Temporary hypothyroidism in severe crush syndrome: a potential novel entity

BACKGROUND

Thyroid hormone synthesis is a complex process in the human body. Although the thyroid gland is essential for thyroid hormone synthesis, skeletal muscles also have crucial roles in thyroid hormone metabolism due to the deiodinase activities of the muscle cells. Hypothyroidism-related myopathy is a well-known entity. However, systemic effects of acute myopathies, such as rhabdomyolysis, on thyroid hormone metabolism have not to date been fully clarified.

METHODS

Fifty-three earthquake victims were evaluated retrospectively. We investigated the thyroid function tests (TFTs) among patients with creatine kinase (CK) levels higher than 10.000 U/L at admission. Fifteen patients had CK levels higher than 10.000 U/L and 12 of them had data of TFTs, including thyroid stimulating hormone (TSH), free T4 (FT4), and free T3 (FT3) during hospitalization. These patients were evaluated.

RESULTS

TSH levels were increased in all seven patients who required HD due to severe crush syndrome. Decreased FT4 levels were detected in 71.4% of them. None of the five non-HD patients had increased TSH levels or reduced FT4 levels. During follow-up, all patients survived. Renal and thyroid functions were normalized during follow-up without thyroxin replacement in patients with no prior history of hypothyroidism. Moreover, TFTs were normalized in two patients with history of hypothyroidism under thyroxine treatment without dose adjustments.

CONCLUSIONS

In severe forms of crush syndrome, temporary hypothyroidism might be seen. The exact mechanism underlying this entity is not well-known. Further clinical and experimental trials should be conducted to illuminate the mechanism of disrupted thyroid hormonogenesis in crush syndrome victims.

Thromboprophylaxis in pediatric patients with earthquake-related crush syndrome: a single centre experience

PURPOSE

Injuries increase the risk of venous thromboembolism (VTE). However, the literature on the management of anticoagulant therapy in pediatric patients with crush injury is limited. In this study, we aimed to share our experience about anticoagulant thromboprophylaxis in pediatric patients with earthquake-related crush syndrome.

METHODS

This study included patients who were evaluated for VTE risk after the Turkey-Syria earthquake in 2023. Since there is no specific pediatric guideline for the prevention of VTE in trauma patients, risk assessment for VTE and decision for thromboprophylaxis was made by adapting the guideline for the prevention of perioperative VTE in adolescent patients.

RESULTS

Forty-nine patients [25 males and 24 females] with earthquake-related crush syndrome had participated in the study. The median age of the patients was 13.5 (8.8-15.5) years. Seven patients (14.6%) who had no risk factors for thrombosis were considered to be at low risk and did not receive thromboprophylaxis. Thirteen patients (27.1%) with one risk factor for thrombosis were considered to be at moderate risk and 28 patients (58.3%) with two or more risk factors for thrombosis were considered to be at high risk. Moderate-risk patients (n = 8) and high-risk patients aged < 13 years (n = 11) received prophylactic enoxaparin if they could not be mobilized early, while all high-risk patients aged ≥ 13 years (n = 13) received prophylactic enoxaparin.

CONCLUSION

With the decision-making algorithm for thyromboprophylaxis we used, we observed a VTE rate of 2.1% in pediatric patients with earthquake-related crush syndrome.

Zinc chelator treatment in crush syndrome model mice attenuates ischemia-reperfusion-induced muscle injury due to suppressing of neutrophil infiltration

In crush syndrome, massive muscle breakdown resulting from ischemia-reperfusion muscle injury can be a life-threatening condition that requires urgent treatment. Blood reperfusion into the ischemic muscle triggers an immediate inflammatory response, and neutrophils are the first to infiltrate and exacerbate the muscle damage. Since free zinc ion play a critical role in the immune system and the function of neutrophils is impaired by zinc depletion, we hypothesized that the administration of a zinc chelator would be effective for suppressing the inflammatory reaction at the site of ischemia-reperfusion injury and for improving of the pathology of crush syndrome. A crush syndrome model was created by using a rubber tourniquet to compress the bilateral hind limbs of mice at 8 weeks. A zinc chelator N,N,N',N'-tetrakis-(2-pyridylmethyl)-ethylenediamine (TPEN) was administered immediately after reperfusion in order to assess the anti-inflammatory effect of the chelator for neutrophils. Histopathological evaluation showed significantly less muscle breakdown and fewer neutrophil infiltration in TPEN administration group compared with control group. In addition, the expression levels of inflammatory cytokine and chemokine such as IL-6, TNFα, CXCL1, CXCL2, CXCR2, CCL2 in ischemia-reperfusion injured muscle were significantly suppressed with TPEN treatment. Less dilatation of renal tubules in histological evaluation in renal tissue and significantly better survival rate were demonstrated in TPEN treatment for ischemia-reperfusion injury in crush syndrome. The findings of our study suggest that zinc chelators contributed to the resolution of exacerbation of the inflammatory response and attenuation of muscle breakdown in the acute phase after crush syndrome. In addition, our strategy of attenuation of the acute inflammatory reaction by zinc chelators may provide a promising therapeutic strategy not only for crush syndrome, but also for other diseases driven by inflammatory reactions.

[Hepatoprotective properties of cytochrome C in traumatic toxicosis]

Experiments on rats showed that traumatic toxicosis (crush syndrome) was accompanied by disorders of both excretion and detoxication functions of the liver and a decrease in the energy potential of the liver. Systemic administration of cytochrome C (10 mg/kg) immediately after trauma and decompression increased the level of endogenous cytochrome C, recovered the pool of adenine nucleotides, normalized bromsulfaleine excretion from the blood, and decreased the content of toxic metabolites in the blood. The obtained experimental data show that cytochrome C possesses high hepatoprotective properties with respect to the development of traumatic toxicosis.

[Efficacy of cytoflavine in treating traumatic toxicosis]

Experiments on rats showed that traumatic toxicosis (crush syndrome) was accompanied with hypotension, bradycardia, reduction in temperature, breath frequency, and oxygen intake, and violation of acid-base buffer state with elevation of lactate acidosis in the blood serum that is typical of shock performance. Substrate combined antihypoxant cytoflavine (1.5 ml/kg) administered systemically to rats immediately after decompression, increased percentage of survived rats and recovered the main indexes of functional systems and acid-base buffer state 12 h after trauma, which provided general protection of rats against traumatic toxicosis.

[Treatment for crush syndrome of extremities with antioxidants]

OBJECTIVE

To study the clinical therapeutic effect of antioxidants assistant treatment of extremities crush syndrome (CS)in order to find new therapy.

METHODS

Twenty-one male patients (aged from 24 to 48 years, mean 36 years) were treated with the next antioxidants in early stage: (1) 20% Mannitol 250 ml intravenous drip in 30 minutes (one time per 6 to 8 h). (2) Sodium aescinate 20 mg, Salvia Miltiorrhiza 20 ml were dissolved respectively in isotonic saline or 5% glucose 200 ml and dripped by intravenous drip (50 to 60 drips per minute). The drugs were used for 5 to 7 days (one time per day). Basifying urine, keeping the nagative liquid banlance and electrolyte banlance, preventing infection and hold out treatment were done. When the pressure of muscular osteofascial compartment was more than 30 mmHg, deep fasia was cut to decompress timely and the above-mentioned drugs were continuously applied for patients.

RESULTS

Myoglobin urine of 21 cases died out after 2 to 3 days, of them, 13 cases were performed to decompress. After open decompression, 2 cases suffered from amputation because of long time of ischemia, 2 cases took place slight dysfunction of lower limbs, one hand had ischemia muscular contracture in 1 case and one foot down-vertical in 1 case. After followed-up of 8 months to 1 year, according to the function standard, the result were excellent in 8 cases, good in 7 cases, fair in 2 cases, poor in 4 cases. The excellent and good rate was about 71.4% (15/21).

CONCLUSION

After extremities crushed for long time, application of antioxidents as early as possible can decrease significantly the incidence and invalidity rate of CS.

Pregabalin does not impact peripheral nerve regeneration after crush injury

Timely repair and robust regeneration after traumatic peripheral nerve injury are essential to ensure optimal recovery. Pregabalin (Lyrica; Pfizer Inc., Morris Plains, NJ), frequently prescribed to attenuate neuropathic pain in patients with traumatic nerve injury, was evaluated for its potential to alter nerve regeneration in the rat sciatic crush model. Rats were randomly assigned to one of three groups of 12 animals each: (1) sham surgery and pregabalin injections; (2) crush injury and pregabalin injections; and (3) crush injury and saline vehicle injections. Nerve regeneration was evaluated with weekly walking tracks and histomorphometry. There were no significant differences in sciatic function index or histomorphometric parameters at the 21-day endpoint between the pregabalin-treated rats undergoing crush injury and the saline-treated controls. Although we have observed a subjectively improved clinical course in human patients treated with pregabalin after traumatic nerve injury, the effect does not appear to be due to accelerated nerve regeneration.

Proline-rich polypeptides in Alzheimer's disease and neurodegenerative disorders -- therapeutic potential or a mirage?

The development of effective and safe drugs for a growing Alzheimer disease population is an increasing need at present. Both experimental and clinical evidence support a beneficial effect of proline-rich polypeptides in a number of neurodegenerative diseases, including Alzheimer disease. Experimental data have shown that proline-rich polypeptides isolated from bovine neurohypophisis possess neuroprotective and neuromodulatory properties in mice with aluminum neurotoxicosis or neuronal damage caused by venoms and toxins. Proline-rich polypeptides from ovine colostrums, so called Colostrinin, have been shown to produce cognitive improvement in an experimental model and in patients with Alzheimer disease. However, the precise mechanism underlying the neuroprotective action of proline-rich polypeptides is not very well established. Moreover, studies pointing at a neuroprotective effect of proline-rich polypeptides from bovine neurohypophisis in humans have not been reported thus far. The authors conclude that more detailed information on the mode of action of proline-rich polypeptides is needed as well as confirmation of their efficacy in broad clinical trials before this approach can really show its potential in the treatment of neurodegenerative disorders.

[Effects of ionol, alpha-tocopherol and lipin on the processes of peroxidation in the syndrome of prolonged crush]

Experimental investigations of the influence of ionol and alpha-tokoferol in combined usage and liposomes on the processes of lipids peroxidation in the heart and blood at the cellular and subcellular level during crunch syndrome were made. The injection of ionol and alfa-tokoferol combined and lipid decreases the production of lipids peroxidation and increase antioxidation organism status and as a result the survival abilities of animals. These data, refected antioxidation provision of the heart and blood under crunh syndrome at the cellular and subcellular levers are given. Low antioxidation provision of the heart must be taken in consideration, that grounds the necessity of taking into account of the antioxidation cellular defence modulations factors under the complex therapy working out.

[The liver monooxygenase system activity in the long-term compression syndrome and treatment with benzonal in prepubertal rats and rabbits]

A compression syndrome was reproduced in rats and rabbits aged one month. Efficacy of the benzonal treatment in the postcompression period was evaluated by measuring the parameters of antipyrin pharmacokinetics, hexenal sleep duration, and the level of medium-molecular-weight (MMW) peptides in the blood serum. It was established that benzonal restored the detoxicating liver function (significantly reduced in animals with the compression syndrome) and eliminated the pronounced endotoxemia manifestations.

[Phytin efficacy in correction of the impaired detoxication liver function in the long-term compression syndrome in rats in prepubertal period]

The compression syndrome was reproduced in rats aged one month and the efficacy of phytin in correcting the activity infringement and restoring the content of basic components of the hepatocyte monooxygenase enzyme system was studied in the postcompression period. The compression led to pronounced inhibition of the activity of aniline hydroxylase and amidopyrine M-demethylase, reduced the content of liver microsomal protein and cytochromes P-450 and b5, and increased the level of medium- molecular-weight (MMW) peptides in the blood serum. A six-day treatment with phytin restored the normal level of the liver monooxygenase system components and MMW peptides. Phytin reduced the level of lactic acid (LA) and increased that of pyruvic acid (PA) in liver tissues, which led to a sharp drop in the LA/MA ratio indicative of a decrease in the extent of hypoxia.

[Antihypoxants in emergency medicine]

Presents the results of many-year experimental studies, clinical trials, and medical use of drugs of a new pharmacological class: antihypoxants. Antihypoxants are perspective drugs of urgent medicine, which was demonstrated on various models (all types of hypoxia, myocardial, brain, renal, and liver ischemia, grave mechanical and thermal injuries, blood loss, etc.) and in patients with these states.

Amantadine treatment of a patient with anoxic brain injury

An 18-year-old boy with anoxic brain injury, suffering from severe psychomotor inhibition, tetrarigidity and dystonia, was treated with amantadine in order to ameliorate his symptoms. Neuropsychological tests showed improvement in motor and cognitive functions.

[Effect of liposomes on lipid peroxidation in the heart and liver in crush syndrome]

The increased lipid peroxidation has been determined to be one of general mechanisms of disturbance in the functional state of the heart and liver fraction cells, regularities of inter-system disturbance in metabolic activity under the crush syndrome have been revealed. Administration of lecithin liposomes results in the decreased POL levels, increased antioxidant capacity of the organism. That permits recommending to include liposomes into complex therapeutics of the crush syndrome as detoxicating, antiinflammatory and antihypoxic drug.

[The expediency of the clinical use of prostaglandin E2 for treating acute renal failure]

The effect of exogenous prostaglandin (PG) E2 ("PROSTENON") on the renal function and some metabolic parameters have been studied in 10 dogs with acute renal failure (ARF) caused by the crush-syndrome. It has been shown that intravenous PGE2 at a dose of 0.25 mg/kg 1 h after relief of soft tissue compression leads to prompt and stable recovery of all the renal functions under study, normalises metabolism and promotes the survival of animals. However, side effects of the drug have been revealed: blood pressure decrease and induction of vomiting effect and diarrhea. Critical analysis of the literature data has shown that, despite positive PGE2 effect on the renal function in ARF, prostenon, because of its immunosuppressive properties, cannot be used in the clinical practice for the treatment of this pathology. It is suggested that PGE2 be widely used in transplantology.

[Experimental prostaglandin E2 therapy of acute kidney failure due to the crush syndrome]

It has been shown for the first time that intraaortal injection of PGE2 to dogs with acute renal failure caused by the crush syndrome makes renal function (glomerular filtration, tubular reabsorption, renal plasmaflow, maximal tubular secretion, minute and diurnal diuresis) return to normal.

[Use of liposomes as a nonspecific detoxifier in the crush syndrome]

The possibility of parenteral detoxification was studied in dogs with the experimental crush syndrome. Infusion of lecithin liposomes (25 and 50 mg/kg) prevented the development of postcompression toxemia and hemodynamic disorders characteristic for endogenous intoxication. The use of the nonspecific parenteral sorbent lecithin liposomes permitted the maintenance of an adequate function of the animals' cardiovascular system for 5 hours after decompression.

[Effect of serotonin on the lysosomal apparatus of liver cells and on hydrolase activity in the blood in severe mechanical injury]

A study was made of the pattern of changes in overall and non-sedimented activity of lysosomal hydrolases of the liver of rats injected with serotonin under grave mechanical trauma. Lability of the lysosomal membranes was found to be twice as increased, with remarkable hyperfermentemia being seen starting from the 3rd hour of compression in the presence of an appreciable rise of overall enzymatic activity. The role of serotonin in the mechanism of exocytosis of lysosomal enzymes is discussed.