LONG – TERM SMASH TISSUE SYNDROME (CRUSH-SYNDROME)

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LONG TERM SMASH TISSUE SYNDROME(CRUSH-SYNDROME)

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• Long term smash tissue syndrome is a kind of
  traumatic pathology, which arises after long
  term crushing soft tissues of limbs by destroyed
  buildings, stones, ground. There are other
  synonyms long-term crumple syndrome,
  crush-syndrome, traumatic compress, also
  recirculative syndrome.

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The are following versions of the long-term smash
tissue syndrome

• By influence mechanism
• - crush
• - direct pressing
• - positional pressing
• By localization of force
• - Thorax
• - Abdomen
• - Pelvis
• - Hand
• - Forearm
• - Brachium
• - Foot
• - Crus
• - Femur

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• 3. By combinations of injures
• - Internal organs
• - Bones
• - Joints
• - Main arteries
• - Nerves
• 4. By complications
• - Limb ischemia (compensative, non-compensative,
  non-reverse)
• - Inner organs and systems (pneumonia, heart
  infarction, lungs swelling, fat embolism, etc).

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• 5. By degree of critically
• Easy
• Middle
• Hard
• 6. By periods of compression
• Early
• Middle
• Late.
• 7. By present of combined injuries
• Blood loss
• Burns, frostbite
• Barotraumas
• Radiation sickness
• Intoxication (poisoning) of chemical substances.

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There are three periods of long-term smash tissue
syndrome, those are distinguished in a clinics

• Early shock manifestation (till third day after
  trauma)
• Intermediate manifestates by acute renal
  insufficiencia
• Late, or a period of convalence (a beginning of
  second week till 1 2 month).

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• After shock an intermidiate or light period
  begins. It can be also in a hard form, and those
  can lead to death. A condition of a patient
  getting better, there is no pain, normalization
  of a pulse and blood pressure are observed, body
  temperature is 37,6 38,5 C an olyguria
  registates.

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• Next period of long-term smash tissue syndrome
  manifestates till 4 5 day after trauma with
  acute renal insufficient (dyshydria,
  hyperazotemia, hyperpotassiumemia, increasing of
  metabolic acidosis). Diuresis gets shorter till
  critical level (30 20 ml/h). Also there are
  anemia, hyposodiumemia, hypocalciumemia, and
  albumen contents get down till 5 0,1 g. An
  acute renal insufficient can be observed also at
  those cases, when there is no shock.

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• At the end of long-term smash tissue syndrome
  during a convalence period functions of kidney
  renew other organs, a water-electrolytic balance
  are normalizes.
• Anaesthetization should be given at first medical
  care, before getting out from ruins and stones.
  Ketaminum is used very often in prehospitalic
  anaesthetization it combines with seduxenum
  effectively an analgesic effect manifests in a
  doses 0,1 1 mg/kg per body weight after
  intravenous introduction.

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• The first specialist who had singled out shock
  was Le Dran (1737). He described the symptoms and
  introduced the term shock (stroke, shake, jolt)
  and treated the patients with rest, alcohol and
  opium.

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• There are two mechanisms in the pathogenesis of
  the long term smash tissue syndrome first is
  forced crumpling of soft tissues with long-term
  ischemia and second is destroying of anatomic
  structures closed or opened types.

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• The syndrome belongs to one of traumatic diseases
  and it has universal nonspecific reactions of
  organism on a trauma. The reaction of central
  nervous system and violation of microcirculation,
  which in the hardest cases develop as a shock are
  on the first place. They develop on the very
  beginning of factor activity and continue after
  its cessation a toxemia and plasmorrhagia
  increasing.

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• Generalized and long-term process of micro
  circulative violations cause globules formation
  of fat and micro thrombus in the micro vessels
  gap, after resuming of hemodynamics a large
  quantity of this globules spread with blood
  flowing in different organs and tissues. The
  obstruction of tissue micro circulative system
  promotes a disorganization of brain, lungs,
  liver, kidneys work long-term smash tissue
  syndrome is many-sided, intricate for diagnosis.

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• Pathological result of direct cells destroying
  appears immediately, but during ischemic injuring
  of muscle result appears some hours later. Since
  middle term of ischemic death of striated muscles
  is near six hours, so the cause of early necrosis
  (first hours) is mechanical factor, but in the
  later period is hypoxya. Because of direct tissue
  destruction intra cellular substances get into
  blood during the compressive-ischemic muscle
  injuring in the most cases ischemic toxin
  penetrate into system of blood flowing
  (metabolites of anaerobic glycolysis). In both
  cases appears destroying of blood circulation and
  breathing, but symptoms of ischemic toxins
  influence increase slowly.

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• Over dosage causes not desired anesthesia till
  time of patients getting into the hospital. It
  hardens diagnostics by loss of contact with
  patients, changing of clinical picture of
  possible craniocerebral trauma, intracavital
  injuries. In specialized emergency car it is
  possible to provide blockades (conductive) using
  local anesthetics and also inhalation of
  nitrogenium oxydulatum with oxygen (through the
  mask), trichlorineethylene, inhalation (through
  special sets). In case of opened injuries local
  anesthesia is provided to solution of novocainum
  there might be added modern antibiotics of wide
  action spectrum. It considerably improves fight
  with infection. elimination.

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• In large injuries of soft tissues, and
  especially in fractures immobilization of all
  injured limb is necessary. Its good to use
  pneumatic immobilizers, which help to prevent
  plasma loss by moderate pressing on limbs. Last
  time anti-shock pants is used with the same
  aim. During their usage pressure in abdomen and
  lower limbs is near 80 mm Hg that decreases blood
  loss in intra-abdominal bleeding. It is
  considered that these pants are effective measure
  in shock

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First aid at the crush-syndrome

• Remove the compressing factor
• Made the proximal tourniquet to prevent spreading
  of toxins for all organism
• Prescribe the narcotic analgetics to prevent the
  formation of pain shock

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• Nowadays in system of pre-hospital measures
  during crush syndrome special accent is put on
  early base infusion into the organism. But there
  must be excluded solutions containing potassium
  (Ringers, Hartmanns solutions, Lactasolum).

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• Special attention to infusion anti-shock therapy
  must be put during not fast enough transportation
  of medical group to focus of catastrophe that
  leads to late of these measures. It is needed to
  continue infusion therapy and during
  transportation (especially long-term). During
  evacuation by air transport it is needed to use
  special apparatus for infusion because during
  changes of pressure infusion therapy in air by
  usual way practically stops. During combination
  of crush syndrome with overcooling infusion
  therapy must be provided by solutions heated to
  38-40oC they provide body and limbs massage by
  special tampons with alcohol, use hot water
  bottles.

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• On the stage of hospital treatment elimination of
  hyperkaliemia it is needed to make an urgent
  intravenous infusion of hypertonic (40) solution
  of glucose (50 ml) with insulin, 10 solution of
  calcium chloride or gluconate (30 ml for 20 min.)
  If the level of potassium in blood plasma is more
  than 7 mmol/liter except glucose with insulin and
  calcium preparates it is indicated to use
  absorbents (polystiren-sulfonate, haemo- or
  peritoneal dialisis). Special attention should be
  paid to diuresis control.

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• Intensive therapy during crush syndrome is to be
  started in the earliest time, because the
  characteristic changes are formed during 5-6
  hours after trauma.

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• If the response on diuresis stimulation is
  absent, you should not prescribe furosemidum
  (lasix) or mannitum one more time, because there
  is already tubular necrosis in kidneys. For
  saving such patient there are needed
  haemoabsorbtion, haemodialisis. Large attention
  is paid to simple and safe method of detoxication
  haemo- and lymphosorbtion. During sorbtions the
  content of potassium, magnesium, phosphorum and
  some toxic substances is decreased. During
  regional haemosorbtion there are absorbed acid
  metabolites.

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• Crush syndrome of medium and high severity is an
  indication for haemosorbtion providing and
  development of acute renal insufficiency to
  start haemodialisis. During treatment of patients
  with severe form of syndrome it is necessary to
  provide both procedures. Absorption helps to
  eliminate encephalopathy, improves general
  condition, but it hardly changes level of urea
  and kreatinine in blood haemodialisis
  effectively eliminates hyperazotemia and
  hyperhydration. Haemodialisis must be early,
  regular and individual depending on catabolism
  level dangerous hyperkaliemia and hyperhydration
  are absolute indications for artificial kidney
  usage.

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Usage of hyperbaric oxygenation in complex
therapy of crush syndrome helps to eliminate
blood hypoxia, increase quantity of thrombocytes,
decrease intoxication, and improve kidneys
function. Experience of early and wide usage of
plasmapheresis in complex treatment says about
its high effectiveness of liquidation of
DIC-syndrome, providing of organisms
detoxication.
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• Early amputation is to be provided in ischemia of
  limbs of III degree when there is edema of
  injured limbs, there are absent all kinds of
  sensitivity, active and passive movements,
  despite of kept arterial pulsation. You cannot
  amputate the limb on the place of catastrophe not
  freeing it, if time of crush is less than 15
  hours.

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• From first stages of treatment systematic
  injection of highly effective antibiotics without
  nephrotoxic properties is needed. Effective
  antibiotic prophylaxis may be by usage of equal
  combinations of antibiotics, effective for most
  causative agents of wound infection. Combined
  antibiotic therapy is an important method of
  effective treatment improvement. During crush
  syndrome there is recommended usage of two
  antibiotics combination because injection of more
  remedies may have not desired consequences.

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The most adequate in crush symdrome are such
combinations of antibiotics

• Modern aminoglycosides (gentamycini sulfas,
  tobramycinum, sizomycini sulfas, amykacinum) with
  penicillines (benzylpenicillinum-natrium,
  ampicillinum, carbenicillinum, oxacillinum),
  cephalosporines (excluding ceporinum), macrolides
  (erythromycinum), tetracyclines (rondomycinum),
  antibiotics of different groups (rifampicinum,
  linkomycinum, laevomycetinum).
• Polymixinum B combined with penicillines,
  cephalosporines (excluding ceporinum),
  macrolides, tetracyclines, and antibiotics of
  different groups.

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• For prophylaxis and fight with secondary
  immunodeficiency there might be used
  immunomodulators like thymalinum, T-activinum,
  immunoglobulines.
• As a result of plasmorrhagia a hem concentration,
  decreasing of chemical and osmotic erythrocyte
  resistance, intracellular hemolisis and anemia
  appear very important is an indication of
  mioglobinemia, resistance of erythrocytes.
  Processes of hem coagulation activate during the
  long-term smash tissue syndrome, the
  concentration of heparin go down, but fibrinogen
  concentration increases. Hyper coagulation
  aggravates reological properties of blood.

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There are three stages of limb ischemia

• Compensative ischemia. There are no violations of
  micricirculation and metabolism. All movements
  are kept. Pain sensitivity is saved too. A
  tourniquet that was put on a pressed limb should
  be taken off immediately.
• Uncompensative ischemia. Pain sensitivety is
  absent. Passive movements, are free, but active
  are absent. A tourniquet be taken off, because
  ischemia continues by its pressing, and death of
  extremity can be (during 6 12 hours from the
  beginning of crumpling).
• Unreverse ischemia. Pain sensitivity is lost
  there are no active movements. Pay attention
  there are no passive movements. Dont take off a
  tourniquet. An amputation of a limb upper of a
  tourniquet is necessary.

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Its necessary to distinguish in the crush
syndrome a compression period.
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The summary

• Long term smash tissue syndrome which arises
  after long term crushing soft tissues of limbs
  by destroyed buildings, stones, ground
• First aid a/ Remove the compressing factor made
  the proximal tourniquet to prevent spreading of
  toxins for all organism prescribe the narcotic
  analgetics to prevent the formation of pain shock
• Treatment complex infusion therapy, and
  sometimes AMPUTATION OF EXTREMITES (the worse
  variant - death)