5·12汶川地震挤压伤患者高钾血症的救治及相关因素分析

[目的]回顾性分析5·12汶川地震挤压伤患者高钾血症的救治情况、预后及相关危险因素,更好地指导类似灾害事件的救治工作.[方法]地震发生后1周内,本院收治挤压伤患者66例,根据患者伤情分3组:(1)单纯挤压伤,无挤压综合征;(2)挤压综合征,血钾浓度正常;(3)挤压综合征,高钾血症.针对性给予补液、利尿及碱化尿液、纠正电解质紊乱、血液透析、防治感染及支持治疗.探讨挤压时间、挤压部位与高钾血症发生的关系.[结果]66例患者中49例发生了挤压综合征,39例患者合并高钾血症.随着受累肢体的增加和受压时间的延长,患者发生挤压综合征、高钾血症的风险显著上升.经过积极有效的治疗,全部高钾血症患者均在入院后1 d内得以控制,3 d内完全纠正高钾.截止至2008年11月28日,66例患者无1例死亡.[结论]灾害现场救治时,通过患者挤压时间及受累部位可以迅速判断患者伤情,预测挤压综合征、高钾血症的发生,尽早采取措施.对于挤压综合征、高钾血症的治疗,应及时快速补液、利尿及碱化尿液、血液透析,适时骨筋膜室切开减压、截肢或关节离断,遵循抢救生命、挽留肢体、促进康复的原则.     

地震所致挤压综合征的早期诊治

[目的] 回顾性分析挤压综合征的早期诊断和治疗.[方法] 回顾性研究汶川大地震后发生挤压综合征的27例患者,致伤原因均为地震中被重物砸伤.其中男15例,女12例;年龄5.8～72岁,平均33.6岁;受挤压时间7～101 h,平均27.8 h;受伤到接受治疗的时间8～112 h,平均38 h;单纯一侧下肢挤压伤13例,单纯一侧上肢挤压伤5例,臀部挤压伤2例,双下肢挤压伤4例,上下肢联合挤压伤3例.出现少尿15例,无尿7例.实验室检查:27例患者均出现肌红蛋白尿,BUN平均21.34 mmol/L,Cr平均365.6 μmol/L,CK平均54 022 IU/L,12例血钾升高(5.01～7.82 mmol/L,平均值6.0 mmol/L),17例血钙降低(1.25～2.09 mmol/L,平均值1.71 mmol/L).6例患者肌酐水平轻度升高,平均164 μmol/L,CK平均8 723 IU/L,无少尿.入院后予以静脉快速补液和静脉用抗生素,碱化尿液,纠正酸碱平衡、电解质紊乱.对于高钾血症患者,除快速补液外,静脉输入5%NaHCO3、10%葡萄糖酸钙或5%氯化钙、葡萄糖溶液(50%葡萄糖溶液,胰糖比1∶4)以及速尿等静脉注射.21例无尿或少尿合并急性肾功衰(acute renal failure,ARF)者,接受血液透析透析治疗.截肢或关节离断手术16例,骨筋膜室切开减压11例.截肢患者均为受压肢体缺血坏死或气性坏疽.[结果] 截至2008年5月30日(地震后18日),无1例患者死亡.21例合并ARF患者中,16例患者肾功能明显改善停止透析,继续透析治疗5例,其中2例患者肾功能改善不明显.6例肾功能不全但无少尿的患者,经碱化尿液、大量补液以及甘露醇利尿治疗后,无1例发展为ARF.截肢后创面Ⅰ期愈合9例,经换药、创面处理扩创Ⅱ缝合愈合6例;减压创面直接缝合4例,游离植皮3例,Ⅱ期扩创缝合3例.所有患者均接受不同数量的输血治疗,平均输血量1 834 ml.而且部分患者多次、长时间输血.[结论] 挤压综合征早期治疗的关键是早期及时明确诊断,并采取积极有效的治疗措施如补液、纠正低血容量和高钾血症、适时筋膜切开减压或截肢,创面积极有效的处理、血液透析、合并症和全身营养支持下的多科协作综合治疗是挤压综合征成功治疗的保证.     

挤压综合征伴急性胰腺炎1例报道

病例资料患者,男,40岁,因"地震伤后1+d"入院。查体:左下肢与右下肢的肌力分别为3级和2级,右侧足部动脉搏动较左侧差。实验室检查:肌酐501μmol/L,尿素氮22.85 mmol/L,肌红蛋白>3 000 ng/ml,肌酸激酶216 579 U/L。入院诊断"挤压综合征、急性肾功能衰竭"。入院后即行通过连续性静脉-静脉血液滤过治疗急性肾功能     

汶川地震挤压综合征患者肌肉挤压伤的特点

目的 分析汶川地震挤压综合征患者肌肉挤压伤的特点.方法 回顾性分析2008年5月12日汶川地震后成都军区总医院收治的挤压综合征患者8例,男女各4例;年龄25～45岁,平均35.4岁.压埋时间9～152h,平均52h.均行筋膜切开手术,截肢者6例8肢.8例患者均行连续肾脏替代治疗.2例死于颅脑出血及肠穿孔.术后发生ARDS2例,DIC1例,气性坏疽1例.结果 汶川地震肌肉挤压伤的特点:(1)挤压时间超长,导致急性肾衰;(2)挤压伤因皮肤破损轻微而被误诊,延误病情;(3)受压深层肌肉常比浅层肌肉损伤更严重;(4)肌肉坏死区多发且呈不规律分布;(5)早期坏死组织与正常肌肉混杂造成治疗困难;(6)创面在坏死组织脱落后,可有继发性出血.结论 汶川地震中肌肉挤压伤有其自身特点.治疗中应注意观察,发现肌肉肿胀应行切开减压引流.创面易发生突发性出血及感染.隐匿的肌肉坏死区肌肉溶解、感染是长期发热的主要原因.肢体MR检查有助于发现病灶、及时处理肌肉坏死区.连续肾脏替代治疗是治疗挤压综合征的有效手段.     

地震挤压伤对肢体骨折术后伤口愈合影响的临床观察

目的：观察地震挤压伤对术后伤口愈合影响。方法：肢体在地震时曾被挤压而接受骨折内固定手术的患者28例为观察组；以地震时肢体未被挤压接受骨折内固定手术的患者27例为对照Ⅰ组，以同期本地骨折内固定手术的患者30例为对照Ⅱ组。分别检查尿常规、肌酸激酶、观察伤口并发症及伤口愈合情况。结果：各组尿颜色、尿常规、肌酸激酶没有明显差异，而观察组的伤口并发症、伤口愈合率与两个对照组均有差异。结论：地震挤压伤对术后伤口愈合有影响。     

地震伤致严重挤压综合征1例救治体会

挤压综合征(crush syndrome,CS)又称外伤性无尿综合征、缺血性肌坏死综合征、Bywaters氏综合征、外伤性肌红蛋白尿急性肾功能衰竭综合征.1941年Bywaters首次分析16例挤压伤患者,并提出"挤压综合征".CS是指四肢或躯干肌肉丰满的部位被长时间压榨导致广泛的肌肉组织缺血性坏死、横纹肌溶解,而后引起身体一系列的病理改变.临床上主要表现为受压肢体肿胀、肌红蛋白尿、高血钾及少尿甚至无尿的急性肾功能衰竭.在这次四川地震中本院一共收治了34名四川地震伤员,这些伤员都有不同程度的挤压伤,其中1例典型的严重挤压综合征患者,经过积极的内外科综合处理,取得满意疗效,现报告如下.     

地震挤压综合征血液透析患者营养状态分析

目的评估地震致挤压综合征血液透析患者营养状态,为临床提供治疗依据。方法收集我院2008年5月12日后收治的汶川地震所致挤压综合征接受血液透析的患者24例,用比色法测量相关生化指标进行营养评估。结果所有患者血尿素氮、血肌酐、血白介素-6、C反应蛋白均升高;95．8％的患者血清白蛋白减低,100%的患者血清铁及转铁蛋白饱和度降低,87．5％的患者血清前白蛋白降低,92．9％的患者转铁蛋白降低,56．3％的患者总胆固醇降低。结论地震所致挤压综合征透析患者均存在营养不良,应对地震急性挤压伤透析患者加强营养支持治疗。     

地震伤致严重挤压综合征的救治体会

目的：探讨地震伤挤压综合征的诊断及治疗，为地震伤挤压综合征的救治提供参考。方法：对地震伤致严重挤压综合征35例治疗进行总结回顾，观察全身营养支持、积极局部创面处理辅助血液透析，对挤压综合征患者恢复的作用。结果：经过正确的早期处理，逐步清除局部坏死组织，恢复患者心、肾功能，为后续修复创面打下良好基础。结论：尽早解除压迫，正确处理伤肢，及时对坏死组织清除，减少毒素吸收，辅助人工血液透析治疗，有利于提高挤压综合征患者救治成功率。     

地震中肢体挤压伤的液体治疗

目的 评价静脉补液对预防肢体挤压伤后肾功能衰竭发生的重要性.方法 分析解放军第四五二医院收治的11例汶川地震肢体挤压伤伤员临床资料.结果 伤员被废墟下掩埋平均时间(10.90±4.81)h(2-18h),震后(96.18±26.59)h(24-143h)经直升机转运至中心医院.入院第1天血清肌酸激酶峰值(22327.3±26881.0)U/L(1500-102400U/L).入院24h液体入量可以达到12000mL.无死亡和肾功能衰竭发生.结论 尽早、快速、大量静脉补液可以预防挤压综合征发生肾功能衰竭.     

汶川地震伤致挤压综合征合并肾功能衰竭患者的救治

目的 回顾性分析汶川地震挤压综合征(CS)的治疗结果,为指导类似灾难性事件中挤压伤、cs的救治提供理论依据和指导.方法 2008年5月12口汶川地震后所致49例合并急性肾脏功能衰竭(ARF)的cS患者,致伤原因均为地震中被重物砸伤;受挤压时间4～102 h,平均24.7 h.男27例,女22例;年龄6.8～76.0岁,平均31.8岁.平均累计肢体1.5肢.49例存在ARF,血Cr平均365.6μmol/L(169～842 μmol/L),CK平均64 022 U/L(34 571～76 836 U/L),均出现肌红蛋白尿,39例合并有高钾血症(血钾5.23～6.38 mmoL/L).所有患者均予持续肾脏替代疗法(CRRT)治疗,补液、利尿、碱化尿液和纠正电解质紊乱、输血、改善低蛋白血症、预防或治疗创面感染治,扩创换药、扩创缝合.结果 CRRT治疗49例,肾脏功能在11～37 d恢复.高钾血症均在入院后当天纠正.CK在人院后13～45 d恢复正常.无1例死亡.骨筋膜间室切开减压30例52肢,截肢35例45肢.5例因感染、肢体坏死行二次截肢手术.24例创而经换药、扩创或植皮愈合,8处创面(4例)因感染、组织坏死或创面过大等原因未愈合,均为长时间(>20 d)接受CRRT治疗患者,并合并有其他系统、器官损伤.结论 及时明确诊断、积极有效的早期局部和全身治疗,是成功治疗CS,降低并发症发生率和病死率的关键.CS时创面愈合与长时间CRRT治疗之间的协调,是目前部分尚存创而患者治疗的难点.     

Predictive model for estimating risk of crush syndrome: a data mining approach

BACKGROUND: There is no standard triage method for earthquake victims with crush injuries because of a scarcity of epidemiologic and quantitative data. We conducted a retrospective cohort study to develop predictive models based on clinical data for crush injury in the Kobe earthquake. METHODS: The medical records of 372 patients with crush injuries from the Kobe earthquake were retrospectively analyzed. Twenty-one risk factors were assessed with logistic regression analysis for three outcomes relating to crush syndrome. Two types of predictive triage models--initial evaluation in the field and secondary assessment at the hospital--were developed using logistic regression analysis. Classification accuracy, Brier score and area under the receiver operating characteristic curve (AUC) were used to evaluate the model. RESULTS: The initial triage model, which includes pulse rate, delayed rescue, and abnormal urine color, has an AUC of 0.73. The secondary model, which includes WBC, tachycardia, abnormal urine color, and hyperkalemia, shows an AUC of 0.76. CONCLUSIONS: These triage models may be especially useful to nondisaster experts for distinguishing earthquake victims at high risk of severe crush syndrome from those at lower risk. Application of the model may allow relief workers to better utilize limited medical and transportation resources in the aftermath of a disaster.     

The clinical features and outcome of crush patients with acute kidney injury after the Wenchuan earthquake: differences between elderly and younger adults

BackgroundOn May 12, 2008, a devastating earthquake hit Wenchuan county of China's Sichuan province. Acute kidney injury (AKI) is one of the most lethal but reversible complications of crush syndrome after an earthquake. However, little is known about the epidemiological features of elderly crush patients with AKI. The aim of the present study is to compare clinical features and outcome of crush related AKI between elderly and younger adults in the Wenchuan earthquake.Materials and methodsA questionnaire was sent to 17 reference hospitals that treated the victims after the earthquake. Clinical and laboratory characteristics of crush patients with AKI were retrospectively analysed.Results228 victims experienced crush related AKI, of which 211 were adults, including 45 elderly (age ≥ 65 years) and 166 younger adults (age, 15–64 years). Compared with the resident population, the percentage of patients was higher amongst elderly (19.7% versus 7.6%, P < 0.001). The distribution of gender was similar in elderly and younger adults. Mean systolic blood pressure was higher in elderly groups. Although no statistical differences in number of injury and injury severity score were observed between elderly and younger adults, elderly victims had lower frequency of extremities crush injury; higher incidences of thoracic traumas, limb, rib, and vertebral fractures; lower serum creatinine, potassium and creatinine kinase levels; lower incidence of oliguria or anuria; lower dialysis requirement; underwent less fasciotomies and amputations, received less blood and plasma transfusions. Mortality were 17.8% and 10.2% in elderly and younger adults, respectively (P = 0.165). Stratified analysis demonstrated the elderly receiving dialysis had higher mortality rate compared with younger patients (62.5% versus 10.5%, P < 0.001). Multivariate logistic regression analysis indicated that need for dialysis and sepsis were independent risk factors for death in the elderly patients.ConclusionsElderly crush victims more frequently developed AKI in the Wenchuan earthquake, and they differ from younger adults in injury patterns and treatment modalities. The elderly patients with AKI requiring dialysis were at a relatively high risk of mortality.     

Serum potassium in the crush syndrome victims of the Marmara disaster

BACKGROUND: Hyperkalemia is a major cause of mortality in the patients who suffer from crush syndrome in the aftermath of major earthquakes. The aim of this study is to investigate the frequency and effects of hyperkalemia in the 639 victims of catastrophic Marmara earthquake that struck northwestern Turkey, in August 1999. PATIENTS AND METHODS: Within the first week of disaster, questionnaires were sent to 35 reference hospitals that treated the victims. Information on serum potassium which was provided in 595 out of 639 questionnaires was submitted to analysis. RESULTS: In the patients who were admitted within the first 3 days of the disaster (n = 401) serum potassium was 5.4 +/- 1.3 mEq/l, which was higher than in those admitted thereafter (n = 171) (4.5 +/- 1.1 mEq/l) (p = 0.02). Considering the whole series, males (p = 0.01), patients needing dialysis support (p < 0.001) and non-survivors (p = 0.001) were characterized by higher serum potassium at admission. Seventy patients' serum potassium was above 7 mEq/l, while 22 patients were hypokalemic (< 3.5 mEq/l). Admission potassium correlated with many clinical and laboratory variables indicating the severity of the trauma, and a logistic regression model with clinical and laboratory parameters upon admission, revealed potassium as the most significant predictor of dialysis needs in the victims admitted within the first 3 days (p = 0.008, OR = 3.33). Among the victims who were admitted to hospitals 1 week after the disaster, 8 had serum potassium levels above 6.5 mEq/l; among 4 of them were complicated by hyperkalemia even higher than 7.5 mEq/l. These findings undeline the importance of hyperkalemia during clinical course. CONCLUSION: The most important and fatal medical complication in crush syndrome patients is hyperkalemia. Risk of fatal hyperkalemia continues even after hospitalization. Empirical therapy at the scene is indicated especially in male victims with severe soft tissue traumas. Early detection and treatment of hyperkalemia may improve the final outcome of renal disaster victims.     

汶川地震伤致严重挤压综合征救治体会——附一例报告

目的 探讨地震伤致挤压综合征的诊断及治疗,为地震伤挤压综合征的救治提供参考.方法 对地震伤致严重挤压综合征1例治疗进行总结回顾,观察全身营养支持、积极局部创面处理辅助血液透析对挤压综合征伤员恢复的作用.结果 经过积极处理,局部坏死组织得到清除.心、肾功能进一步好转,为后续修复创面打下良好基础.结论 清除坏死组织、减少毒素吸收、辅助人工血液透析治疗,有利于提高挤压综合征伤员的救治成功率.     

Vertebral crush fracture syndrome and reflex sympathetic dystrophy

The association of reflex sympathetic dystrophy in one or more extremities with vertebral crush fracture syndrome is reported in six cases. In two of them the reflex sympathetic dystrophy preceded the vertebral crush fractures. The 99mTc-methylene diphosphonate scintigraphy results of the skeletons of 42 consecutive patients suffering from vertebral collapse and of 30 matched controls without osteoporosis have been evaluated by three independent observers for abnormal uptakes in the extremities. An abnormal radioactive bone tracer uptake in the extremities has been observed in 15 osteoporotics (36%) and 8 controls (29%). In most cases, osteoporotics and controls, the abnormal uptake was of the zonal type in a localized area, probably reflecting bone remodeling due to localized degenerative changes. An abnormal uptake of the segmental type involving multiple joints and even multiple extremities, as seen in reflex sympathetic dystrophy, was observed in 7 patients of the osteoporotic group (17%) and in none of the control group (P less than 0.05). The patients with an abnormal segmental uptake were younger and had a significantly higher mean 24 h calcium:creatinine ratio as well as a higher urinary hydroxyproline excretion. These observations and results suggest that in some cases of idiopathic osteoporosis there might be a relation between reflex sympathetic dystrophy and vertebral crush fracture syndrome, the vertebral crush fracture syndrome being the axial type of reflex sympathetic dystrophy.