https://orcid.org/0009-0008-7823-5789
Abstract
Crush trauma of extremities, resulting from a crushing force, can be life-threatening even without involving vital organs. Crush syndrome, or traumatic rhabdomyolysis, occurs when muscle cell breakdown releases contents into the bloodstream, leading to systemic complications like acute renal failure. A 35-year-old woman trapped under rubble during11 hours during a seismic event, presenting with compartment syndrome in her left arm and thigh and crush syndrome. Emergent fasciotomy and aggressive fluid resuscitation were performed, preventing renal failure and metabolic derangement. Post-fasciotomy, pulses returned to her affected limbs. She was extubated and moved to the ICU under close surgical supervision. Early, aggressive resuscitation is critical, ideally before extrication, to minimize complications. Awareness of hyperkalemia and acute renal failure risk post-extrication is essential. Continuous fluid resuscitation is the cornerstone of treatment, and prompt fasciotomies are crucial for compartment syndrome management.
Introduction
Every year, millions of people worldwide are confronted with primary disasters of natural such as earthquakes [1]. The earthquake of 2023 that struck Turkey, Syria, and Morocco has led to the deaths of more than 50 000 people [2]. Emergency physicians play a crucial role in assessing and treating those impacted by such catastrophic events and are often tasked with managing patients suffering from crush syndrome.
Extremity crush trauma, even if it does not engage vital organs, can be potentially life-threatening. Crush trauma is defined as injury caused by crushing force. Crush syndrome is a systemic condition of muscular cell degradation, releasing its components into the blood circulation [3]. Bywaters and Beall described crush syndrome for the first time after the Battle of London in 1941. Survivors pulled from the rubble initially appeared healthy, but later suffered from increasing limb swelling and circulatory collapse. Tragically, kidney failure claimed their lives within days [3]. An autopsy revealed muscle death and brownish pigment deposits within their kidney tubes [4]. Crushing injuries are common during natural disasters like earthquakes, due to the forceful impact on the body from external forces [5].
We report the case of a 35-year-old female victim of the Marrakesh earthquake (September 2023) who presented to the emergency department with crush syndrome.
Case report
A 35-year-old female with a history of recurrent miscarriages was brought to the emergency after she was trapped for 11 hours during an earthquake. Upon arrival, medical staff found the following vitals: Blood pressure: 100/40 mmHg, Heart rate: 137 beats/min, Temperature: 37.2°C, Respiratory rate: 26 breaths/min and Oxygen saturation: 96%. The Glasgow Coma Scale was assessed, yielding a score of 14/15 (patient confused).
Physical examination revealed significant swelling with ecchymosis and muscle tension in the left arm and thigh. Total functional impairment was noted, and peripheral pulses were challenging to discern in the traumatized limbs. Cervicofacial examination showed facial swelling in the left parotid region.
Laboratory findings were remarkable for hemoglobin of 17.6 g/dl, hematocrit of 53.3%, white blood cell count of 41 630 cells/ml, and platelets of 396 000/mm3. Electrolyte abnormalities included blood urea nitrogen at 0.43 g/l, creatinine at 18.87 g/l, potassium at 5.89 mmol/l sodium at 138.4 mmol/l, chloride at 112.8 mmol/l, calcium at 84.44 mmol/l, phosphorus at 67.24 mmol/l., Additional laboratory results included alanine aminotransferase at 185 IU/l, and aspartate aminotransferase at 538 IU/l. Arterial blood gas analysis showed metabolic acidosis with a pH of 7.19, bicarbonate of 9.11 mmol/l, and PaCO2 of 21.3 mm Hg. The initial creatinine kinase was 42 670 IU/l, and lactate dehydrogenase was 3325 IU/l.
Head computed tomography and abdominal ultrasound showed no signs of acute injury or pathology.
The trauma team immediately began resuscitation efforts, establishing two intravenous lines. Upon admission, the patient received an agressive vascular filling by isotonic saline and was promptly transported to the operating room for fasciotomy incisions on the left upper and lower limbs. Massive fluid resuscitation continued for the first 24 hours, with a total of 12 liters of 0.9% normal saline administered.
Emergent fasciotomies were performed on the left lower extremity and left upper limb in the operating room (Fig. 1). After the procedure, the patient remained intubated and was transferred to the chirurgical intensive care unit (ICU). After fasciotomies (Fig. 2), pulses returned to the left upper and lower extremities, with close monitoring by the surgical team.
Immediate postoperative image of fasciotomies performed with tension sutures, illustrating precise surgical closure and tissue tension management.
Image of fasciotomies a few days post-operation during the course of intensive care evolution.
Diuretic treatment (furosemide) was initiated after massive fluid resuscitation and in the face of persistent oliguria. Hemodialysis was subsequently performed on the same day of admission, with a total of 9 hemodialysis sessions conducted during the stay in ICU.
The patient stayed in ICU for 25 days, and her overall evolution was favorable. There was normalization of biological parameters; renal function and creatine kinase (Fig. 3 and 4). She was referred to plastic surgery for further.
Evolution of creatinine kinase (UI/l).
Evolution of urea and creatinine.
Discussion
Crush injury from direct trauma and compression it can damage body tissues, including muscles, nerves, and bones [6]. In seismic events, building collapse causes crush injuries in 3%–20% of casualties, mainly affecting legs (74% of cases), followed by arms (10%) and torso (9%) [7]. Entrapment necessitates specialized rescue teams during large-scale trauma events. Time under rubble correlates with morbidity and mortality, emphasizing prompt extrication within 24 hours, especially for vulnerable populations like children and the elderly [6]. Approximately 20% of earthquake-related deaths occur shortly after extrication, termed rescue death, due to reperfusion-induced cardiac dysrhythmias.
Crush syndrome, prevalent in severe crush injuries, poses significant risks. Symptoms like high blood pressure, oliguria, swelling, difficulty breathing, and nausea/vomiting suggest crush syndrome. Warning signs that someone might have crush syndrome include rapid heart rate, unusual urine color, a high white blood cell count, and high potassium levels in the blood [6]. Fluid resuscitation aims to prevent acute kidney injury, with ongoing hemorrhage assessment. Hyperkalemia management includes calcium, insulin/glucose, and sodium bicarbonate, while severe acidemia may require bicarbonate infusion and hemodialysis [8].
Compartment syndrome in severe crush injuries requires early identification and treatment, including fasciotomy [4, 6].
Clinicians need to evaluate for several signs and symptoms suggestive of compartment syndrome. These include severe pain (whether at rest or with movement), swelling, tingling or numbness (paresthesias), changes in skin color (pale or dusky), and weak pulses. Delays in a surgical procedure called fasciotomy can lead to permanent nerve and blood vessel damage, potentially resulting in limb loss. While fasciotomy is the primary treatment, it’s not recommended as a preventative measure due to potential complications like amputation, bleeding, nerve problems, and infection [6]. Other steps can help reduce pressure within the muscle compartments, such as intravenous fluids, pain medication, elevating the affected limb above the heart, realignment of any fractures or dislocations, and removing restrictive dressings or splints. In some cases, a medication called mannitol may be used to further decrease pressure and muscle swelling, potentially improving movement and reducing pain and swelling in the limb. Consider mannitol for elevated pressures not yet meeting fasciotomy criteria, barring contraindications [9].
This case report is significant as it demonstrates the complex, multidisciplinary management required for severe crush injuries and crush syndrome following a seismic event.
Acknowledgements
We thank all the clinical staff who participated in treating the patient.
Conflict of interest
The authors declare no conflicts of interest.
Funding
This research did not receive any specific grant funding from public, commercial, or non-profit organizations.
Ethical approval
Ethical approval from an ethics committee or institutional review board was not required for this study.
Consent
Written informed consent was obtained from the patient for publication of this report, as per the journal’s patient consent policy.
Guarantor
Ali ZIDOUH. Anesthesiology, Intensive Case and Emergency Department, University Hospital Mohammed VI of Marrakesh BP2360 Principal, Av. Ibn Sina, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakesh, Morocco. Mail: [email protected]
