Crush Sendromlu Olguya Yaklaşım
Özet
Maraş merkezli depremde göçük altında kalan 17 yaşında 110 kilogram ağırlığında hasta göçük altından çıkarılıp; acil serviste üst extremite ve alt extremitede çoklu kırıklar ile sağ pnömotorax tanıları konularak göğüs tüpü takılı olarak yoğum bakım servisimize kabul edildi. Kliniğimize gelişinde kreatinin kinaz (CK), miyoglobin, karaciğer enzim yüksekliği ve potasyum yüksekliği olan olgu kompartman sendromu olmaması nedeniyle cerrahi işlem yapılmayıp acil diyalize alındı. Yatışının 3. gününde CK, miyoglobin değerleri kompartman sendromu gelişmemesine ve diyaliz tedavisinin yapılmasına rağmen CK değeri düşmeyen, anürik olup metabolik asidozu derinleşip Glaskow Koma Skoru gerileyen olgu elektif entübe edilerek sağ üst extremiteye dirsek üstü ampütasyon yapıldı. Yatışının 23. günü solunum parametreleri ve böbrek fonksiyonları normale dönmesi üzerine extübe edilerek; CVVHD tedavisi sonlandırıldı. 30. günde böbrek fonksiyonları normale dönen, kliniği düzelen ve solunum parametreleri normal seyreden hasta servise devredildi.
The 17-year-old patient weighing 110 kg was rescued from under the collapse in the Maraş earthquake and diagnosed with multiple fractures in the upper and lower extremities and right pneumothorax in the emergency department and admitted to our intensive care unit with a chest tube. The patient who had elevated creatinine kinase (CK), myoglobin, liver enzymes and potassium at the time of admission to our clinic was put on urgent dialysis without surgical procedure because of the absence of compartment syndrome. On the 3rd day of hospitalisation, CK and myoglobin levels did not decrease despite the absence of compartment syndrome and dialysis treatment, the patient became anuric and metabolic acidosis deepened. The patient was intubated and above elbow amputation of the right upper extremity was performed. On the 23rd day of hospitalisation, respiratory parameters and renal functions returned to normal, the patient was intubated and CVVHD treatment was terminated. On the 30th day, the patient was transferred to the ward with improved renal function, improved clinic and normal respiratory parameters.
Referanslar
Kodadek, L.; Carmichael, S.P., II; Seshadri, A.; Pathak, A.; Hoth, J.; Appelbaum, R.; Michetti, C.P.; Gonzalez, R.P. Rhabdomyolysis: An American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg. Acute Care Open 2022, 7, e000836. [CrossRef] [PubMed]
Sever, M.S.; Lameire, N.; van Biesen, W.; Vanholder, R. Disaster nephrology: A new concept for an old problem. Clin. Kidney J. 2015, 8, 300–309. [CrossRef] [PubMed]
Sever, M.S.; Vanholder, R. Management of crush victims in mass disasters: Highlights from recently published recommendations. Clin. J. Am. Soc. Nephrol. 2013, 8, 328–335. [CrossRef]
Ersoy, A.; Yavuz, M.; Usta, M.; Ercan, I.; Aslanhan, I.; Güllülü, M.; Kurt, E.; Emir, G.; Dilek, K.; Yurtkuran, M. Survival analysis of the factors affecting in mortality in injured patients requiring dialysis due to acute renal failure during the Marmara earthquake: Survivors vs non-survivors. Clin. Nephrol. 2003, 59, 334–340. [CrossRef]
Long, S.; Garrett, J.; Bhargava, P.; Aguilar, G.; Simoncini, A.; Sangster, G. Multimodality imaging findings in rhabdomyolysis and a brief review of differential diagnoses. Emerg. Radiol. 2017, 24, 387–392. [CrossRef] 6) Stahl K, Rastelli E, Schoser B. A systematic review on the definition of rhabdomyolysis. J Neurol 2020; 267:877.
[Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Crit Care 2005; 9:158.
Khan FY. Rhabdomyolysis: a review of the literature. Neth J Med 2009; 67:272. 9) Akmal M, Massry SG. Reversible hepatic dysfunction associated with rhabdomyolysis. Am J Nephrol 1990; 10:49
Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med 2009; 361:62.
Gabow PA, Kaehny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine (Baltimore) 1982; 61:141.
Veenstra J, Smit WM, Krediet RT, Arisz L. Relationship between elevated creatine phosphokinase and the clinical spectrum of rhabdomyolysis. Nephrol Dial Transplant 1994; 9:637.
Criddle LM. Rhabdomyolysis. Pathophysiology, recognition, and management. Crit Care Nurse 2003; 23:14.
Long B, Koyfman A, Gottlieb M. An evidence-based narrative review of the emergency department evaluation and management of rhabdomyolysis. Am J Emerg Med 2019; 37:518. 15) Grifoni E, Fabbri A, Ciuti G, et al. Hypokalemia-induced rhabdomyolysis. Intern Emerg Med 2014; 9:487.
Sani MA, Campana-Salort E, Begu-LeCorroller A, et al. Non-traumatic rhabdomyolysis and diabetes. Diabetes Metab 2011; 37:262. 17) Cabral BMI, Edding SN, Portocarrero JP, Lerma EV. Rhabdomyolysis. Dis Mon 2020; 66:101015.
Weidhase L, de Fallois J, Haußig E, et al. Myoglobin clearance with continuous veno-venous hemodialysis using high cutoff dialyzer versus continuous veno-venous hemodiafiltration using high-flux dialyzer: a prospective randomized controlled trial. Crit Care 2020; 24:644.
Stewart IJ, Faulk TI, Sosnov JA, et al. Rhabdomyolysis among critically ill combat casualties: associations with acute kidney injury and mortality. J Trauma Acute Care Surg. 2016 Mar;80(3):492–8
Gibney RT, Sever MS, Vanholder RC. Disaster nephrology: crush injury and beyond. Kidney Int. 2014 May;85(5):1049–57. 21) Wald R, Quinn RR, Luo J, et al. Chronic dialysis and death among survivors of acute kidney injury requiring dialysis. JAMA 2009; 302:1179.
Janice L. Zimmerman, Michael C. Shen MD, Rhabdomyolysis, Chest Volume 144, Issue 3, September 2013, Pages 1058-1065
Muhammed Köroğlu, Mustafa Karakaplan, Mohammed Barakat, Predictive factors for acute kidney injury and amputation in crush injuries from the Kahramanmaraş earthquakes, Ulus Travma Acil Cerrahi Derg, June 2024, Vol. 30, No. 7
