Injury through Inhibiting TLR4/NF-κB Signaling Pathways in Rats

BACKGROUND

To investigate if toll-like receptor (TLR) 4/nuclear factor-kappa B (NF-κB) signaling pathways mediated crush injury induced acute kidney injury (AKI) in rats, and if TAK-242 (a specific inhibitor of TLR4) attenuates the injury through inhibiting the signaling pathways.

METHODS

This study was divided into two parts: (1) Establish the crush injury model: 50 rats were randomly divided into control group and four crush injury groups (n = 10/group). Crush injury groups were given 3kg pressure for eight hours and were sacrificed at the time points of 0h, 6h, 12h, and 24h after relieving pressure. And (2) Select the most obvious injury group (12h group) for drug intervention group. Thirty rats were randomly divided into control group, 12h group, and 12h+TAK-242 group (n = 10/group). Two parts detection were as follows: pathological changes of kidney tissues were observed in Haematoxylin and Eosin (HE) staining. Serum creatinine, blood urea nitrogen (BUN), myoglobin (Mb), and blood potassium were examined by automatic biochemical analysis instrument. Interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were measured by enzyme-linked immunosorbent assay (ELISA). The TLR4 messenger ribonucleic acid (mRNA), TLR4, and P65 were detected by real-time polymerase chain reaction (PCR), western blot, immunohistochemistry staining.

RESULTS

Compared with the control group, kidney tissues were damaged in crush injury groups, and most obvious in the 12h group. The level of serum creatinine, BUN, Mb, blood potassium, IL-6, TNF-α, and TLR4mRNA were increased in the crush injury groups and significantly increased in the 12h group (P <.05). The TLR4 and P65 were significantly increased in the 12h group (P <.05). Compared with the 12h group, kidney tissue damage was significantly reduced in the TAK-242 group (P <.05). The level of serum creatinine, BUN, Mb, blood potassium, IL-6, TNF-α, TLR4mRNA, TLR4, and P65 in the TAK-242 group were significantly reduced (P <.05).

CONCLUSION

The present findings conclude that TLR4/NF-κB signaling pathways mediated crush injury induced AKI in rats, and TAK-242 attenuates the injury through inhibiting the signaling pathways.

Disasters, children and the kidneys

Following disasters, children are physically, psychologically and socially more vulnerable than adults; consequently, their morbidity and mortality are higher. The risks are especially high for orphans and unaccompanied children who are separated from their families, making them frequently victims of human trafficking, slavery, drug addiction, crime or sexual exploitation. Education of children and families about disaster-related risks and providing special protection in disaster preparedness plans may mitigate these threats. Kidney disease patients, both paediatric and adult, are extra vulnerable during disasters, because their treatment is dependent on technology and functioning infrastructure. Acute kidney injury, chronic kidney disease patients not on dialysis and dialysis and transplant patients are faced with extensive problems. Overall, similar treatment principles apply both for adults and paediatric kidney patients, but management of children is more problematic, because of substantial medical and logistic difficulties. To minimize drawbacks, it is vital to be prepared for renal disasters. Preparedness plans should address not only medical professionals, but also patients and their families. If problems cannot be coped with locally, calling for national and/or international help is mandatory. This paper describes the spectrum of disaster-related problems in children and the specific features in treating acute and chronic kidney disease in disasters.

Renal Crisis in Children during Armed Conflict

Armed conflicts continue to occur in some regions of the globe, mostly in developing countries. These man-made disasters affect all segments of the population; however, some groups are more vulnerable and suffer more seriously from the unfavorable consequences of such conflicts. Among these, the pediatric population deserves special attention because they cannot protect themselves, and hence carry a higher threat of injuries and probability of death during conflicts. In addition, children who do survive the disaster are more prone to exploitation. Pediatric victims, including those who sustain acute kidney injury or those suffering from chronic kidney disease before armed conflicts, face higher risks of morbidity and mortality as a result of treatment problems, specifically limited dialysis options. Displaced children, forced to flee their homes as a result of armed conflicts, are also at risk for various health problems because they may not find ideal circumstances for disease treatment. Making preparations in anticipation of armed conflicts, such as disaster-relief scenarios and action plans, may be useful to decrease the death toll in these children, who are dependent on their caregivers for survival. Adopting principles of disaster nephrology may contribute to improved survival chances of pediatric kidney patients in chaotic circumstances.

[Expert consensus on on-site medical rescue and transfer of children in an earthquake]

Children, as a special vulnerable group, are more susceptible to severe physical injury and psychological trauma in an earthquake. The Pediatric Disaster Branch of Chinese Pediatric Society of Chinese Medical Association and the Pediatric Branch of Chinese People's Liberation Army formulated the expert consensus on on-site medical rescue and transfer of children in an earthquake. The consensus introduces the treatment principles and precautions of on-site treatment and subsequent transfer for children in an earthquake, in order to better serve children in this emergency.

Carbon Monoxide Rescues the Developmental Lethality of Experimental Rat Models of Rhabdomyolysis-Induced Acute Kidney Injury

Many victims, after being extricated from a collapsed building as the result of a disaster, suffer from disaster nephrology, a term that is referred to as the crush syndrome (CS). Recommended treatments, which include dialysis or the continuous administration of massive amounts of fluid are not usually easy in cases of such mass natural disasters. In the present study, we examined the therapeutic performance of a biomimetic carbon monoxide (CO) delivery system, CO-enriched red blood cells (CO-RBCs), on experimental animal models of an acute kidney injury (AKI) induced by traumatic and nontraumatic rhabdomyolysis, including CS and rhabdomyolysis with massive hemorrhage shock. A single CO-RBC treatment was found to effectively suppress the pathogenesis of AKI with the mortality in these model rats being improved. In addition, in further studies using glycerol-induced rhabdomyolysis model rats, the pathogenesis of which is similar to that for the CS, AKI and mortality were also reduced as the result of a CO-RBC treatment. Furthermore, CO-RBCs were found to have renoprotective effects via the suppression of subsequent heme protein-associated renal oxidative injury; the oxidation of myoglobin in the kidneys, the generation of reactive oxygen species by free heme produced from degraded-cytochrome P450 and hemoglobin-associated renal injury. Because CO-RBCs can be prepared and used at both hospitals and at a disaster site, these findings suggest that CO-RBCs have the potential for use as a novel cell therapy against both nontraumatic and traumatic rhabdomyolysis including CS-induced AKI. SIGNIFICANCE STATEMENT: After mass natural and man-made disasters, people who are trapped in collapsed buildings are in danger of acute kidney injury (AKI), including crush syndrome (CS)-related AKI. This paper reports that carbon monoxide-enriched red blood cells (CO-RBCs), which can be prepared at both hospitals and disaster sites, dramatically suppressed the pathogenesis of CS-related AKI, thus improving mortality via suppressing heme protein-associated renal injuries. CO-RBCs have the potential for serving as a practical therapeutic agent against disaster nephrology associated with the CS.

Anisodamine Ameliorates Hyperkalemia during Crush Syndrome through Estradiol-Induced Enhancement of Insulin Sensitivity

Hyperkalemia is a major cause of on-site death in crush syndrome (CS), which is more severe and common in male victims. Anisodamine is a belladonna alkaloid and widely used in China for treatment of shock through activation of α7 nicotinic acetylcholine receptor (α7nAChR). The present work was designed to study the protective effect of anisodamine in CS and the possible role of estradiol involved. Male and ovariectomized female CS mice exhibited lower serum estradiol and insulin sensitivity, and higher potassium compared to the relative female controls at 6 h after decompression. There was no gender difference in on-site mortality in CS mice within 24 h after decompression. Serum estradiol increased with similar values in CS mice of both gender compared to that in normal mice. Anisodamine decreased serum potassium and increased serum estradiol and insulin sensitivity in CS mice, and methyllycaconitine, selective antagonist of α7nAChR, counteracted such effects of anisodamine. Treatment with anisodamine or estradiol increased serum estradiol and insulin sensitivity, decreased serum potassium and on-site mortality, and eliminated the difference in these parameters between CS mice received ovariectomy or its sham operation. Anisodamine could also increase blood pressure in CS rats within 3.5 h after decompression, which could also be attenuated by methyllycaconitine, without influences on heart rate. These results suggest that activation of α7nAChR with anisodamine could decrease serum potassium and on-site mortality in CS through estradiol-induced enhancement of insulin sensitivity.

Fluid resuscitation with preventive peritoneal dialysis attenuates crush injury-related acute kidney injury and improves survival outcome

Background

In-hospital renal replacement therapy (RRT) is widely used for the treatments of acute kidney injury (AKI) in crush injury (CI) victims. This study was designed to investigate whether preventive peritoneal dialysis (PPD) is useful for renal protection in CI.

Methods

Animals received hindlimb compressions for 6 h to induce CI. Then, animals were untreated or treated with PPD and/or massive fluid resuscitation (MFR) for 8 h since the onset of compression release. Blood and renal tissue samples were collected at various time points for biological and morphological analysis.

Results

PPD attenuated lactic acidosis and reduced serum K⁺ and myoglobin levels in CI animals. In addition, PPD was effective in removing blood urea nitrogen (BUN) and creatinine, and reduced renal expressions of neutrophil gelatinase-associated lipocalin (NGAL). The combination of PPD and MFR furtherly attenuated AKI with significantly decreased histological scores (p = 0.037) and reduced NGAL expressions (p = 0.0002) as compared with the MFR group. Moreover, MFR + PPD group had a significantly higher survival rate than that in the MFR and the PPD groups (p < 0.05, respectively).

Conclusion

The use of PPD at the onset of compression release is beneficial for renal protection and survival outcome in a rabbit model of CI.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0644-0) contains supplementary material, which is available to authorized users.

Renal Failure Patients in Disasters

Disasters occur regularly, and frequently large numbers of patients treated with maintenance dialysis or with the recent onset of acute kidney injury are put at risk owing to the lack of access to dialysis care precipitating also a kidney failure disaster. The absence of necessary dialysis treatments can result in excessive emergency department visits, hospitalizations, morbidity, or an early death. Those with kidney failure are often evaluated in disaster medical locations or hospitals without nephrologists in attendance. Here we offer guidance for medical personnel evaluating such patients so that dialysis-dependent individuals can be properly assessed and managed with the need for urgent dialysis recognized. A disaster dialysis triage system is proposed. (Disaster Med Public Health Preparedness. 2019;13:782-790).

Bathroom Entrapment Leading to Cardiac Arrest From Crush Syndrome

Crush injuries have the potential to cause life-threatening systemic effects such as hyperkalemia, dysrhythmias, acute kidney injury, and renal failure. Systemic involvement is known as crush syndrome (CS) and results from tissue ischemia and muscle necrosis. This is a report of a 76-year-old female who developed a fatal dysrhythmia following release of her extremity from prolonged entrapment in bathroom safety equipment. Hyperkalemia should be presumed in any crush injury and be treated empirically and aggressively. Although tourniquet application prior to extrication is not widely recommended to prevent CS, it should be considered in prolonged extremity entrapment.

Comparison of the effects of volemic reposition with 7.5% NaCl or blood in an experimental model of muscular compression and hemorrhagic shock

Objective

Crush syndrome is characterized by traumatic muscular injuries with severe systemic clinical repercussions. The systemic inflammatory reaction characterized acutely by infiltration of neutrophils in the lungs has been studied as part of the spectrum of crush syndrome. Experimental research may demonstrate alternative treatments for crush syndrome. The authors studied the hypothesis that hypertonic saline solution (7.5% NaCl) could minimize the local and systemic effects in a model of muscular compression and hemorrhagic shock.

Methods

Rabbits were submitted to a new model of muscle compression associated with hemorrhagic shock. Compression was applied through an Esmarch bandage, used for 1 h on the entire right lower limb. Hemorrhagic shock was induced for 1 h by dissection and catheterization of the carotid artery. Blood replacement or hypertonic saline solution was used to treat the shock. Biochemical analysis of plasma, quantification of muscular edema, and infiltration of inflammatory cells in the lungs were carried out.

Results

Animals treated with hypertonic solution presented the same hemodynamic response as the blood treated patients, less water in the compressed muscles and less infiltration of inflammatory cells in the lungs. The blood group presented hypocalcemia, a facet of crush syndrome.

Conclusions

The proposed model was effective for the study of crush syndrome associated with hemorrhagic shock. The treatment with hypertonic solution showed benefits when compared with blood volume replacement.

First Rescue Under the Rubble: The Medical Aid in the First Hours After the Earthquake in Amatrice (Italy) on August 24, 2016

a. Event Type: Earthquake measuring 6.2 (SD=0.016) on the moment magnitude;

b. Event Onset: August 24, 2016 - 03:36:32 CEST (01:36 UTC);

c. Location of Event: Central Italy, in the town of Amatrice;

d. Geographic Coordinates: latitude (DMS): 42°37′45.77″N; longitude (DMS): 13°17′18.14″E; elevation: 955 meters above sea-level;

e. Dates: August 24, 2016 at 4:48 AM;

f. Response Type: Medical Relief.

Abstract

On August 24, 2016, an earthquake hit the town of Amatrice (Italy). This study aims to document the first medical aid provided to earthquake victims in Amatrice immediately following the earthquake.

Patient data were collected and recorded during the first clinical evaluation and before definitive hospitalization. Blood gas tests were performed on survivors extricated from the rubble using the iSTAT (Abbott Point of Care Inc.; Princeton, New Jersey USA) handheld blood analyzer.

Performing “victim-side” blood gas tests could provide concrete information to facilitate clinical evaluation and decision making when treating buried victims. After a natural disaster, it is essential to provide effective analgo-sedation to victims.

BlasettiAG, PetrucciE, CofiniV, PizziB, ScimiaP, PozoneT, NecozioneS, FuscoP, MarinangeliF. First rescue under the rubble: the medical aid in the first hours after the earthquake in Amatrice (Italy) on August 24, 2016. Prehosp Disaster Med. 2018;33(1):109–113.

The Use of Coupled Plasma Filtration Adsorption in Traumatic Rhabdomyolysis

Severe musculoskeletal injuries induce the release of sarcoplasmic elements such as muscle enzymes, potassium, and myoglobin in the systemic circulation. The circulating myoglobin damages the glomerulus and renal tubules. Conventional haemodialysis is not able to remove myoglobin, due to its high molecular weight (17,8 kilodaltons [kDa]). We treated four traumatic rhabdomyolysis patients with Coupled Plasma Filtration Adsorption (CPFA) in order to remove myoglobin followed by 14 hours of Continuous Veno-Venous Hemofiltration (CVVH). During the treatment, all patients showed clinical improvement with a decrease in muscular (creatine kinase [CK] and myoglobin) and renal (creatinine and potassium) damage indices. One patient, in spite of full renal recovery, died of cerebral haemorrhage on the 26th day of hospital stay.

A contrast study of the traumatic condition between the wounded in 5.12 Wenchuan earthquake and 4.25 Nepal earthquake

PURPOSE

5.12 Wenchuan earthquake and 4.25 Nepal earthquake are of the similar magnitude, but the climate and geographic environment are totally different. Our team carried out medical rescue in both disasters, so we would like to compare the different traumatic conditions of the wounded in two earthquakes.

METHODS

The clinical data of the wounded respectively in 5.12 Wenchuan earthquake and 4.25 Nepal earthquake rescued by Chengdu Military General Hospital were retrospectively analyzed. Then a contrast study between the wounded was conducted in terms of age, sex, injury mechanisms, traumatic conditions, complications and prognosis.

RESULTS

Three days after 5.12 Wenchuan earthquake, 465 cases of the wounded were hospitalized in Chengdu Military General Hospital, including 245 males (52.7%) and 220 females (47.3%) with the average age of (47.6±22.7) years. Our team carried out humanitarian relief in Katmandu after 4.25 Nepal earthquake. Three days after this disaster, 71 cases were treated in our field hospital, including 37 males (52.1%) and 34 females (47.9%) with the mean age of (44.8±22.9) years. There was no obvious difference in sex and mean age between two groups, but the age distribution was a little different: there were more wounded people at the age over 60 years in 4.25 Nepal earthquake (p<0.01) while more wounded people at the age between 21 and 60 years in 5.12 Wenchuan earthquake (p<0.05). The main cause of injury in both disasters was bruise by heavy drops but 5.12 Wenchuan earthquake had a higher rate of bruise injury and crush injury (p<0.05) while 4.25 Nepal earthquake had a higher rate of falling injury (p<0.01). Limb fracture was the most common injury type in both disasters. However, compared with 5.12 Wenchuan earthquake, 4.25 Nepal earthquake has a much higher incidence of limb fractures (p<0.01), lung infection (p<0.01) and malnutrition (p<0.05), but a lower incidence of thoracic injury (p<0.05) and multiple injury (p<0.05). The other complications and death rate showed no significant differences.

CONCLUSION

Major earthquakes of the similar magnitude can cause different injury mechanisms, traumatic conditions and complications in the wounded under different climate and geographic environment.When an earthquake occurs in a poor traffic area of high altitude and large temperature difference, early medical rescue, injury control and wounded evacuation as well as sufficient warmth retention and food supply are of vital significance.

A historical perspective on crush syndrome: the clinical application of its pathogenesis, established by the study of wartime crush injuries

Crush syndrome is a fine example of how pathology can play a direct role in revealing the best treatment and management for diseases. It can occur when crush injuries are sustained. Skeletal muscle becomes damaged under the weight of a heavy object, and victims experience severe shock and renal failure. The discovery of the pathology of crush syndrome belongs to two individuals: Seigo Minami and Eric Bywaters. They separately helped to define the pathogenesis of crush syndrome during World Wars I and II. Seigo Minami is believed to have been the first to record the pathogenesis of crush syndrome. In 1923, he described the cases of three soldiers who died of renal failure caused by crush injury during World War I. Using microscopic studies to investigate the pathology of their kidneys, he found the soldiers had died due to 'autointoxication' caused by rhabdomyolysis. This discovery was not known to Eric Bywaters, who described crush syndrome in 1941, having studied victims of the London Blitz during World War II. He defined the 'autointoxication' as the release of rhabdomyolysis products via reperfusion. He therefore established the need for emergency fluid replacement to treat crush syndrome. The findings made by Minami and Bywaters highlight a remarkable achievement in clinical pathology, despite the adversity of war. It is these findings on which current guidelines are based. By reviewing their work, it is hoped that the role of pathology can be better appreciated as a valuable resource for delineating the treatment and management of diseases.

Combined administration of anisodamine and neostigmine rescued acute lethal crush syndrome through α7nAChR-dependent JAK2-STAT3 signaling

Previously we showed that Ani (anisodamine)/Neo (neostigmine) combination produced anti-shock effect via activating α7 nicotinic acetylcholine receptor (α7nAChR). In this study, we aim to investigate the therapeutic effect and underlying mechanisms of Ani/Neo combination in acute lethal crush syndrome (CS). In rat and rabbit CS models, Ani/Neo combination increased the 24 h survival rates, improved hemodynamics and decreased the levels of creatine kinase, MB isoenzyme of creatine kinase, blood urea nitrogen, creatinine, K⁺ in serum. It also decreased the levels of H₂O₂, myeloperoxidase (MPO) and nitric oxide (NO) in serum and compressed muscle in rat CS model. In wild-type (WT) mice with CS, Ani/Neo combination increased 24 h survival rate and decreased the levels of H₂O₂, MPO, NO, TNFα, IL-6 and IL-10 in compressed muscle. These effects were attenuated by α7nAChR knockout (KO). Moreover, Ani/Neo combination prevented the decrease of phosphorylation of Janus kinase 2 (JAK2) and phosphorylation of signal transducer and activator of transcription 3 (STAT3) induced by CS. These effects of Ani/Neo in CS mice were cancelled by methyllycaconitine (α7nAChR antagonist) and α7nAChR KO. Collectively, our results demonstrate that Ani/Neo combination could produce therapeutic effects in CS. The underlying mechanism involves the activation of α7nAChR-dependent JAK2-STAT3 signaling pathway.

Activation of α7 Nicotinic Acetylcholine Receptor Decreases On-site Mortality in Crush Syndrome through Insulin Signaling-Na/K-ATPase Pathway

On-site mortality in crush syndrome remains high due to lack of effective drugs based on definite diagnosis. Anisodamine (Ani) is widely used in China for treatment of shock, and activation of α7 nicotinic acetylcholine receptor (α7nAChR) mediates such antishock effect. The present work was designed to test whether activation of α7nAChR with Ani decreased mortality in crush syndrome shortly after decompression. Sprague-Dawley rats and C57BL/6 mice with crush syndrome were injected with Ani (20 mg/kg and 28 mg/kg respectively, i.p.) 30 min before decompression. Survival time, serum potassium, insulin, and glucose levels were observed shortly after decompression. Involvement of α7nAChR was verified with methyllycaconitine (selective α7nAChR antagonist) and PNU282987 (selective α7nAChR agonist), or in α7nAChR knockout mice. Effect of Ani was also appraised in C2C12 myotubes. Ani reduced mortality and serum potassium and enhanced insulin sensitivity shortly after decompression in animals with crush syndrome, and PNU282987 exerted similar effects. Such effects were counteracted by methyllycaconitine or in α7nAChR knockout mice. Mortality and serum potassium in rats with hyperkalemia were also reduced by Ani. Phosphorylation of Na/K-ATPase was enhanced by Ani in C2C12 myotubes. Inhibition of tyrosine kinase on insulin receptor, phosphoinositide 3-kinase, mammalian target of rapamycin, signal transducer and activator of transcription 3, and Na/K-ATPase counteracted the effect of Ani on extracellular potassium. These findings demonstrated that activation of α7nAChR could decrease on-site mortality in crush syndrome, at least in part based on the decline of serum potassium through insulin signaling-Na/K-ATPase pathway.

Prevention of Crush Syndrome through Aggressive Early Resuscitation: Clinical Case in a Buried Worker

Introduction Crush syndrome, of which little is known, occurs as a result of compression injury to the muscles. This syndrome is characterized by systemic manifestations such as acute kidney injury (AKI), hypovolemic shock, and hydroelectrolytic variations. This pathology presents high morbidity and mortality if not managed aggressively by prehospital care. Clinical Case A 40-year-old worker was rescued after being buried underground in a ditch for 19 hours. The patient was administered early resuscitation with isotonic solutions and monitored during the entire rescue operation. Despite having increased plasma levels of total creatine kinase (CK), the patient did not develop AKI or hydroelectrolytic variations.

CONCLUSION

Aggressive early management with isotonic solutions before hospital arrival is an effective option for nephron-protection and prevention of crush syndrome. Mardones A , Arellano P , Rojas C , Gutierrez R , Oliver N , Borgna V . Prevention of crush syndrome through aggressive early resuscitation: clinical case in a buried worker. Prehosp Disaster Med. 2016;31(3):340-342.

Disaster nephrology: a new concept for an old problem

Natural and man-made mass disasters directly or indirectly affect huge populations, who need basic infrastructural help and support to survive. However, despite the potentially negative impact on survival chances, these health care issues are often neglected by the authorities.

Treatment of both acute and chronic kidney diseases (CKDs) is especially problematic after disasters, because they almost always require complex technology and equipment, whereas specific drugs may be difficult to acquire for the treatment of the chronic kidney patients. Since many crush victims in spite of being rescued alive from under the rubble die afterward due to lack of dialysis possibilities, the terminology of ‘renal disaster’ was introduced after the Armenian earthquake. It should be remembered that apart from crush syndrome, multiple aetiologies of acute kidney injury (AKI) may be at play in disaster circumstances.

The term ‘seismonephrology’ (or earthquake nephrology) was introduced to describe the need to treat not only a large number of AKI cases, but the management of patients with CKD not yet on renal replacement, as well as of patients on haemodialysis or peritoneal dialysis and transplanted patients. This wording was later replaced by ‘disaster nephrology’, because besides earthquakes, many other disasters such as hurricanes, tsunamis or wars may have a negative impact on the ultimate outcome of kidney patients.

Disaster nephrology describes the handling of the many medical and logistic problems in treating kidney patients in difficult circumstances and also to avoid post-disaster chaos, which can be made possible by preparing medical and logistic scenarios. Learning and applying the basic principles of disaster nephrology is vital to minimize the risk of death both in AKI and CKD patients.

Comparison of Injury Epidemiology Between the Wenchuan and Lushan Earthquakes in Sichuan, China

Objective

We aimed to compare injury characteristics and the timing of admissions and surgeries in the Wenchuan earthquake in 2008 and the Lushan earthquake in 2013.

Methods

We retrospectively compared the admission and operating times and injury profiles of patients admitted to our medical center during both earthquakes. We also explored the relationship between seismic intensity and injury type.

Results

The time from earthquake onset to the peak in patient admissions and surgeries differed between the 2 earthquakes. In the Wenchuan earthquake, injuries due to being struck by objects or being buried were more frequent than other types of injuries, and more patients suffered injuries of the extremities than thoracic injuries or brain trauma. In the Lushan earthquake, falls were the most common injury, and more patients suffered thoracic trauma or brain injuries. The types of injury seemed to vary with seismic intensity, whereas the anatomical location of the injury did not.

Conclusions

Greater seismic intensity of an earthquake is associated with longer delay between the event and the peak in patient admissions and surgeries, higher frequencies of injuries due to being struck or buried, and lower frequencies of injuries due to falls and injuries to the chest and brain. These insights may prove useful for planning rescue interventions in trauma centers near the epicenter. (Disaster Med Public Health Preparedness. 2014;8:541-547)

Wars, disasters and kidneys

This paper summarizes the impact that wars had on the history of nephrology, both worldwide and in the Ghent Medical Faculty notably on the definition, research and clinical aspects of acute kidney injury. The paper briefly describes the role of 'trench nephritis' as observed both during World War I and II, supporting the hypothesis that many of the clinical cases could have been due to Hantavirus nephropathy. The lessons learned from the experience with crush syndrome first observed in World War II and subsequently investigated over many decades form the basis for the creation of the Renal Disaster Relief Task Force of the International Society of Nephrology. Over the last 15 years, this Task Force has successfully intervened both in the prevention and management of crush syndrome in numerous disaster situations like major earthquakes.

Disaster nephrology: crush injury and beyond

Disasters result in a substantial number of renal challenges, either by the creation of crush injury in victims trapped in collapsed buildings or by the destruction of existing dialysis facilities, leaving chronic dialysis patients without access to their dialysis units, medications, or medical care. Over the past two decades, lessons have been learned from the response to a number of major natural disasters that have impacted significantly on crush-related acute kidney injury and chronic dialysis patients. In this paper we review the pathophysiology and treatment of the crush syndrome, as summarized in recent clinical recommendations for the management of crush syndrome. The importance of early fluid resuscitation in preventing acute kidney injury is stressed, logistic difficulties in disaster conditions are described, and the need for an implementation of a renal disaster relief preparedness program is underlined. The role of the Renal Disaster Relief Task Force in providing emergency disaster relief and the logistical support required is outlined. In addition, the importance of detailed education of chronic dialysis patients and renal unit staff in the advance planning for such disasters and the impact of displacement by disasters of chronic dialysis patients are discussed.