This syndrome was first identified as a separate disease in 1941 by the English physician Eric Bywaters, who treated people affected by the bombings in London during World War II [1]. In patients who spent a long time under rubble with compressed limbs, a special form of shock was observed. The peculiarity was that if the injuries were not too severe (the internal organs of such patients, as a rule, were not injured), after a set of therapeutic measures the patients’ condition improved significantly, but then a sharp deterioration occurred. Most patients developed acute renal failure and soon died. There are several options for the names of this syndrome: compartment syndrome, compression injury, crash syndrome (from the English crush - “crushing, crushing”), traumatic toxicosis.
Bywaters was able to identify three successive stages leading to the development of crash syndrome:
- compression of the limb and subsequent tissue necrosis;
- development of edema at the site of compression;
- development of acute renal failure and ischemic toxicosis.
Pathogenesis
Bywaters syndrome occurs as a result of compression of the limb, damage to the main vessels and main nerves. This type of injury occurs in approximately 30% of people injured in natural or man-made disasters.
In the pathogenesis of this disease, three factors are of leading importance: regulatory, associated with the painful effect on the body, significant plasma loss and, finally, tissue toxemia. Note that such factors are observed to one degree or another in almost any injury, but in crash syndrome they manifest themselves especially clearly. Each of these factors contributes to the clinical picture of long-term compartment syndrome.
The painful effect affects the person caught under the rubble most strongly. There is a reflex spasm of the vessels of peripheral organs and tissues, which leads to disruption of gas exchange and subsequent tissue hypoxia. Vascular spasm and developing hypoxia cause dystrophic changes in the epithelium of the renal convoluted tubules, and glomerular filtration decreases significantly.
Plasma loss develops soon after injury and even after the cause of compression has been eliminated.
Plasma loss is associated with an increase in capillary permeability due to injury, which leads to the release of blood plasma from the bloodstream.
The volume of circulating blood decreases, viscosity increases, and oxygen transport becomes more difficult. Swelling and numerous hemorrhages develop at the site of injury, the outflow of blood from the compressed limb is disrupted, since the edematous fluid leads to a narrowing of the lumen of the blood vessels until they are completely blocked. As a result, limb ischemia develops, cellular metabolic products accumulate in tissues, and the amount of myoglobin, creatinine, potassium and calcium ions increases. An increase in the concentration of myoglobin in the circulating blood and developing metabolic acidosis have a detrimental effect on the functioning of the renal tubules. Toxemia is also aggravated by other protein factors that accumulate as a result of compression of the limb and damage to muscle tissue. After blood circulation is restored, they “in one gulp” begin to enter the vascular bed. At this moment, a number of symptoms characteristic of ischemic toxicosis appear.
Intoxication of the body is more pronounced, the greater the mass of compressed tissues and the duration of the compression effect.
Severity of crash syndrome
Depending on the volume of damage and the duration of compression, there are 4 degrees of severity of the syndrome [2].
Mild degree - compression of a small segment of a limb for no more than two hours. In this case, toxemia is mild, although acute renal failure and hemodynamic disturbances are noted. In most cases, with timely therapy, improvement occurs within a week.
The average degree occurs when the entire limb is compressed for four hours. This condition is characterized by intoxication, myoglobinuria and oliguria.
Prolonged compression of the extremities (4–7 hours) leads to the manifestation of symptoms characteristic of severe Bywaters syndrome. Significant hemodynamic disturbances are noted, symptoms of intoxication are pronounced, and acute renal failure quickly develops.
Untimely and incorrect provision of medical care in most cases leads to death.
It is also important to act correctly and quickly if the patient is diagnosed with an extremely severe degree of crash syndrome. This diagnosis is made when there is compression of the lower extremities for 8 hours or more. Developing ischemic toxicosis will be disastrous for the patient soon after decompression. The mortality rate of such patients is extremely high even with timely treatment.
Treatment
The choice of treatment approach begins with assessing the degree of compression and duration of compression of the limbs. For specialists taking part in rescue operations, it is important to try to free the maximum number of victims in the first two hours after the emergency occurs. It is in this case that the prognosis will be favorable for most patients.
During the earthquake in Marmara (Turkey) in 1999, many children were injured. At that time, enormous experience was accumulated in eliminating the consequences of compression injury in young patients. The specificity of treatment for Bywaters syndrome in children is due to the fact that their injuries are often much more severe than in adults [3].
It is more difficult to communicate with children during a rescue operation, so they often spend more time under the rubble than adults. Children's bodies are more susceptible to hypothermia and fluid loss, so special attention should be paid to rehydration immediately after rescuing the child.
Regardless of the severity and age of the patient, anti-shock measures are carried out: analgesics and cardiovascular drugs are administered to normalize blood pressure. In most cases, this is done before the victim is removed from the rubble.
Treatment started before the abdomen is removed makes it possible to avoid the development of ischemic toxicosis. This primarily applies to extensive compression injuries.
After releasing the injured limb, a tourniquet is applied to the site of compression, which helps prevent a “volley” release of accumulated toxic substances into the bloodstream. This is an important feature of providing medical care for Bywaters syndrome. After moving the victim and removing the compression, the limb is bandaged with an elastic bandage, and only then the tourniquet is removed. Cooling of the injured limb is also recommended.
Following the sequence of treatment steps for patients with compression injuries is very important. Timely use of infusion therapy and understanding the pathogenesis of Byouters syndrome significantly increases the number of lives saved.
For mild cases of the syndrome, surgical treatment is not performed; such patients are often treated on an outpatient basis. With moderate severity, hemodynamic disturbances are quite pronounced: swelling increases, microcirculation is disrupted, and the number of microthromboses increases, but surgical treatment in this case is not always indicated. Infusion therapy is recommended to prevent the development or progression of acute renal failure.
In cases of severe and extremely severe crash syndrome, conservative treatment is ineffective and surgical treatment is necessary. A fasciotomy of the injured limb is performed, which helps restore blood circulation and makes it possible to avoid complete necrotization of the limb. It is often necessary to amputate distal limbs to save the patient.
In parallel, acute renal failure is treated - a strict drinking regime, hemodialysis, plasmapheresis and infusion therapy (administration of glucose solutions, albumin, etc.) are prescribed.
During the rehabilitation period, attention should be paid to physiotherapy (for example, massage) and physical therapy, which contribute to more effective restoration of the limb, minimizing atrophy of muscles and nerves.
Long-term compartment syndrome - symptoms and treatment
The fundamental points in the treatment of crash syndrome are related to the release and evacuation of the victim. The correctness of the doctor’s actions at the scene of the incident largely determines the success of inpatient treatment.[10]
First aid algorithm:
Measures before release from compression:
- ensure the safety of yourself and others at the scene of the incident;
- call emergency medical assistance;
- release the victim from compression, if possible and safe.
Measures after removing the press:
- if the victim is unconscious and not breathing, begin cardiopulmonary resuscitation and continue until spontaneous breathing and pulse appear;
- if the victim is breathing but unconscious, ensure airway patency;
- stop visible bleeding, apply bandages to wounds;
- fix fractures with splints;
- treat manifestations of shock: anesthetize and warm the victim (avoid hypothermia);
- Monitor the condition of the victim until paramedics arrive.
There is no proven effectiveness of applying a tourniquet to a limb before release from the rubble. A tourniquet is used only when massive bleeding continues and in this case can be applied to stop the bleeding before or after removing the victim.
Preliminary and most effective assistance depends on the stage of SDS. And although the general treatment of crash syndrome is complex, the priority method of treatment also depends on the stage of this condition.
Immediately after detection, the victim is given analgesics, including narcotic, antihistamines, sedatives and vascular drugs proximally, that is, closer to the area of compression of the limb, and a tourniquet is also applied. Without removing the tourniquet, the damaged segment is bandaged with an elastic bandage, immobilized and cooled. After this initial amount of medical care has been completed, the tourniquet can be removed.
Then the wounds are cleaned and aseptic dressings are applied. Permanent venous access (peripheral) is established, and solutions are infused.
Infusion therapy
Infusions are carried out under the control of diuresis (the volume of urine produced over a certain period of time). This requires a Foley catheter, a type of catheter with an inflatable retention balloon, used to drain urine from the bladder and to administer medicinal fluids into the bladder.
Warm saline solution is used for infusions. Sodium bicarbonate and 20% mannitol can also be used. Diuresis must be maintained at 8 liters per day (except in the elderly), infusion of up to 12 liters per day may be required.
Against the background of ongoing analgesia (relief of pain symptoms), the patient is transported to the hospital under the control of hemodynamic parameters (blood movement through the vessels). Treatment is effective in an intensive care unit.[7] Puncture and catheterization of the central vein, continuation of infusion-transfusion therapy (introduction of necessary biochemical fluids) with transfusion of fresh frozen plasma, crystalloid and high molecular weight solutions are indicated. Plasmapheresis, hemodialysis (purification of blood outside the body), oxygen therapy, hyperbaric oxygenation (high pressure oxygen treatment) are performed.
Based on the indications, symptomatic treatment is also carried out. Continuous monitoring of diuresis, heart rate, pulse, and central venous pressure is carried out. Control the ionic composition of the blood.
The effectiveness of general measures directly depends on local surgical treatment.[16] There are no universal schemes for treating wounds and managing the victim. Active prevention of compartment syndrome (swelling and compression of muscles in fascial sheaths) is carried out, including early implementation of subcutaneous fasciotomy.
Assessing tissue viability during primary surgical treatment can be difficult: the lack of delineation between healthy and damaged areas, borderline and mosaic disturbances of perfusion (blood release through body tissues) keep surgeons from taking radical actions.[1]
In case of doubt, amputation of the limb with dissection of most of the fascial sheaths, additional access for adequate examination, drainage, application of delayed sutures or packing of the wound is indicated.
The clinical picture of local damage is poor in the initial period of DFS. Therefore, there is a need for a secondary examination of the wound or revision of the limb after 24-28 hours.[20] Such tactics make it possible to sanitize (clean) emerging foci of necrosis against the background of secondary capillary thrombosis, assess the viability of tissues and the segment as a whole, and adjust the surgical plan.
Correction of hyperkalemia at the prehospital stage
Correction of hyperkalemia is possible after its confirmation: laboratory tests and an ECG in the field are necessary. Avoid eating foods containing potassium. Colloidal solutions for infusion without potassium content are used.
Calcium gluconate 10% is administered intravenously. Calcium gluconate solution is administered at the rate of 50-100 mg/kg body weight (administered slowly!). 1 unit of short-acting or ultra-short-acting insulin mixed with glucose is also administered. The indicated amount of insulin should account for 1-3 g of glucose. In this case, glucose in a 40% concentration is introduced into saline to obtain a 5-20% solution.
Hospitalization
Hospitalization for long-term compartment syndrome is always necessary. The need for hospitalization is explained by the exceptional severity of the injuries and the impossibility of their treatment on an outpatient basis. Rare cases of compression of small segments of the limbs do not give the right to regard the injury as minor and also require hospitalization.
This is due to the fact that without an additional and comprehensive hospital examination it is impossible to determine the extent of the injury - the clinical picture of long-term compartment syndrome may not correspond to the true severity of the injury. Hospitalization in peacetime is carried out by the emergency medical service.
Patient discharge criteria
The criterion for discharge after treatment of SDS is stabilization of the general condition and healing of traumatic injuries. Stabilization of the general condition is understood as compensation of vital signs and adequate diuresis without drug and infusion support. Healing of injuries means stabilization of fractures and healing of wounds (or a clear tendency to heal during dressings).
Case from practice
A 21-year-old man spent 10 hours trapped in a damaged vehicle after a car accident. He was taken to a hospital in Nizwa (Oman) while fully conscious [4]. The examination showed that the chest, abdomen, back and pelvis were not damaged. At the same time, swelling of the right shoulder was observed, and the right upper limb was immobilized. X-ray examination revealed a fracture of the right clavicle.
Swelling of the right lower limb was also noted, but the skin was not damaged. There was diffuse swelling in the left leg involving the calf and thigh, as well as deep abrasions. Both legs were practically immobile at the ankle joints, and there were sensory disturbances in the shin area. A Doppler ultrasound study showed impaired venous blood flow in the foot and leg. Further observation revealed rapid accumulation of creatinine, myoglobin, potassium in the blood serum, as well as myoglobinuria.
Infusion therapy was carried out: saline solution, glucose, sodium bicarbonate. Despite this, the patient developed anuria and blood potassium levels continued to rise. The victim was prescribed hemodialysis and underwent fasciotomy of the left thigh and lower leg, as a result of which it was discovered that part of the thigh muscles was necrotic. On the 7th day of treatment, gram-negative bacteria – E.coli and bacteria of the genus Proteus – were found in a smear from the wound. The patient was prescribed adequate antibiotic therapy, and the wound was regularly treated with antiseptics. The patient's condition progressively worsened. Despite taking antibiotics, bacterial septicemia developed and amputation of the left leg was recommended, but the patient and his family refused. They decided to continue treatment abroad, where the victim died of severe sepsis three days after arrival.
First aid for compartment syndrome
First aid should be provided immediately at the place where the victim is located. Before you begin to free a person from a pressing object, it is necessary to eliminate pain syndromes and restore the patient’s psycho-emotional state. Analgin, promedol solution or any other sedative medications can be used as an anesthetic. If you notice that the patient’s abdominal area is not compressed, then you can give him any strong alcoholic beverage to drink.
Proper liberation of a person begins from the head to the torso. But there are exceptions, so you need to be guided by the situation. It is very important to prevent the patient from suffocating, which happens quite often. To do this, if possible, place the person in a comfortable position and clear all the upper respiratory tract. This way you can avoid asphyxia. If you notice external bleeding in a person, you should stop it immediately.
