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Travmatik Rabdomiyoliz (CRUSH Yaralanması) Yönetimi

Year 2023, Volume: 6 Issue: 1, 41 - 46, 08.03.2023
https://doi.org/10.54996/anatolianjem.1252372

Abstract

Travmatik rabdomiyoliz (Crush yaralanması) vücudun bir bölümünün veya tamamının harici ezici bir güç altında ezilmesi sonucu ortaya çıkan kas hücresi yıkımına bağlı metabolik bozuklukları tanımlar. Özellikle ezici kuvvetin kaldırılması sonrası kas dokusunun reperfüzyonu ile ortaya çıkan serbest radikaller kas hücre yıkımına neden olur. Kas hücre yıkımı ile hücre içi elektrolitler ve enzimler dolaşıma geçer. Travmatik rabdomiyoliz sonucu serum potasyum, fosfat, myoglobin, kreatinin kinaz (CK), aspartat transferaz (AST) ve laktat dehidrogenaz (LDH) seviyeleri artar. Özellikle myoglobinin renal tübüllerde birikmesi sonucu akut böbrek hasarı, potasyum düzeyinin yükselmesi sonucu ise ölümcül disritmiler ve ani kardiyak ölüm gelişebilir.

Travmatik rabdomiyoliz tanısında kullanılan klasik triyad kas ağrısı, kas zayıflığı ve koyu renkli idrar bulgularıdır. Serum kreatinin kinaz seviyesinin 1000 U/L nin üzerinde olması veya normal üst sınırının beş katından fazla olması rabdomiyoliz için tanı koydurucudur.

Travmatik rabdomiyoliz tedavisinin ana hedefi yeterli ve uygun sıvı resüsitasyonudur. Özellikle ölümcül seyredebilecek durumların önlenmesi için hastaya ulaşılan ilk anda uygun sıvı tedavisi başlanmalıdır. Sıvı resüsitasyonunda öncelikli olarak kristaloid sıvılar tercih edilmelidir. Her ne kadar kristaloid sıvılar arasında bir ortak görüş sağlanamamış olsa da sıvı resüsitasyonunun izotonik salin ile yapılması yönünde yaygın bir görüş vardır. Hastaya ulaşıldığı ilk anda uygun damar yolu erişimi sağlanıp 1000 ml/saat hızında izotonik salin infüzyonu başlanmalıdır. Çocuklarda sıvı resüsitasyonu için önerilen başlangıç hızı 15-20 ml/kg/saattir. Sıvı resüsitasyonunun yeterliliğini değerlendirmek için hedeflenen idrar çıkışı miktarı ise 1-3 ml/kg/saat veya 300 ml/saattir.

Travmatik rabdomiyolizin oluşturduğu en önemli elektrolit bozukluğu hiperpotasemidir. Yüksek serum potasyum düzeyleri ölümcül disritmilere ve ani kardiyak ölümlere neden olabilir. Bu sebeple hiperpotasemi tedavisinde insülin-glikoz infüzyonları, inhale beta 2 adrenerjik ajanlar kullanılmalıdır. Serum potasyum seviyesi 7 mmol/L nin üzerinde olan veya kardiyak etkilenim düşünülen hastalarda kardiyak uyarılabilirliği azaltmak için kalsiyum klorit veya kalsiyum glukonat kullanılabilir. Potasyum seviyesi kontrol altına alınamayan hastalarda hemodiyaliz uygulaması yapılmalıdır.

Travmatik rabdomiyoliz tedavisinde ortak görüş sağlanamamış dahi olsa geçmiş çalışmalar ve elde edilen deneyimler standart hasta yönetiminin oluşturulmasını sağlamıştır. Bu yönetim planına uygun düzenlenecek olan tedavi şemaları mortalitenin ve morbiditenin azalmasına katkı sağlayacaktır.

References

  • Bywaters EG, Beall D. Crush Injuries with Impairment of Renal Function. Br Med J. 1941 Mar 22;1(4185):427-32. doi: 10.1136/bmj.1.4185.427. PMID: 20783577; PMCID: PMC2161734.
  • Smith J, Greaves I. Crush injury and crush syndrome: a review. J Trauma. 2003 May;54(5 Suppl):S226-30. doi: 10.1097/01.TA.0000047203.00084.94. PMID: 12768130.
  • Gonzalez D. Crush syndrome. Crit Care Med. 2005 Jan;33(1 Suppl):S34-41. doi: 10.1097/01.ccm.0000151065.13564.6f. PMID: 15640677.
  • Chavez LO, Leon M, Einav S, Varon J. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care. 2016 Jun 15;20(1):135. doi: 10.1186/s13054-016-1314-5. PMID: 27301374; PMCID: PMC4908773.
  • Parekh R, Care DA, Tainter CR. Rhabdomyolysis: advances in diagnosis and treatment. Emerg Med Pract. 2012 Mar;14(3):1-15; quiz 15. PMID: 22497086.
  • Peiris D. A historical perspective on crush syndrome: the clinical application of its pathogenesis, established by the study of wartime crush injuries. J Clin Pathol. 2017 Apr;70(4):277-281. doi: 10.1136/jclinpath-2016-203984. Epub 2016 Dec 5. PMID: 27920043.
  • Cabral BMI, Edding SN, Portocarrero JP, Lerma EV. Rhabdomyolysis. Dis Mon. 2020 Aug;66(8):101015. doi: 10.1016/j.disamonth.2020.101015. Epub 2020 Jun 10. PMID: 32532456.
  • Smith J, Greaves I. Crush injury and crush syndrome: a review. J Trauma. 2003 May;54(5 Suppl):S226-30. doi: 10.1097/01.TA.0000047203.00084.94. PMID: 12768130.
  • Zutt R, van der Kooi AJ, Linthorst GE, Wanders RJ, de Visser M. Rhabdomyolysis: review of the literature. Neuromuscul Disord. 2014 Aug;24(8):651-9. doi: 10.1016/j.nmd.2014.05.005. Epub 2014 May 21. PMID: 24946698.
  • Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Crit Care. 2005 Apr;9(2):158-69. doi: 10.1186/cc2978. Epub 2004 Oct 20. PMID: 15774072; PMCID: PMC1175909.
  • Galvagno SM Jr, Nahmias JT, Young DA. Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations. Anesthesiol Clin. 2019 Mar;37(1):13-32. doi: 10.1016/j.anclin.2018.09.009. Epub 2018 Dec 27. PMID: 30711226.
  • Melli G, Chaudhry V, Cornblath DR. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine (Baltimore). 2005 Nov;84(6):377-385. doi: 10.1097/01.md.0000188565.48918.41. PMID: 16267412.
  • BI Cabral, SN Edding, JP Portocarrero, EV Lerma, Rhabdomyolysis, Disease-a-Month, Volume 66, Issue 8, 2020, 101015, ISSN 0011-5029, https://doi.org/10.1016/j.disamonth.2020.101015.
  • Llach F, Felsenfeld AJ, Haussler MR. The pathophysiology of altered calcium metabolism in rhabdomyolysis-induced acute renal failure. Interactions of parathyroid hormone, 25-hydroxycholecalciferol, and 1,25-dihydroxycholecalciferol. N Engl J Med. 1981 Jul 16;305(3):117-23. doi: 10.1056/NEJM198107163050301. PMID: 6894630.
  • Akmal M, Bishop JE, Telfer N, Norman AW, Massry SG. Hypocalcemia and hypercalcemia in patients with rhabdomyolysis with and without acute renal failure. J Clin Endocrinol Metab. 1986 Jul;63(1):137-42. doi: 10.1210/jcem-63-1-137. PMID: 3011837.
  • Sever MS, Vanholder R; RDRTF of ISN Work Group on Recommendations for the Management of Crush Victims in Mass Disasters. Recommendation for the management of crush victims in mass disasters. Nephrol Dial Transplant. 2012 Apr;27 Suppl 1:i1-67. doi: 10.1093/ndt/gfs156. PMID: 22467763.
  • Ron D, Taitelman U, Michaelson M et al. Prevention of acute renal failure in traumatic rhabdomyolysis. Arch Intern Med 1984; 144:277–280
  • Better OS. The crush syndrome revisited (1940–1990). Nephron 1990; 55: 97–103
  • Kodadek L, Carmichael Ii SP, Seshadri A, et al. Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open. 2022 Jan 27;7(1):e000836. doi: 10.1136/tsaco-2021-000836. PMID: 35136842; PMCID: PMC8804685.
  • Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009;361(1):62–72.
  • Petejova N, Martinek A. Acute kidney injury due to rhabdomyolysis and renal replacement therapy: a critical review. Crit Care 2014;18:224.
  • Altintepe L, Guney I, Tonbul Z, Turk S, Mazi M, Agca E, et al. Early and intensive fluid replacement prevents acute renal failure in the crush cases associated with spontaneous collapse of an apartment in Konya. Ren Fail. 2007;29(6):737–41.
  • Berend K, de Vries AP, Gans RO. Physiological approach to assessment of acid-base disturbances. N Engl J Med. 2015;372(2):195.

Management of Traumatic Rhabdomyolysis (CRUSH Injury)

Year 2023, Volume: 6 Issue: 1, 41 - 46, 08.03.2023
https://doi.org/10.54996/anatolianjem.1252372

Abstract

Traumatic rhabdomyolysis (Crush injury) describes metabolic disorders due to muscle cell destruction resulting from the crushing of part or whole body under an external crushing force. Especially after the removal of the overwhelming force, free radicals that occur with the reperfusion of the muscle tissue cause muscle cell destruction. With muscle cell destruction, intracellular electrolytes and enzymes influx the circulation. As a result of traumatic rhabdomyolysis, serum potassium, phosphate, myoglobin, creatinine kinase (CK), aspartate transferase (AST) and lactate dehydrogenase (LDH) levels increase. Acute kidney injury may occur especially as a result of accumulation of myoglobin in the renal tubules, and fatal dysrhythmias and sudden cardiac death may develop as a result of increased potassium level.

The classic triad used in the diagnosis of traumatic rhabdomyolysis are muscle pain, muscle weakness, and dark urine. A serum creatinine kinase level above 1000 U/L or more than five times the upper limit of normal is diagnostic for rhabdomyolysis.

The main goal of traumatic rhabdomyolysis treatment is adequate and appropriate fluid resuscitation. Appropriate fluid therapy should be initiated as soon as possible, especially in order to prevent potentially fatal conditions. Crystalloid fluids should be preferred primarily in fluid resuscitation. Although there is no consensus among crystalloid fluids, there is a widespread opinion that fluid resuscitation should be performed with isotonic saline. As soon as the patient is reached, appropriate vascular access should be provided and isotonic saline infusion at a rate of 1000 ml/hour should be started. The recommended initial rate for fluid resuscitation in children is 15-20 ml/kg/hour. The targeted urine output to assess the adequacy of fluid resuscitation is 1-3 ml/kg/hr or 300 ml/hr.

The most important electrolyte disorder caused by traumatic rhabdomyolysis is hyperkalemia. High serum potassium levels can cause fatal dysrhythmias and sudden cardiac death. For this reason, insulin-glucose infusions and inhaled beta 2 adrenergic agents should be used in the treatment of hyperkalemia. Calcium chloride or calcium gluconate can be used to reduce cardiac excitability in patients with a serum potassium level above 7 mmol/L or in suspected cardiac involvement. Hemodialysis should be applied in patients whose potassium level cannot be controlled.

Even if a consensus could not be reached in the treatment of traumatic rhabdomyolysis, past studies and experiences have enabled the establishment of standard patient management. Treatment schemes to be arranged in accordance with this management plan will contribute to the reduction of mortality and morbidity.

References

  • Bywaters EG, Beall D. Crush Injuries with Impairment of Renal Function. Br Med J. 1941 Mar 22;1(4185):427-32. doi: 10.1136/bmj.1.4185.427. PMID: 20783577; PMCID: PMC2161734.
  • Smith J, Greaves I. Crush injury and crush syndrome: a review. J Trauma. 2003 May;54(5 Suppl):S226-30. doi: 10.1097/01.TA.0000047203.00084.94. PMID: 12768130.
  • Gonzalez D. Crush syndrome. Crit Care Med. 2005 Jan;33(1 Suppl):S34-41. doi: 10.1097/01.ccm.0000151065.13564.6f. PMID: 15640677.
  • Chavez LO, Leon M, Einav S, Varon J. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care. 2016 Jun 15;20(1):135. doi: 10.1186/s13054-016-1314-5. PMID: 27301374; PMCID: PMC4908773.
  • Parekh R, Care DA, Tainter CR. Rhabdomyolysis: advances in diagnosis and treatment. Emerg Med Pract. 2012 Mar;14(3):1-15; quiz 15. PMID: 22497086.
  • Peiris D. A historical perspective on crush syndrome: the clinical application of its pathogenesis, established by the study of wartime crush injuries. J Clin Pathol. 2017 Apr;70(4):277-281. doi: 10.1136/jclinpath-2016-203984. Epub 2016 Dec 5. PMID: 27920043.
  • Cabral BMI, Edding SN, Portocarrero JP, Lerma EV. Rhabdomyolysis. Dis Mon. 2020 Aug;66(8):101015. doi: 10.1016/j.disamonth.2020.101015. Epub 2020 Jun 10. PMID: 32532456.
  • Smith J, Greaves I. Crush injury and crush syndrome: a review. J Trauma. 2003 May;54(5 Suppl):S226-30. doi: 10.1097/01.TA.0000047203.00084.94. PMID: 12768130.
  • Zutt R, van der Kooi AJ, Linthorst GE, Wanders RJ, de Visser M. Rhabdomyolysis: review of the literature. Neuromuscul Disord. 2014 Aug;24(8):651-9. doi: 10.1016/j.nmd.2014.05.005. Epub 2014 May 21. PMID: 24946698.
  • Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Crit Care. 2005 Apr;9(2):158-69. doi: 10.1186/cc2978. Epub 2004 Oct 20. PMID: 15774072; PMCID: PMC1175909.
  • Galvagno SM Jr, Nahmias JT, Young DA. Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations. Anesthesiol Clin. 2019 Mar;37(1):13-32. doi: 10.1016/j.anclin.2018.09.009. Epub 2018 Dec 27. PMID: 30711226.
  • Melli G, Chaudhry V, Cornblath DR. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine (Baltimore). 2005 Nov;84(6):377-385. doi: 10.1097/01.md.0000188565.48918.41. PMID: 16267412.
  • BI Cabral, SN Edding, JP Portocarrero, EV Lerma, Rhabdomyolysis, Disease-a-Month, Volume 66, Issue 8, 2020, 101015, ISSN 0011-5029, https://doi.org/10.1016/j.disamonth.2020.101015.
  • Llach F, Felsenfeld AJ, Haussler MR. The pathophysiology of altered calcium metabolism in rhabdomyolysis-induced acute renal failure. Interactions of parathyroid hormone, 25-hydroxycholecalciferol, and 1,25-dihydroxycholecalciferol. N Engl J Med. 1981 Jul 16;305(3):117-23. doi: 10.1056/NEJM198107163050301. PMID: 6894630.
  • Akmal M, Bishop JE, Telfer N, Norman AW, Massry SG. Hypocalcemia and hypercalcemia in patients with rhabdomyolysis with and without acute renal failure. J Clin Endocrinol Metab. 1986 Jul;63(1):137-42. doi: 10.1210/jcem-63-1-137. PMID: 3011837.
  • Sever MS, Vanholder R; RDRTF of ISN Work Group on Recommendations for the Management of Crush Victims in Mass Disasters. Recommendation for the management of crush victims in mass disasters. Nephrol Dial Transplant. 2012 Apr;27 Suppl 1:i1-67. doi: 10.1093/ndt/gfs156. PMID: 22467763.
  • Ron D, Taitelman U, Michaelson M et al. Prevention of acute renal failure in traumatic rhabdomyolysis. Arch Intern Med 1984; 144:277–280
  • Better OS. The crush syndrome revisited (1940–1990). Nephron 1990; 55: 97–103
  • Kodadek L, Carmichael Ii SP, Seshadri A, et al. Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open. 2022 Jan 27;7(1):e000836. doi: 10.1136/tsaco-2021-000836. PMID: 35136842; PMCID: PMC8804685.
  • Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009;361(1):62–72.
  • Petejova N, Martinek A. Acute kidney injury due to rhabdomyolysis and renal replacement therapy: a critical review. Crit Care 2014;18:224.
  • Altintepe L, Guney I, Tonbul Z, Turk S, Mazi M, Agca E, et al. Early and intensive fluid replacement prevents acute renal failure in the crush cases associated with spontaneous collapse of an apartment in Konya. Ren Fail. 2007;29(6):737–41.
  • Berend K, de Vries AP, Gans RO. Physiological approach to assessment of acid-base disturbances. N Engl J Med. 2015;372(2):195.
There are 23 citations in total.

Details

Primary Language Turkish
Subjects Clinical Sciences
Journal Section Review
Authors

Ali Batur 0000-0002-2057-3215

Early Pub Date March 9, 2023
Publication Date March 8, 2023
Published in Issue Year 2023 Volume: 6 Issue: 1

Cite

AMA Batur A. Travmatik Rabdomiyoliz (CRUSH Yaralanması) Yönetimi. Anatolian J Emerg Med. March 2023;6(1):41-46. doi:10.54996/anatolianjem.1252372