地震所致挤压综合征的早期诊治
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摘要
[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7~101h,平均27.8h;受伤到接受治疗的时间8~112h,平均38h;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21.34mmol/L,Cr平均365.6μmol/L,CK平均54022IU/L,12例血钾升高(5.01~7.82mmol/L,平均值6.0mmol/L),17例血钙降低(1.25~2.09mmol/L,平均值1.71mmol/L)。6例患者肌酐水平轻度升高,平均164μmol/L,CK平均8723IU/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1834ml。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。
[Objective]To assess the early diagnosis and treatment and outcome of patients with crush syndrome in earthquake disaster.[Method]We conducted a retrospective analysis of 27 patients with crush syndrome and subsequent acute renal failure (ARF) and wound complication who were treated in our university hospital.All of patients had been extricated from buildings that collapsed in the Wenchuan earthquake.Crush injury involved the upper extremities and low extremities.Each patient received intravenous fluids and diuretic drugs.Twenty-one patients received hemodialysis.Emergency fasciotomy performed in 11 patients and amputation were performed in 16 patients,4 to 102 hours after extrication.[Result]No patient died.Twenty-one patients among the ARF patients were retracted from hemodialysis.Among the patients who were performed fasciotomy or amputation,13 patients had wound complication including infection,however,the wounds in 10 patients were healed by dressing change,debridement and coordinate treatment with ICU and related subjectives.[Conclusion]Crush syndrome requires urgent recognition and prompt surgical treatment with simultaneous measures to control hyperkalemia and ARF.Wound healing is a difficult task for the crush syndrome patients.The authors believe that immediate intensive care therapy and multisubjective coordination would improve the survival rate.
[Objective]To assess the early diagnosis and treatment and outcome of patients with crush syndrome in earthquake disaster.[Method]We conducted a retrospective analysis of 27 patients with crush syndrome and subsequent acute renal failure (ARF) and wound complication who were treated in our university hospital.All of patients had been extricated from buildings that collapsed in the Wenchuan earthquake.Crush injury involved the upper extremities and low extremities.Each patient received intravenous fluids and diuretic drugs.Twenty-one patients received hemodialysis.Emergency fasciotomy performed in 11 patients and amputation were performed in 16 patients,4 to 102 hours after extrication.[Result]No patient died.Twenty-one patients among the ARF patients were retracted from hemodialysis.Among the patients who were performed fasciotomy or amputation,13 patients had wound complication including infection,however,the wounds in 10 patients were healed by dressing change,debridement and coordinate treatment with ICU and related subjectives.[Conclusion]Crush syndrome requires urgent recognition and prompt surgical treatment with simultaneous measures to control hyperkalemia and ARF.Wound healing is a difficult task for the crush syndrome patients.The authors believe that immediate intensive care therapy and multisubjective coordination would improve the survival rate.
引文
[1]Dario G.Crush syndrome[J].Crit Care Med,2005,33:34-41.
[2]Demirkiran O,Dikmen Y,Utku T,et al.Crush syndrome patients after the Marmara earthquake[J].Emerg Med J,2003,20:247-250.
[3]Pepe E,Mosesso VN,Falk JL.Prehosipital fluid resuscitation of the patient with major traum[J].Prehosp Emerg Care,2002,6:81-91.
[4]Better OS,Stein JH.Early management of shock and prophylaxis of a-cute renal failure in traumatic rhabdomyolysis[J].N Eng J Med,1990,322:825-829.
[5]Ran D.Taitelman U,Michaelson M,et al.Prevention acute renal fail-ure in traumatic rhabdomyalysis[J].Arch Intern Med,1984,144:277-280.
[6]Hussain A,Kwak HC,Pallister I.Crush syndrome:a comprehensivesurgical strategy improves outcome[J].Injury,2006,12:53.
[7]Shemazu T,Yoshioka T,Nakata Y,et al.Fluid resuscitation and sys-tem complications in crush syndrome:14Hanshin-Awaji earthquake patients[J].J Truma,1997,42:641-646.
[8]Simth J,Greaves I.Crush injury and crush sundrome:a review[J].J Trauma,2003,54:226-230.
[9]Collins AJ.Kidney dialysis treatment for victims of the Armenian earthquake[J].N Engl J Med,1989,320:1291-1292.
[10]Atef Zafarmamd A,FademS.Disaster nephrology:medical perspective[J].Adv Ren Replace Ther,2003,10:104-106.
[11]Tanaka H,Oda J,Iwai A,et al.Morbidity and mortality of hospitalized patients after the1995Hanshin-Awaji earthquake[J].Am J Emerg Med,1999,17:186-191.
[12]Coupland RM.Epidemiological approach to surgical management of the casualties of war[J].Br Med J,1994,308:1693-1697.
[13]Kuwagata Y,Oda J,Tanaka H,et al.Analysis of2702traumatized pa-tients in the1995Hanshin-Awaji earthquake[J].J Trauma,1997,43:427-432.
[14]Shoaf KI,Sareen HR,Nguyen LH,et al.Injuries as a results of Cali-fornia earthquakes in the past decade[J].Disasters,1998,22:218-235.
[15]Roy N,Shah H,Patel V,et al.The Gujarat erathquake experience in a seismically unprepared area:community hospital medical response[J].Prehosp Disaster Med,2002,17:186-195.
[2]Demirkiran O,Dikmen Y,Utku T,et al.Crush syndrome patients after the Marmara earthquake[J].Emerg Med J,2003,20:247-250.
[3]Pepe E,Mosesso VN,Falk JL.Prehosipital fluid resuscitation of the patient with major traum[J].Prehosp Emerg Care,2002,6:81-91.
[4]Better OS,Stein JH.Early management of shock and prophylaxis of a-cute renal failure in traumatic rhabdomyolysis[J].N Eng J Med,1990,322:825-829.
[5]Ran D.Taitelman U,Michaelson M,et al.Prevention acute renal fail-ure in traumatic rhabdomyalysis[J].Arch Intern Med,1984,144:277-280.
[6]Hussain A,Kwak HC,Pallister I.Crush syndrome:a comprehensivesurgical strategy improves outcome[J].Injury,2006,12:53.
[7]Shemazu T,Yoshioka T,Nakata Y,et al.Fluid resuscitation and sys-tem complications in crush syndrome:14Hanshin-Awaji earthquake patients[J].J Truma,1997,42:641-646.
[8]Simth J,Greaves I.Crush injury and crush sundrome:a review[J].J Trauma,2003,54:226-230.
[9]Collins AJ.Kidney dialysis treatment for victims of the Armenian earthquake[J].N Engl J Med,1989,320:1291-1292.
[10]Atef Zafarmamd A,FademS.Disaster nephrology:medical perspective[J].Adv Ren Replace Ther,2003,10:104-106.
[11]Tanaka H,Oda J,Iwai A,et al.Morbidity and mortality of hospitalized patients after the1995Hanshin-Awaji earthquake[J].Am J Emerg Med,1999,17:186-191.
[12]Coupland RM.Epidemiological approach to surgical management of the casualties of war[J].Br Med J,1994,308:1693-1697.
[13]Kuwagata Y,Oda J,Tanaka H,et al.Analysis of2702traumatized pa-tients in the1995Hanshin-Awaji earthquake[J].J Trauma,1997,43:427-432.
[14]Shoaf KI,Sareen HR,Nguyen LH,et al.Injuries as a results of Cali-fornia earthquakes in the past decade[J].Disasters,1998,22:218-235.
[15]Roy N,Shah H,Patel V,et al.The Gujarat erathquake experience in a seismically unprepared area:community hospital medical response[J].Prehosp Disaster Med,2002,17:186-195.
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