LONG-TERM SEDDRIVING BY SYNDROME
DURATION OF SYNDROME SURGERY (syn: prolonged crush syndrome, crash syndrome) develops as a result of prolonged crushing of the limbs (often lower ones) with earth, heavy objects, debris. It occurs in people affected by earthquakes, shoals in mines, collapses, etc. As a rule, the syndrome develops with compression, the duration of which is more than 4 hours (sometimes less), and the mass of injured tissues exceeding the mass of the upper limb. There is also positional compression syndrome, or positional syndrome , resulting from prolonged (during 8-24 hours) stay of the victim in one position due to unconsciousness (coma, poisoning, etc.) or strong alcohol intoxication. In this case, one of the limbs is pressed down (often the upper one).
Clinical picture . The severity of clinical manifestations depends on the degree and duration of compression of the limb, the extent and depth of the lesion, as well as on the combined damage of other organs and structures (craniocerebral trauma, internal organs, bones, joints, vessels, nerves, etc.).
I period (initial, or early) is characterized by local changes and endogenous intoxication. It lasts 2 to 3 days after being released from compression. Typical is the relatively prosperous condition of the victims immediately after removal from the obstruction. Only in a few hours there are local changes in the segment that has been squeezed. The limb becomes pale, cyanosis of the fingers appears, the swelling rapidly builds up, the skin acquires a woody density. Pulsation of peripheral vessels is not determined. With the deepening of local changes, the general condition of the victim worsens. The pain syndrome prevails, psychoemotional stress, falling blood pressure. The condition of the victim can rapidly deteriorate with the development of acute cardiovascular failure.
II period (intermediate) - the period of acute renal failure - lasts from 3 - 4 to 8-12 days. The swelling of the limb that has undergone compression is increased, which is accompanied by the formation of blisters with transparent or hemorrhagic contents, dense infiltrates, local, and sometimes total necrosis of the entire limb. Anemia increases, diuresis drastically decreases, down to anuria. In the blood, the content of residual nitrogen, urea, creatinine, potassium increases, the picture of uremia develops. The body temperature rises, the condition of the victim dramatically worsens, lethargy and inhibition increase, vomiting and thirst, icteric sclera and skin appear. Despite intensive therapy, mortality in this period can reach 35%.
III period (regenerative) begins with the 3rd -4th week. In this period, local changes prevail over the general, the function of the kidneys is restored. Infectious complications of open injuries, as well as injuries after lamphatic incisions and fasciothiomas, come to the fore. It is possible to generalize the infection with the development of sepsis. In uncomplicated cases, edema of the limb and pain in it by the end of the month pass. The long-term anemia, hypoproteinemia, dysproteinemia (hypoalbuminemia, hyperglobulinemia), hypercoagulability of blood are preserved for the victims; Changes in the urine (protein, cylinders). These changes are persistent and, despite intensive infusion therapy, tend to normalize by the end of the month of intensive treatment.
The majority of victims for a long time remain deviations in the emotional and mental status in the form of depressive or reactive psychoses and hysteria.
Urgent care. Before releasing the limb, a tourniquet should be applied to its free proximal part. Intake of intravenous or intramuscular injection of 2 ml of a 2% solution of promedol, 2 ml of a 1% solution of dimedrol. They release the limb and tightly bandage it from the fingertips to the harness. Carry out transport immobilization. Finish the limb with ice. The victim must be delivered as soon as possible to the nearest surgical hospital.
If possible, a case of Novocaine blockade with a 0.25% solution of novocain in the proximal part of the squeezed limb can be carried out. In the presence of wounds, they are mechanically cleaned, bandages are applied with antiseptic and dehydrating properties. During the evacuation, the immobilization is corrected, the analgesics and sedatives are continued, infusion therapy is performed (polyglucin, reopolyglucin, 5% glucose solution, 4% sodium hydrogen carbonate solution, etc.). For the prevention of wound infection, combinations of broad-spectrum antibiotics are used with the mandatory inclusion of an antibiotic in the penicillin group (given the frequent isolation of the clostridial flora from the wound).
At the hospital stage, intensive anti-shock and resuscitation measures are carried out. The amount and composition of intravenous transfusion media in the volume of 2000-4000 ml and more per day is regulated by the data of daily diuresis and indices of homeostasis. The composition of the infusion liquids includes fresh frozen plasma, glucose-novocaine mixture, 5% glucose solution with vitamins, 5% or 10% albumin solution, 4% sodium hydrogen carbonate solution, mannitol solution at the rate of 1 g per 1 kg of body weight, detoxification agents (hemodez , Neohemodesis). To stimulate diuresis, furosemide is prescribed up to 80 mg or more per day, papaverine, and euphyllinum, for the prevention of thrombosis, 2500 U of heparin is administered 4 times a day, disaggregants (dipyridamole, pentoxifylline), indications are retabolil or phenoboline, cardiovascular agents, Immunocorrectors. In the prevention of acute renal failure effectively use prostaglandin E2 (prostenone), which is administered intravenously for 3 to 5 days. Intensive conservative treatment should ensure urination in an amount of at least 30 ml per hour.
If the treatment is ineffective for 8-12 h, the appearance of signs of cerebral edema and lungs shows hemodialysis in the ultrafiltration regime. Victims with severe intoxication are recommended to conduct plasmapheresis, which ensures the most complete removal of toxic metabolic products from the body. The sessions of hyperbaric oxygenation reduce the degree of tissue hypoxia. With the goal of detoxification, daily cleansing enemas are made, an enterozeis is prescribed for 1 teaspoon per 1/2 cup water 3 times a day or activated charcoal.
With bleeding due to uremia and disseminated intravascular coagulation, an urgent plasmapheresis is shown, followed by transfusion of fresh-frozen plasma to 1000 ml, administration of a protease inhibitor (gordox, contrikal) against the background of continued administration of heparin.
Surgical tactics depend on the condition of the victim, the degree of ischemia of the injured limb, the presence or absence of crushed wounds and fractures of bones. The pronounced edema and tension of the soft tissues of the compressed segment of the limb, the appearance of blisters with hemorrhagic contents, the rapid growth of cyanosis indicate gross violations of microcirculation and the danger of developing a vast necrotic process. Conducting wide fasciotomy with dissection of fascial cases can restore blood flow and eliminate compression of tissues. After fasciotomy, rare stitches are left on the skin leaving the drainage tubes. The non-viability of the limb that has undergone compression is an indication of its amputation.
In the presence of crushed wounds, thorough primary surgical treatment with wide opening of wounds, excision of obviously nonviable tissues, removal of foreign bodies and freely lying bone fragments, extensive washing with antiseptics are carried out.
Fixation of bone fractures should be carried out with the help of compression-distraction apparatus at first even without the final and complete adaptation of the fragments. If there are no possibilities or conditions for imposing these devices, fixation is performed with gypsum longots (circular gypsum dressing can not be applied!) Or skeletal traction (the evacuation of the victim to other specialized institutions is not planned himself).
In the following days, depending on the condition of the victim, the position of the fragments is corrected, stage necrosectomies, intensive local treatment with the use of antiseptic, enzymatic and dehydrating agents. After purification of the wound surface from necrotic tissues and the appearance of fresh granulations, the skin is plasticized.
In the late recovery period, the victims need rehabilitation and restorative treatment with the use of physiotherapy exercises, physiotherapy methods and sanatorium-and-spa treatment. The indications are reconstructive and restorative interventions.