List Archives

Sun Aug 26 01:30:22 BST 2007

Sa'ad - Salaam and many warm welcomes to the trauma list.

Tim H has a good lecture on crush injury, as it pertains to the
traditional massive blunt trauma patient but also with respect to our
well-whipped victimes of community assault, and also the so-called
harness suspension syndrome.  I'm sure he can be persuaded to part
with the content of the slides.

I'm also intrigued to know the basis of the use of BSA for predicting
severity of the rhabdomyolysis and myoglobinuria that follows severe
beatings.  My teaching has been that the CK is not of clinical value
(while often being numerically impressive); creatinine is more useful,
but it is the quality of the urine that is truly imortant.

As Mark indicates, volume diuresis with alkalinisation of the urine is
the mainstay; hyperkalaemia is treated in the usual fashion.  I would
personally be avoiding fluids with potassium (eg. ringers) in this
situation.  Early consideration should be made for dialysis, where
appropriate.  The use of mannitol for additional osmotic diuresis is
controversial but has it's moments.

I'm sure Tim will have his say on the subject shortly...let's hope
something has sunk into my cerebrum despite the thickness of my
calvarium...

On 26/08/07, MARK FORREST <atacc.doc at btinternet.com> wrote:
> Dear Sa'ad
> The kinemtics and extent of the injuires will certainly put your patient
> into the high risk category for ARF and potential late death.
>
> Estimation of the injury based on the skin appearance can be very unreliable
> and in fact we have had several patients with severe rhadmyolysis, from
> lying on the floor unconscious overnight, with no skin changes in the early
> stages.
>
> The urine can be checked for myoglobin and often appears like coca-cola! CK
> levels in the thousands can develop within 6-12 hours and continue to rise.
>
> Much of the work on crush has come from earthquake disaster victims and
> victims of severe beatings in S Africa:
>
> Gunal AI, Celiker H, Dogukan A, et. al. Early and vigorous fluid
> resuscitation prevents acute renal failure in the crush victims of
> catastrophic earthquakes.  J Am Soc Nephrol. 2004 Jul;15(7):1862-7
>
> Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit
> Care Clin. 2004 Jan;20(1):171-92
>
> Papadopoulos IN, Kanakaris N, Triantafillidis A, et. al.  Autopsy findings
> from 111 deaths in the 1999 Athens earthquake as a basis for auditing the
> emergency response. Br J Surg. 2004 Dec;91(12):1633-40
> Knottenbelt JD. Traumatic rhabdomyolysis from severe beating-experience of
> volume diuresis in 200 patients. J Trauma 1994; 37:214-19
>
> This is one area of trauma where early aggressive fluid therapy is
> essential.
> Numerous treatment regimes exist but one of the current most popular is that
> produced by the International Nephrology Society who still support the
> production of a forced alkalline diuresis (3ml/Kg/hr)
> They use a combination of alternating litres of 0.9% saline and 5% dextrose
> with 50mEq NaHCO3 added to each litre to maintain the alkaline pH
>
> If the target urine outputs are not achieved then interventional renal
> support should be considered early, especially if serum potassium levels are
> elevated and rising on serial results.
>
> My good friend Jason Van Der Velde has a specialist interest in this area
> and I will ask him to post some more information for you on the list.
>
> Hope that this helps, good luck!
> Mark F
> UK
>
> I hope that this helps
>
>
>
> ----- Original Message ----
> From: Sa'ad Lahri <slahri at webmail.co.za>
> To: trauma-list at trauma.org
> Sent: Saturday, 25 August, 2007 8:45:29 PM
> Subject: crush injury
>
>
> requesting opinions and possible suggestion for management
>
> A 25
> y old man was caught by members of his community for stealing chickens. He
> was beaten with a belt (community assault) and arrived to hospital with
> his relatives.
>
> his back, both arms and thighs were bruised.
>
> couple of questions regarding crush injury?
> how do you
> estimate severity? do you use % body surface area involved?
> How
> useful is CK measurement?
> what type of fluid is used?
> ringers/saline?
>
> kind regards
> Sa'ad
>
> Dr Sa'ad
> Lahri
> Emergency Medicine Registrar
> UCT/US
> Cape Town
> South Africa
>
>
> South Africas premier free email service - www.webmail.co.za
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-- 
_____________________
Ross Hofmeyr
MBChB (Stell) ATLS ACLS
wildmedic at gmail.com
ross at wildmedix.com
www.wildmedix.com

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