Crush syndrome mainly affects accident victims and disaster victims. Crushing or injury to muscles causes muscle tissue to necrotize as part of the phenomenon and can cause kidney failure or liver failure as it progresses. Treatment at the scene of the accident significantly affects the prognosis for crush syndrome.
What is crush syndrome?
In crush syndrome, muscle tissue disintegrates as a result of necrotic injury to major sections of skeletal muscle. The phenomenon is also known as myorenal syndrome or Bywaters disease. In crush syndrome, the disintegration of the muscles results in acute renal or hepatic insufficiency. Therefore, the syndrome is also referred to as a systemic disease. Necrosis in this phenomenon affects the entire organism and especially the organ system of the affected person. By necrosis, physicians mean the irreversible destruction of cells in body tissues. This cell death is caused by inflammation of the affected areas, which attracts phagocytes. Thus, apoptosis, or programmed cell death, also takes place in necrotic tissue. Crush syndrome is particularly relevant to accident and emergency medicine and disaster relief. Eric Bywaters described the syndrome in 1941 in patients who had fallen victim to the London Blitz air raid. Japanese physician Seigo Minami documented the crush syndrome as early as 1923.
Causes
Crush syndrome is most commonly seen in connection with earthquakes and other environmental disasters. Victims usually suffer from muscle contusions that cause muscle necrosis. However, mechanical muscle injuries from accidents can also trigger the syndrome. The same is true for oxygen deprivation, which can occur in the context of carbon monoxide poisoning from a fire scenario. When muscle tissue perishes, the muscle protein myoglobin is released. Although many sources suggest this protein is the cause of renal and hepatic failure, this relationship has not yet been conclusively established. Thus, systemic organ failure may also be caused by shock-induced decreased organ perfusion. In the context of shock, for example, many accident, earthquake, and fire victims suffer from a lack of circulating blood volume. The heart‘s pumping capacity decreases and its vascular tone is reduced. In this way, hypoxia can occur in the organs.
Symptoms, complaints, and signs
Signs of shock are most noticeable in patients with crush syndrome. Parts of the skeletal muscles are crushed and develop muscle necrosis. After blood flow is restored, reperfusion trauma occurs. As part of this phenomenon, muscle cells break down, releasing potassium, phosphorus, and myoglobin. Analogously, the blood level of all the above substances increases. Often, enormous hyperkalemia sets in, which can be accompanied by cardiac arrhythmias. In addition, liver cells often die after blood flow is restored, causing icterus in the liver tissue. Kidney tissue is also affected by cell death in crush syndrome. If the affected person does not receive professional care, death sets in within a very short time. Shortly before death, the patient appears to be almost entirely asymptomatic. Therefore, crush syndrome is often associated with the term smiling death.
Diagnosis and course
The initial suspected diagnosis of crush syndrome is ideally made by first responders. At the latest, emergency physicians recognize the phenomenon by eye. In the hospital, blood tests can confirm the initial tentative diagnosis. In crush syndrome, the prognosis depends primarily on the initial treatment after the accident. If the wrong treatment is given at the scene of the accident or in the hospital, the phenomenon can have a fatal outcome. If there are no signs of kidney failure or liver failure at the scene of the accident, this can change within a very short time during the course of the disease. Proper treatment prevents serious organ damage as a result of muscle necrosis and thus improves the prognosis.
Complications
Various complications may occur during and after the onset of crush syndrome. For example, the clinical picture can lead to multiple organ failure, depending on the location and severity of the injuries. Initially, however, muscle necrosis occurs as part of crush syndrome, triggered by the damaged skeletal muscles and other trauma.If blood flow to the muscles is restored, reperfusion trauma may occur, which is associated with muscle cell breakdown and the release of potassium, myoglobin and phosphorus. As a result, the blood level of the above substances increases, aggravating existing cardiac arrhythmias and other circulatory problems. Often, the patient also develops so-called hyperkalemia, a disturbance in the electrolyte balance of the body, which is associated with fluctuations in blood pressure and heart attacks. As a result of major crush injuries, the blood supply to vital organs is also restricted, which in the course of time can lead to jaundice in the liver or kidney tissue, for example. If left untreated, crush syndrome leads to the death of the patient within a short time. If the affected person is treated before organ failure occurs, crush syndrome can often be treated without severe complications; if renal failure or liver failure is already present, permanent damage is likely.
When should you see a doctor?
In the event of an accident involving serious injuries, the emergency physician must be called immediately. First responders should first check whether the injured are conscious and then initiate appropriate first aid measures or wait for medical assistance. In the case of visible muscle or bone injuries, crush syndrome may be present – it is essential to refrain from self-treatment in this case. If not already done, a physician must be called in immediately, especially if there are signs of cardiac arrhythmia or multiple organ failure. The affected person should ideally be taken immediately to the nearest hospital or the ambulance service should be alerted. A longer hospital stay is necessary in any case, since crush syndrome is almost always based on severe internal and external injuries. The affected person requires comprehensive medical and physiotherapeutic treatment. In most cases, psychological counseling or trauma therapy is also necessary. It is recommended to plan the necessary steps together with the responsible physician and a trusted person. Close monitoring of injuries is indicated in crush syndrome.
Treatment and therapy
Treatment of crush syndrome begins at the scene of the accident. The behavior of first responders and emergency physicians is all-important to the victim’s prognosis. Crushed limbs must be ligated as quickly as possible. As a blood volume substitute, patients are administered an infusion that preferably does not contain any potassium. If the victims are buried or heavy objects on their limbs cause necrosis, ligation of the affected areas of the body is done before the victims are extricated. The same applies to the supply of the potassium-free infusion solution and the administration of sodium bicarbonate. If these principles are not followed, smiling death may occur immediately after liberation. In fact, by restoring blood flow, the cardiovascular system is overwhelmed in the worst case scenario and thus experiences a fatal shock. In the emergency room, patients are ECG-monitored. Their blood electrolytes are regularly rechecked in a blood gas analysis and their infusion continues at around 1.5 liters every hour. Thus, victims will be saved from hypotensions, renal insufficiencies, acidosis and hyperkalemia or hypocalcemia. Wounds are treated surgically in the hospital. Surgical care is combined with the administration of antibiotics and tetanus protection.
Outlook and prognosis
The prognosis for crush syndrome varies from case to case. Relevant factors include the rapid onset of proper treatment and care of the wounds and the amount of tissue damaged. Damage to the kidneys caused by crush syndrome can have different effects. Both kidneys may fail completely, or at least one may still retain function. It is similar with the liver: some people’s livers survive the effects of rhabdomyolysis better than others. The same is true of the effects of any resulting shock. Whether and to what extent the externally injured areas can be restored – to the extent that crush syndrome has such an underlying cause – also depends on the extent of compression. Anything from surgical reconstruction to medically indicated amputation is possible.Rapidly recovered patients should be cared for in a way that prevents their bodies from being overloaded with degradation products of necrosis. If the various strategies are applied here, the chances for survival are good. However, the aspects to be monitored extend across the circulatory system, renal function, any secondary damage, trauma and more. Moreover, in combination with the trigger of a crush syndrome, it is not uncommon for compartment syndrome to occur even after the fact.
Prevention
Theoretically, crush syndrome can occur after any type of accidental muscle necrosis. For prevention, ligation of the affected limb immediately after the accident is a critical step. Blood volume administration should also be mentioned as an important preventive measure in this context.
Aftercare
In most cases, those affected by crush syndrome have no or only very few aftercare measures available to them. In most cases, the further measures and further treatment depend very much on the exact accident and the extent of the injuries, so that no general prediction can be made. Frequently, the life expectancy of those affected by the crush syndrome is also extremely reduced. First and foremost, the victim must be treated and cared for directly at the scene of the accident to prevent further complications or other ailments. Treatment of the syndrome itself is primarily through the administration of medication. The affected person should always make sure to take the medication regularly and also the appropriate dosage so that the symptoms can be alleviated. Regular examinations of the internal organs must also be carried out so that damage to the internal organs can be detected at an early stage. Since crush syndrome often requires the use of antibiotics, sufferers should take care not to take them together with alcohol. Similarly, hourly checks of blood levels are necessary to prevent renal insufficiency.
What you can do yourself
Crush syndrome can cause serious complications and long-term symptoms. The most important self-help measure is to support recovery with physical therapy and physiotherapy in consultation with the physician. The patient can also engage in moderate sports, insofar as this is compatible with the state of health and the individual injuries. In general, all measures that take place away from medical treatment should first be discussed with the family doctor. In this way, self-help can be optimally coordinated with any medical, surgical or physiotherapeutic treatment. After an operation, strict adherence to the doctor’s instructions applies. Whether and to what extent physical activity is possible must be decided by the physician based on the individual course of recovery. Crush syndrome often occurs in connection with an accident. Trauma therapy can help to process the triggering event and thereby also give courage for physical self-help. If this is not possible because of severe injuries, long-term therapy is necessary. Talks with other affected persons are a supportive measure. The physician can establish contact with a self-help group and give further tips on how to deal with the condition. Crush syndrome itself usually presents sufferers with a lifetime of physical discomfort, which must always be individually recognized and treated.
