LONG PRESSURE SYNDROME
LONG PRESSURE SYNDROME (syn: long crush syndrome, crash syndrome) develops as a result of prolonged crushing of limbs (usually lower) by the ground, heavy objects, fragments. It occurs in victims of earthquakes, blockages in mines, landslides, etc. As a rule, the syndrome develops during compression, the duration of which is more than 4 hours (sometimes less), and the mass of injured tissues exceeds the mass of the upper limb. There is also a syndrome of positional compression, or positional syndrome , resulting from a prolonged (within 8 to 24 hours) stay of the victim in one position due to an unconscious state (coma, poisoning, etc.) or severe alcohol intoxication. At the same time, one of the limbs is pressed (usually the upper one).
The clinical picture . The severity of clinical manifestations depends on the degree and duration of compression of the limb, the volume and depth of the lesion, as well as on the combined damage to other organs and structures (traumatic brain injury, trauma to internal organs, bones, joints, blood vessels, nerves, etc.).
I period (initial, or early) is characterized by local changes and endogenous intoxication. It lasts 2 to 3 days after release from compression. Typical is the relatively good condition of the victims immediately after extraction from the blockage. Only a few hours later, local changes occur in the segment subjected to compression. The limb becomes pale, finger cyanosis appears, swelling quickly builds up, the skin acquires a woody density. The pulsation of the peripheral vessels is not determined. With the deepening of local changes, the general condition of the victim worsens. Pain, psycho-emotional stress, and a drop in blood pressure predominate. 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 extremity, which has undergone compression, is enhanced, 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 is increasing, diuresis is sharply reduced, up to anuria. In the blood, the content of residual nitrogen, urea, creatinine, potassium increases, and a picture of uremia develops. The body temperature rises, the condition of the victim deteriorates sharply, lethargy and lethargy increase, vomiting and thirst appear, and yellowness of the sclera and skin. Despite intensive care, mortality in this period can reach 35%.
III period (recovery) begins from 3-4 weeks. In this period, local changes prevail over general ones, and kidney function is restored. Infectious complications of open injuries, as well as wounds after strip incisions and fasciotomy, come to the fore. Generalization of infection with the development of sepsis is possible. In uncomplicated cases, swelling of the limb and pain in it by the end of the month pass. The victims persist for a long time expressed anemia, hypoproteinemia, dysproteinemia (hypoalbuminemia, hyperglobulinemia), blood hypercoagulation; changes in urine (protein, cylinders). These changes are persistent and, despite intensive infusion therapy, tend to normalize on average by the end of the month of intensive treatment.
Most victims for a long time remain deviations in the emotional and psychological status in the form of depressive or reactive psychoses and hysteria.
Urgent care. Before the limb is released, a tourniquet should be applied to its free proximal part. To the victim, 2 ml of a 2% solution of promedol, 2 ml of a 1% solution of diphenhydramine are administered intravenously or intramuscularly. They release the limb and bandage it tightly from the tips of the fingers to the tourniquet. Carry out transport immobilization. Cover the limb with ice. The victim must be taken to the nearest surgical hospital as soon as possible.
If possible, a case-based novocaine blockade can be carried out with a 0.25% solution of novocaine in the proximal part of the stiff limb. If there are wounds, they are mechanically cleaned, dressings with antiseptic and dehydrating properties are applied. During evacuation, immobilization correction is performed, painkillers and sedatives are continued to be administered, and infusion therapy (polyglyukin, reopoliglyukin, 5% glucose solution, 4% sodium bicarbonate solution, etc.) is carried out. For the prevention of wound infection, combinations of broad-spectrum antibiotics are used with the mandatory inclusion of an antibiotic of the penicillin group in them (given the frequent isolation of clostridial flora from wounds).
At the hospital stage, intensive anti-shock and resuscitation measures are carried out. The amount and composition of intravenous transfusion media in the amount of 2000 - 4000 ml or more per day is regulated according to the daily diuresis and homeostasis. The composition of the injected liquids includes freshly frozen plasma, glucose-novocaine mixture, 5% glucose solution with vitamins, 5% or 10% albumin solution, 4% sodium bicarbonate solution, mannitol solution at the rate of 1 g per 1 kg of body weight, detoxification agents (hemodes neohaemodesis). To stimulate diuresis, furosemide is prescribed up to 80 mg or more per day, papaverine, aminophylline , for the prevention of thrombosis, heparin is administered at 2,500 units 4 times a day, antiplatelet agents (dipyridamole, pentoxifylline), according to indications, retabolil or phenobolin, cardiovascular agents are used, immunocorrectors. In the prevention of acute renal failure, the use of prostaglandin E2 (prostenone) is effective, 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 treatment is ineffective for 8-12 hours, signs of cerebral and pulmonary edema appear, hemodialysis in ultrafiltration mode is indicated. Plasmapheresis is recommended for patients with severe intoxication, which ensures the most complete removal of toxic metabolic products from the body. Hyperbaric oxygenation sessions reduce tissue hypoxia. For the purpose of detoxification, cleansing enemas are done daily, enterodesis is prescribed for 1 teaspoon in 1/2 cup of water 3 times a day or activated charcoal.
When bleeding due to uremia and disseminated intravascular coagulation, emergency plasmapheresis is indicated followed by transfusion of freshly frozen plasma up to 1000 ml, the appointment 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 damaged limb, the presence or absence of crushed wounds and bone fractures. Severe edema and tension of the soft tissues of the squeezed limb segment, the appearance of blisters with hemorrhagic contents, the rapid growth of cyanosis indicate gross microcirculation disorders and the danger of developing an extensive necrotic process. Carrying out wide fasciotomies with dissection of the fascial cases can restore blood flow and eliminate tissue compression. After fasciotomies, rare sutures are applied to the skin leaving drainage tubes. The inefficiency of a compressed limb is an indication of amputation.
In the presence of crushed wounds, thorough primary surgical treatment is performed with a wide opening of the wounds, excision of obviously non-viable tissues, removal of foreign bodies and freely lying bone fragments, plentiful washing with antiseptics.
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. In the absence of opportunities or conditions for the application of these devices, fixation is performed using plaster casts (a circular plaster cast cannot be applied!) Or skeletal traction (the victim is not planned to be evacuated to other specialized institutions).
In the following days, depending on the condition of the victim, the position of the fragments is corrected, staged necrectomy, intensive local treatment with the use of antiseptic, enzymatic and dehydrating properties. After cleansing the wound surface from necrotic tissue and the appearance of fresh granulations, skin plastic surgery is performed.
In the late recovery period, victims need rehabilitation and rehabilitation treatment using physiotherapy exercises, physiotherapeutic methods, and spa treatment. Reconstructive interventions are performed according to indications.