A-B-C

and Crush Injury on

Disaster
Respati Suryanto Dradjat
 Disaster
• A sudden event, such as an accident or a
natural catastrophe, that causes great damage
or loss of life.
• Integrate the health care into the larger,
predominately non medical multidisciplinary
response
• Injury
• Disease
 Crush Injury
• Is the result of direct trauma to a limb
• Injury to muscle, soft tissue, and bone
 Crush injury
• Collapsed structure
• Eathquakes, Hurricanes, Tornados, Landslides
• Bombings / terrorist attack
• Traffic accidents
 Earthquakes
• Victims of bulding collaps, particularly the
result of trauma and prolonged time beneath
heavy rubble
The Disaster Cycle
• Reported after the 1976 earthquake in
Tangshan, China, the 1980 earthquake in
southern Italy, the 1988 earthquake in
Armenia, the 1995 earthquake in Hanshin-
Awaji, Japan, and the 1999 earthquake in
Marmara, Turkey.
Spitak earthquake in Armenia in 1988
Marmara earthquake in Turkey in 1999
 Survivor
• 10 to 60 % of survivors extricated from
collapsed buildings
• Up to half may develop renal failure
• At least half of these require dialysis
• Typically about 20 % of injured are
hospitalized, and 5 to 20 % of these have
crush injury, and 0.5 to 1 % end up needing
dialysis
• Discribe in the English literature by Bywaters
and Beall (1941)
• London blitz (bombing of London during the
battle of Britain in the Second World War)
 TRIAGE
• Life threatening (P1)
• Potential life threatening (P2)
• Non life threatening (P3)
• Patient had been rescued suddenly died or
develop severe systemic symptom
 Crush syndrome
• High risk for sudden death
• “smiling death”
• The victim is awake and alert before
extrication and dies within minutes of the
heavy material being removed
• It is a reperfusion injury that appears after the
release of the crushing pressure
• Crush syndrome is localized crush injury with
systemic manifestations
 Armenia and Marmara earthquakes
• I V hydration, early hemodialysis, and
supportive care
• Rehydration should begin before extrication
• Monitored for developing of compartment
syndrome
 A B C
• The airway must be secured and protected
from dust impaction.
• Adequate ventilation must be ensured and
maintained along with adequate oxygenation
• Intravenous Fluid
preexisting dehydration or fluid loss should be
corrected
 Hypotension
• Massive third spacing occurs, requiring
considerable fluid replacement in the first 24
hours; Patients may sequester (third space) >12 L
of fluid in the crushed area over a 48-hour period
• Third spacing may lead to secondary
complications such as compartment syndrome,
which is swelling within a closed anatomical
space; compartment syndrome often requires
fasciotomy
• Hypotension may also contribute to renal failure
• Initiate (or continue) IV hydration—up to 1.5
L/hour
 Metabolic Abnormalities
• Calcium flows into muscle cells through leaky
membranes, causing systemic hypocalcemia
• Potassium is released from ischemic muscle into
systemic circulation, causing hyperkalemia
• Lactic acid is released from ischemic muscle into
systemic circulation, causing metabolic acidosis
• Imbalance of potassium and calcium may cause
life-threatening cardiac arrhythmias, including
cardiac arrest; metabolic acidosis may exacerbate
this situation
 Acidosis
• Alkalinization of urine is critical; administer IV
sodium bicarbonate until urine pH reaches 6.5
to prevent myoglobin and uric acid deposition
in kidneys
• Cardiac Arrhythmias: Monitor for cardiac
arrhythmias and cardiac arrest, and treat
accordingly
 Hyperkalemia/Hypocalcemia
• Consider administering the following (adult
doses): calcium gluconate 10% 10cc or calcium
chloride 10% 5cc IV over 2 minutes; sodium
bicarbonate 1 meq/kg IV slow push; regular
insulin 5-10 U and D5O 1-2 ampules IV
bolus; kayexalate 25-50g with sorbitol 20%
100mL PO or PR
 Cardiac Arrhythmias
• Monitor for cardiac arrhythmias and cardiac
arrest, and treat accordingly
 Acidosis
• Alkalinization of urine is critical; administer IV
sodium bicarbonate until urine pH reaches 6.5
to prevent myoglobin and uric acid deposition
in kidneys
 Renal Failure
• Rhabdomyolysis releases myoglobin,
potassium, phosphorous, and creatinine into
the circulation
• Myoglobinuria may result in renal tubular
necrosis if untreated
• Release of electrolytes from ischemic muscles
causes metabolic abnormalities
 Secondary Complications
• Compartment syndrome may occur, which will
further worsen vascular compromise
 Crush Syndrome
• Is secondary to muscle death and the
subsequent electrolyte fluxes, third spacing of
fluid, and rabdomyolysis
• Breakdown of the muscle causing a release of
intracellular contents into the plasma
• Release into the bloodstream of muscle
breakdown products myoglobin, potasium,
phosphor
 Earthquake
• Incidence of crush syndrome 2-5%
• 50% develop ARF
• 50% will need dialysis
• Rapid death occur from Cardiac Arrythmia
induced by high concentration of intracellular
electrolytes
• Rhabdomyolysis leads to acute renal failure
 Pathofisiology Crush syndrome
• Increased permeability of sarcolemmal
membrane
• Sodium, calcium, and water leak into the
sarcoplasm, trapping extracellular fluide inside
the muscle cells
• The muscle cell releases Potasium, Myoglobin,
Phosphate and Urate into the circulation
• Injury to other cells release; lactic acid, histamin,
Leucotrienes, peroxides, free radical of oxygen,
superoxides, lysozymes and enzyme (creatine
phosphokinase)
• Serum creatinine kinase levels greater than
1000 IU/I
• Myoglobinuria
• Hypovolemic shock
• Hyperkalemia
• Metabolic acidosis
• Compartment syndrome
• ARF (acute renal failure)
 ARF
• Hypovolemia
• Renal vasoconstriction
• Metaboloic acidosis
• Nephrotoxic substances (myoglobin, urate and
phosphate
• Intravenous (IV) fluids containing potassium
(e.g., lactated Ringer's solution) should be
avoided.
• Normal saline is a good initial choice
• formula that can be used to maintain an
alkaline urine output of 8 L/d is the infusion of
12 L/d of Normal Saline Solution (NSS) with 50
mEq of sodium bicarbonate per liter of fluid,
plus 120 grams of mannitol daily to maintain
this urine output
 Sodium Bicarbonate
• reverse the preexisting acidosis
• first steps in treating hyperkalemia.
• increase the urine pH, to decrease the amount
of myoglobin precipitated in the kidneys.
• 50 to 100 mEq of bicarbonate, depending on
severity of injury, to be given prior to release
from compression
 Treatment of Hyperkalemia
• Insulin and glucose.
• Calcium – intravenously for life-threatening
dysrhythmias .
• Beta-2 agonists – albuterol, metaproterenol
sulfate (Alupent), etc.
• Potassium-binding resins such as sodium
polystyrene sulfonate (Kayexalate).
• Dialysis, especially in patients with acute renal
failure
 Alkaline Diuresis
• maintain a urine output of at least 300 ml/h
with a pH higher than 6.5
• intravenous fluids, mannitol, and sodium
bicarbonate (44 to 50 mEq/liter)
 Intravenous Mannitol
• protects the kidneys from the effects of
rhabdomyolysis
• increases extracellular fluid volume
• increases cardiac contractility
• relief symptoms and reduction of swelling of
compartment syndrome
• Mannitol can be given in doses of 1 gm/kg or
added to the patient's intravenous fluid as a
continuous infusion.
• The maximum dose is 200 gm/d
• Mannitol should be given only after good
urine flow has been established
• Wounds should be cleaned, débrided, and
covered with sterile dressings
• Splinting and elevation of the limb will help to
limit edema and maintain perfusion.
• Intravenous antibiotics
• Medications for pain control can be given as
appropriate.
• Tourniquets are controversial and usually not
necessary
 CONCLUSIONS
• Preventable death
• Prehospital
• ED