Problemy terapii pacjentów z zespołem zmiażdżenia (rabdomioliza) – opis przypadku

Waldemar Machała¹, Katarzyna Śmiechowicz¹, Leszek Markuszewski², Wojciech Gaszyński³

Summary
Background. The crush syndrome can be defined as a systemic multi organ failure that follows massive limb injury. The basic physiology of the crush syndrome is rhabdomyolysis, leading to renal failure. Case report. We describe a case of a 49-yr-old man, whose right arm was crushed and traumatically amputated during a traffic accident. The man was trapped in the debris of a bus in which he had been travelling, and firemen needed 60 minutes to free him from the wreck. He was taken to hospital where his arm was initially reimplanted. Immediately after surgery he was transferred to the ICU and extubated after 30 minutes. He underwent re-operation after three hours because of severe bleeding from the reimplanted arm. Fifteen hours after the second operation he became oliguric (0.1 ml kg h^-1), with dark red urine. The serum myoglobin concentration increased to 6400 ng ml^-1, and the creatine kinase was 43240 U l^-1. The reimplanted limb was amputated, and he was treated with massive transfusions of RBC and FFP and continuous arteriovenous haemofiltration for 6 days. The man eventually recovered and was transferred to a low-dependency unit 12 days after the accident. Discussion. The crush syndrome was first described in the 19^th century and its pathophysiology was described during the 2^nd World War. Sudden release of a large amount of myoglobin leads to renal failure, hypokalemia and hypocalcemia. Early and vigorous fluid resuscitation followed by alkaline-mannitol diuresis prevents acute renal failure in crush victims; in late stages renal replacement therapy and parenteral nutrition may be necessary.

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