Renal Failure, 14(3), 245-249 (1992)
Acute Renal Failure in Natural Disasters
Ren Fail Downloaded from informahealthcare.com by University of Toronto on 11/23/14 For personal use only.
Eric K. Noji, MD, MPH Centers for Disease Control Atlanta, Georgia
ABSTRACT
Sudden-impact natural disasters such as earthquakes present a serious challenge to medical personnel in both developed and less developed countries. Crush syndrome with acute renal failure has been identijied as a major medical complication that occurs among people whose limbs are trapped b!. heal:\. objects during natural disasters such as earthquakes or volcanic eruptions. Rescue andjeld medical teams should be trained to recognize and proriiptly trelii the problems associated with prolonged limb compression and shoirlrl cnrr-y the appropriate jluicis and medications to treat the complications of trmrrrr:tic rhabdomyolysis. Early, aggressive volume replacementfolhved byforced solute-alkaline diuresis therapy may protect the kidney against acute renal fi:ilure. Better epidemiologic knowledge of the specijc disaster conditions that predispose traumatic rhabdomyolysis to develop is clearly essential for those who must determine when emergency dialysis services are required in response to injuries sustained during natural disasters. Disaster health care personnel involved with providing emergency acute renal care should have a basic familiarity with disaster epidemiology in order to determine whether a given event requires their intervention. R i s paper includes recommendations for improving medical planning, preparedness, and response to natural disasters that cause acute renal failure.
INTRODUCTION
occurs potentially during this type of natural disaster. I will not discuss the detailed issues of clinical management of traumatic rhabdornyolysis, since those are covered in great depth in other papers in this journal (e.g., “Traumatic rhabdomyolysis: reevaluation of its pathophysiology and early management” by On Better). Rather, I will describe the epidemiology of sudden-impact disasters such as earthquakes and make several important
Sudden-impact naatural disasters such as earthquakes and volcanic eruptions present a serious challenge to medical personnel in both developed and less developed countries. I will focus on earthquakes, since traumatic rhabdornyolysis with acute renal failure (“crush syndrome”) has been identified as a major medical complication that 245 Copyright 0 1992 by Marcel Dekker, Inc.
246
Noji
recommendations for improving medical planning, preparedness, and response to natural disasters that cause injuries that lead to acute renal failure. Better epidemiologic knowledge of the causes of death and of the type of injuries and illnesses caused by natural disasters is clearly essential for workers who must determine what relief supplies, equipment, and personnel are needed to respond effectively to such situations (Guha-Sapir and Lechat, 1986, Noji, 1991).
Ren Fail Downloaded from informahealthcare.com by University of Toronto on 11/23/14 For personal use only.
TRAUMATIC RHABDOMYOLYSIS Traumatic rhabdomyolysis, or crush syndrome, results from prolonged continuous pressure on muscles. As a result of such pressure, muscle tissue disintegrates, releasing myoglobin, potassium, and phosphorus into the circulation. If untreated, hypovolemic shock and hyperkalemia may ensue, then acute renal failure (Odeh, 1991). Crush syndrome is generally associated with a high rate of morbidity and mortality. Apparently, muscle constituents such as myoglobin and potassium are not released into the circulation until the trapped extremities have been freed and decompressed. Decompression is followed rapidly by adverse metabolic changes (e.g., hyperkalemia, hyperphosphatemia, hypocalcemia, and metabolic acidosis) and “third spacing” of fluid (Better, 1989). Acute renal failure may then develop in newly rescued persons with traumatic rhabdomyolysis if the volume of lost intravenous fluids is not replaced within at least 6 h (Better and Stein, 1990). In a recent study of crush injuries, researchers found that acute renal failure developed among 16.5% of the patients with rhabdomyolysis. The mortality rate for this subgroup of patients with acute renal failure was 42.3% (Ward, 1988). There are anecdotal reports of patients who suffered a crush injury, were located by rescuers, initially appeared to be doing well, and then deteriorated rapidly upon successful extrication from entrapment. Several possible causes could explain this phenomenon, which has been called “rescue death.” When a person’s trapped limb is released, several detrimental pathophysiologic processes occur simultaneously-besides the release of myoglobin, potassium, and phosphorus into the circulation. Upon extrication, fairly well oxygenated blood returns to the ischemic extremity. With abnormal vascular integrity, a precipitious loss of intravascular volume (third spacing) occurs immediately and may result in the sudden onset of clinical shock. In extensive rhabdomyolysis, more than 12 L of fluid may be sequestered in injured muscles for 48 h. This amount of “third-spaced” fluid is equal to the
volume of extracellular fluid in a 75-kg adult (Better, 1990). A rescue worker’s lack of knowledge about these rapid and massive changes in internal fluid volume may mean sudden death for the just-rescued person with crush injuries. Clearly, after extensive muscle damage, only quick, aggressive replacement of lost intravenous fluids will prevent irreversible shock. In addition to this loss of intravascular fluid in injured limbs, large amounts of products of anaerobic metabolism, such as organic acids (e.g., lactic acid), enter the circulation rapidly after the limb is released, causing a systemic acidosis. As already mentioned, dangerous quantitites of potassium enter the systemic circulation as the result of the disintegration of muscle tissue and the release of high levels of intracellular potassium. Other not wellcharacterized toxins are also liberated from the extremity and enter the circulation, exposing the rest of the body to their adverse effects (Eneas and Schoenfeld, 1979). Sudden systemic exposure to organic acids, potassium, and various toxins can be rapidly fatal. For example, hyperkalemia and acidosis (which by itself can result in rapid release of intracellular potassium from nondamaged cells) can result in cardiac arrest, usually asystole.
CRUSH SYNDROME IN EARTHQUAKES Trauma caused by partial or complete collapse of structures such as buildings or bridges is the overwhelming cause of death and injury during or immediately after most earthquakes. An overview of several studies done in southern Italy after the 1980 Compania-Basilicata earthquake showed that of 97 randomly chosen patients who had been transported to Naples, at least 19 developed crush syndrome, 12 of whom also developed acute renal failure (Frei, 1990). After an earthquake in North Yemen in 1982, a Swiss team found only 2 adults who had developed acute renal failure. Both had suffered severe injuries to the pelvis and the extremities. Since renal dialysis was unavailable, both died of acute renal failure. Traumatic rhabdomyolysis with secondary acute renal failure was also identified as a major problem after the 1988 Armenian earthquake (Andrews and Souma, 1989; Collins, 1989). The large number of injured patients who developed acute renal failure in Armenia completely overwhelmed the region’s capacity for effective treatment. More than 100 kidney dialysis machines were flown into the country from overseas as part of a massive international relief effort (Van der Reljden and Van der Neut, 1989). Interestingly, in only a few cases have researchers
Ren Fail Downloaded from informahealthcare.com by University of Toronto on 11/23/14 For personal use only.
ARF in Natural Disasters
described finding large numbers of earthquake victims suffering from crush syndrome. Crush syndrome was clearly a major problem following the Armenian earthquake in 1988 (Andrews and Souma, 1989; Collins, 1989; Richards et al., 1989; Noji 1989a) and, to a lesser extent, after the 1985 earthquake in Mexico City (Freeman and Moorhead, 1985; Villazon-Sahagun, 1986); these two events were characterized by the collapse of multistory, reinforced concrete or stone buildings. However, traumatic rhabdomyolysis followed by acute renal failure has not been documented in the wake of other recent great earthquakes in which most of the deaths and injuries resulted from the collapse of single-story adobe or brick structures (Whittaker et al., 1974; de Ville de Goyet C et al., 1976; Ortiz et al., 1986; Durkin, 1987). In the great earthquake in Tangshan, China (1976), crush syndrome accounted for only 2 % to 5 % of all injuries (Zhi-Yong, 1987). This incidence is remarkably low, considering the large number of people whose extremities were trapped for many hours under the debris of crumbled walls and ceiling. Nor was crush syndrome seen after the major California earthquakes in 1971 and 1983 (Drukin et al., 1983), and only one case was reported following the 1989 Loma Prieta Earthquake (Jones et al., 1990). Prolonged entrapment simply has not been a problem in the collapse of one-story adobe and wood-frame structures. Although the absence of reports of crush syndrome after many earthquakes may be due to poor diagnosis and case identification, traumatic rhabdomyolysis is clearly not an inevitable consequence of all earthquakes (Noji, 1990). It appears that the occurrence of acute renal failure after earthquakes depends to a large extent on the type of buildings in the region, the weather conditions, and swiftness with which victims are extricated, the availability of on-site medical care, and the transportation times to hospitals.
MEDICAL RESPONSE TO CRUSH SYNDROME IN EARTHQUAKES When a building collapses-whether due to an earthquake, a terrorist bombing, or structural failure-many challenges confront rescue and medical personnel. Even after trapped persons are discovered, several hours may elapse before they are extricated. Some will even require amputation of their trapped limbs in order to extricate them. As noted previously, rescue personnel must be prepared for the trapped patient to deteriorate rapidly upon extrication because of decompression of limbs, shock, hyperkalemia, hypocalcemia, and severe metabolic
247
acidosis, Hyperkalemia-induced cardiac arrhythmias may be resistant to antiarrhythmic drugs such as lidocaine and to standard prehospital interventions such as defibrillation. After being crushed by a collapsing building, a person may become dehydrated, a major predisposing factor for renal failure. Unless dehydration is treated rapidly, acute renal failure may result, which will require sophisticated technical and clinical support such as hemodialysis. After studying the 1980 earthquake in Italy, Safar (1986) concluded that 25% to 50% of the victims who were injured and died slowly, could have been saved if proper first aid had been rendered immediately. Each trapped person should be evaluated medically while still trapped. As soon as the trapped leg or arm is freed, the person should be given fluids intravenously (e.g., an isotonic saline solution according to the protocol described by Better and Stein: See paper in this series by Dr. Ori Better: “Traumatic rhabdomyolysis: reevaluation of its pathophysiology and early management). While the trapped person is being given medical treatment to prevent hypovolemic shock or systemic crush syndrome, the rescue and medical workers on site should jointly decide when the trapped person will be released. Trapped persons receiving in siru medical treatment will be better stabilized for the often lengthy extrication process. In Armenia, more than 50 person-hours were frequently required to extricate one trapped person (Noji, 1989a). Once the person has been extricated, an infusion of sodium bicarbonate, calcium chloride or gluconate, insulin, and glucose may be immediately necessary to control the influx of potassium. After the person’s intravascular volume status has been stabilized, forced mannitol-alkaline diuresis therapy for prophylaxis against hyperkalemia and acute renal failure should be started (Better and Stein, 1990). Rapid attention to these pathophysiologic changes can prevent the development of systemic complications of crush syndrome, including acute renal failure (Ron and Taitelman, 1984). Other procedures have been used to prevent the systemic complications of crushing from developing. Some disaster experts recommend applying an arterial tourniquet above the trapped limp as a temporary measure to prevent crush syndrome. The rationale for using tourniquets is to prevent the release of harmful substances such as myoglobin and potassium into the central circulation. Although there is potential for irreversible ischemic and neurological damage to still viable proximal tissue, this procedure may be the best procedure in certain situations. No data are available, however, on its efficacy. Rescue personnel must also be able to recognize and
Noji
Ren Fail Downloaded from informahealthcare.com by University of Toronto on 11/23/14 For personal use only.
248
treat other problems of prolonged limb compression such as compartment syndrome. Such conditions cannot wait until the victim has been completely extricated and transported to a treatment area. If extrication cannot be effected by any other means, the entrapped extremity must be amputated in situ. Contingency plans must be in place to ensure that wellequipped, self-sufficient personnel with experience in rescuing people after buildings collapse are deployed immediately after an earthquake. Such plans are critical to avoid high mortality rates among those trapped (Noji, 1989b). On-site medical and rescue teams should work closely with the critical care and renal dialysis teams who will be caring for the trapped person after rescue. The logistics of large-scale emergency hemodialysis operations are discussed by Drs. Kim Solez and Allan Collins in their accompanying papers. Regarding supplies and the maintenance of equipment for emergency hemodialysis, it is important to provide adequate training to local health care workers in earthquake-affected regions who will ultimately be responsible for the continued operation and maintenance of hemodialysis equipment. For example, less than 2 months after the Armenian earthquake, only 28 of 103 dialysis machines were still operational (Van der Reljden and Van der Neut, 1989). Finally, we need more research on more effective ways to prevent or treat traumatic rhabdomyolysis and its associated systemic complications such as acute renal failure. For example, the efficacy of replacing fluids intravenously in situ and of applying arterial tourniquets to trapped limbs during extrication requires thorough evaluation.
CONCLUSION Within minutes to hours after injured people are extricated from collapsed buildings, many die of a combination of shock, hyperkalemia, hypocalcemia, and cardiac arrhythmias. Some of those deaths and some deaths that occur later because of acute renal failure can be prevented by early, aggressive volume replacement, preferably during the extrication process. Members of rescue teams should be trained to recognize and promptly treat the problems associated with prolonged limb compression, and they should carry the appropriate fluids and medications to treat the complications of traumatic rhabdomyolysis.
Address for reprints: Eric K. Noji MD, MPH, EHHE/NCEHIC MS: F28, Centers for Disease Control, 1600 Clifton Road, NE, Atlanta, GA 30333.
REFERENCES Andrews LG, Souma JA: Dialysis relief effort for Armenia. N EngI J Med 321(4):264-265, 1989. Better 0 s : Traumatic rhabdomyolysis (“crush syndrome”)-updated 1989. Isr J Med Sci 25:69-72, 1989. Better 0s: The crush syndrome revisited. Nephron 55:97-103. 1990. Better 0.5, Stein JH: Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med 3221825-829, 1990. Collins AJ: Kidney dialysis treatment for victims of the Armenian earthquake. N EnglJ Med 320 (19):1291-1292, 1989. de Ville de Goyet C, del Cid E, Romero A, et al: Earthquake in Guatemala: Epidemiological evaluation of the relief effort. Bull Pan Am Health Organ 10:95-109. 1976. Durkin M: The San Salvador earthquake of October 10, 1986: Casualties, search and rescue, and response of the health care system. Earrhquake Spectra 3:621-634, 1987. Durkin M, Aroni S, Coulson A: Injuries in the Coalinga earthquake. In 7he Coalinga Earthquake ofMay2. 1983. Berkely, CA: Earthquake Engineering Research Institute, 1983, pp. 271-283. Eneas J, Schoenfeld P: The effect of infusion of mannitol-sodium bicarbonate on the clinical course of myoglobinuria. Arch Int Med 139:801-805, 1979. Freeman C , Moorhead G; 1985 Mexico City earthquake: Medical and health consequences and response. Sacramento, CA: Emergency Medical Services Authority, State of California, 1985, pp. 1-10. Frei E: Crush syndrome and acute renal failure. News1 Int Soc Disaster Med 41:4-7, 1990. Guha-Sapir D, Lechat MF: Information systems and needs assessment in natural disasters: An approach for better disaster relief management. Disasters 10 (3):232-237, 1986. Jones NP, Noji EK, Smith GS, Krimgold F: Preliminary earthquake injury epidemiology report. In Bolin R (ed), 7he Loma Prietu Earthquake: Studies of Short-Term Impacts. A Natural Hazards Center Monograph. Natural Hazards Research Applications Information Center. Boulder, CO: University of Colorado, 1990, pp. 33-43. Noji EK: Medical and healthcare aspects of the 1988 earthquake in Soviet Armenia. Earrhquake Spectra suppl: 101-107, 1989a. Noji EK: Training of search and rescue teams for structural collapse events: A multidisciplinary approach. In Ohta M. Ukai T. Yamamoto Y ( e d s ) , New Aspects of Disasrer Medicine. Tokyo: Herusu Publishing Co., 1989b. pp. 150-155. Noji EK: Prophylaxis of acute renal failure in traumatic rhabdomyolysis [Letter]. N Engl J Med 323:550-551, 1990. Noji EK: Natural disasters. Crir Care Clin 7:271-292, 1991. Odeh M: The role of reperfusion-induced injury in the pathogenesis of the crush syndrome. N Engl J Med 324:1417-1422, 1991. Ortiz MR, Roman MR, Latorre AV, et al: Brief description of the effects on health of the earthquake of 3rd March 1985-Chili. Disasters 10: 125-140, 1986.
ARF in Natural Disasters
Ren Fail Downloaded from informahealthcare.com by University of Toronto on 11/23/14 For personal use only.
Richards NT, Tattersall J , McCann M, et al: Dialysis for acute renal failure due to crush injuries after the Armenian earthquake. Er Med J 298:443-445, 1989. Ron D. Taitelman U: Prevention of acute renal failure in traumatic rhabdomyolysis. Arch Intern Med. 144:277-280, 1984. Safar P: Resuscitation potentials in mass disasters. Prehosp Disaster Med 2:34-47, 1986. Van der Reljden JH, Van der Neut F: Guidelines for dialysis aidYerevan. MSF Med News Int 6: 1-20. 1989. Villazon-Sahagun A: Mexico City earthquake: Medical response. J World Assoc Disaster Med 1 : 15-20. 1986.
249 Ward MM: Factors predictive of ARF in rhabdomyolysis. Arch h e m Med 148:1553-1557, 1988. Whittaker R, Fareed D, Green P, et al: Ehthquake disaster in Nicaragua: Reflections on the initial management of massive casualties. J Trauma 14:37-43, 1974. Zhi-Yong S: Medical support in the Tangshan earthquake: A review of the management of mass casualties and certain major injuries. J Trauma 27:1130-1135, 1987.
Acute Renal Failure in Natural Disasters
Ren Fail Downloaded from informahealthcare.com by University of Toronto on 11/23/14 For personal use only.
Eric K. Noji, MD, MPH Centers for Disease Control Atlanta, Georgia
ABSTRACT
Sudden-impact natural disasters such as earthquakes present a serious challenge to medical personnel in both developed and less developed countries. Crush syndrome with acute renal failure has been identijied as a major medical complication that occurs among people whose limbs are trapped b!. heal:\. objects during natural disasters such as earthquakes or volcanic eruptions. Rescue andjeld medical teams should be trained to recognize and proriiptly trelii the problems associated with prolonged limb compression and shoirlrl cnrr-y the appropriate jluicis and medications to treat the complications of trmrrrr:tic rhabdomyolysis. Early, aggressive volume replacementfolhved byforced solute-alkaline diuresis therapy may protect the kidney against acute renal fi:ilure. Better epidemiologic knowledge of the specijc disaster conditions that predispose traumatic rhabdomyolysis to develop is clearly essential for those who must determine when emergency dialysis services are required in response to injuries sustained during natural disasters. Disaster health care personnel involved with providing emergency acute renal care should have a basic familiarity with disaster epidemiology in order to determine whether a given event requires their intervention. R i s paper includes recommendations for improving medical planning, preparedness, and response to natural disasters that cause acute renal failure.
INTRODUCTION
occurs potentially during this type of natural disaster. I will not discuss the detailed issues of clinical management of traumatic rhabdornyolysis, since those are covered in great depth in other papers in this journal (e.g., “Traumatic rhabdomyolysis: reevaluation of its pathophysiology and early management” by On Better). Rather, I will describe the epidemiology of sudden-impact disasters such as earthquakes and make several important
Sudden-impact naatural disasters such as earthquakes and volcanic eruptions present a serious challenge to medical personnel in both developed and less developed countries. I will focus on earthquakes, since traumatic rhabdornyolysis with acute renal failure (“crush syndrome”) has been identified as a major medical complication that 245 Copyright 0 1992 by Marcel Dekker, Inc.
246
Noji
recommendations for improving medical planning, preparedness, and response to natural disasters that cause injuries that lead to acute renal failure. Better epidemiologic knowledge of the causes of death and of the type of injuries and illnesses caused by natural disasters is clearly essential for workers who must determine what relief supplies, equipment, and personnel are needed to respond effectively to such situations (Guha-Sapir and Lechat, 1986, Noji, 1991).
Ren Fail Downloaded from informahealthcare.com by University of Toronto on 11/23/14 For personal use only.
TRAUMATIC RHABDOMYOLYSIS Traumatic rhabdomyolysis, or crush syndrome, results from prolonged continuous pressure on muscles. As a result of such pressure, muscle tissue disintegrates, releasing myoglobin, potassium, and phosphorus into the circulation. If untreated, hypovolemic shock and hyperkalemia may ensue, then acute renal failure (Odeh, 1991). Crush syndrome is generally associated with a high rate of morbidity and mortality. Apparently, muscle constituents such as myoglobin and potassium are not released into the circulation until the trapped extremities have been freed and decompressed. Decompression is followed rapidly by adverse metabolic changes (e.g., hyperkalemia, hyperphosphatemia, hypocalcemia, and metabolic acidosis) and “third spacing” of fluid (Better, 1989). Acute renal failure may then develop in newly rescued persons with traumatic rhabdomyolysis if the volume of lost intravenous fluids is not replaced within at least 6 h (Better and Stein, 1990). In a recent study of crush injuries, researchers found that acute renal failure developed among 16.5% of the patients with rhabdomyolysis. The mortality rate for this subgroup of patients with acute renal failure was 42.3% (Ward, 1988). There are anecdotal reports of patients who suffered a crush injury, were located by rescuers, initially appeared to be doing well, and then deteriorated rapidly upon successful extrication from entrapment. Several possible causes could explain this phenomenon, which has been called “rescue death.” When a person’s trapped limb is released, several detrimental pathophysiologic processes occur simultaneously-besides the release of myoglobin, potassium, and phosphorus into the circulation. Upon extrication, fairly well oxygenated blood returns to the ischemic extremity. With abnormal vascular integrity, a precipitious loss of intravascular volume (third spacing) occurs immediately and may result in the sudden onset of clinical shock. In extensive rhabdomyolysis, more than 12 L of fluid may be sequestered in injured muscles for 48 h. This amount of “third-spaced” fluid is equal to the
volume of extracellular fluid in a 75-kg adult (Better, 1990). A rescue worker’s lack of knowledge about these rapid and massive changes in internal fluid volume may mean sudden death for the just-rescued person with crush injuries. Clearly, after extensive muscle damage, only quick, aggressive replacement of lost intravenous fluids will prevent irreversible shock. In addition to this loss of intravascular fluid in injured limbs, large amounts of products of anaerobic metabolism, such as organic acids (e.g., lactic acid), enter the circulation rapidly after the limb is released, causing a systemic acidosis. As already mentioned, dangerous quantitites of potassium enter the systemic circulation as the result of the disintegration of muscle tissue and the release of high levels of intracellular potassium. Other not wellcharacterized toxins are also liberated from the extremity and enter the circulation, exposing the rest of the body to their adverse effects (Eneas and Schoenfeld, 1979). Sudden systemic exposure to organic acids, potassium, and various toxins can be rapidly fatal. For example, hyperkalemia and acidosis (which by itself can result in rapid release of intracellular potassium from nondamaged cells) can result in cardiac arrest, usually asystole.
CRUSH SYNDROME IN EARTHQUAKES Trauma caused by partial or complete collapse of structures such as buildings or bridges is the overwhelming cause of death and injury during or immediately after most earthquakes. An overview of several studies done in southern Italy after the 1980 Compania-Basilicata earthquake showed that of 97 randomly chosen patients who had been transported to Naples, at least 19 developed crush syndrome, 12 of whom also developed acute renal failure (Frei, 1990). After an earthquake in North Yemen in 1982, a Swiss team found only 2 adults who had developed acute renal failure. Both had suffered severe injuries to the pelvis and the extremities. Since renal dialysis was unavailable, both died of acute renal failure. Traumatic rhabdomyolysis with secondary acute renal failure was also identified as a major problem after the 1988 Armenian earthquake (Andrews and Souma, 1989; Collins, 1989). The large number of injured patients who developed acute renal failure in Armenia completely overwhelmed the region’s capacity for effective treatment. More than 100 kidney dialysis machines were flown into the country from overseas as part of a massive international relief effort (Van der Reljden and Van der Neut, 1989). Interestingly, in only a few cases have researchers
Ren Fail Downloaded from informahealthcare.com by University of Toronto on 11/23/14 For personal use only.
ARF in Natural Disasters
described finding large numbers of earthquake victims suffering from crush syndrome. Crush syndrome was clearly a major problem following the Armenian earthquake in 1988 (Andrews and Souma, 1989; Collins, 1989; Richards et al., 1989; Noji 1989a) and, to a lesser extent, after the 1985 earthquake in Mexico City (Freeman and Moorhead, 1985; Villazon-Sahagun, 1986); these two events were characterized by the collapse of multistory, reinforced concrete or stone buildings. However, traumatic rhabdomyolysis followed by acute renal failure has not been documented in the wake of other recent great earthquakes in which most of the deaths and injuries resulted from the collapse of single-story adobe or brick structures (Whittaker et al., 1974; de Ville de Goyet C et al., 1976; Ortiz et al., 1986; Durkin, 1987). In the great earthquake in Tangshan, China (1976), crush syndrome accounted for only 2 % to 5 % of all injuries (Zhi-Yong, 1987). This incidence is remarkably low, considering the large number of people whose extremities were trapped for many hours under the debris of crumbled walls and ceiling. Nor was crush syndrome seen after the major California earthquakes in 1971 and 1983 (Drukin et al., 1983), and only one case was reported following the 1989 Loma Prieta Earthquake (Jones et al., 1990). Prolonged entrapment simply has not been a problem in the collapse of one-story adobe and wood-frame structures. Although the absence of reports of crush syndrome after many earthquakes may be due to poor diagnosis and case identification, traumatic rhabdomyolysis is clearly not an inevitable consequence of all earthquakes (Noji, 1990). It appears that the occurrence of acute renal failure after earthquakes depends to a large extent on the type of buildings in the region, the weather conditions, and swiftness with which victims are extricated, the availability of on-site medical care, and the transportation times to hospitals.
MEDICAL RESPONSE TO CRUSH SYNDROME IN EARTHQUAKES When a building collapses-whether due to an earthquake, a terrorist bombing, or structural failure-many challenges confront rescue and medical personnel. Even after trapped persons are discovered, several hours may elapse before they are extricated. Some will even require amputation of their trapped limbs in order to extricate them. As noted previously, rescue personnel must be prepared for the trapped patient to deteriorate rapidly upon extrication because of decompression of limbs, shock, hyperkalemia, hypocalcemia, and severe metabolic
247
acidosis, Hyperkalemia-induced cardiac arrhythmias may be resistant to antiarrhythmic drugs such as lidocaine and to standard prehospital interventions such as defibrillation. After being crushed by a collapsing building, a person may become dehydrated, a major predisposing factor for renal failure. Unless dehydration is treated rapidly, acute renal failure may result, which will require sophisticated technical and clinical support such as hemodialysis. After studying the 1980 earthquake in Italy, Safar (1986) concluded that 25% to 50% of the victims who were injured and died slowly, could have been saved if proper first aid had been rendered immediately. Each trapped person should be evaluated medically while still trapped. As soon as the trapped leg or arm is freed, the person should be given fluids intravenously (e.g., an isotonic saline solution according to the protocol described by Better and Stein: See paper in this series by Dr. Ori Better: “Traumatic rhabdomyolysis: reevaluation of its pathophysiology and early management). While the trapped person is being given medical treatment to prevent hypovolemic shock or systemic crush syndrome, the rescue and medical workers on site should jointly decide when the trapped person will be released. Trapped persons receiving in siru medical treatment will be better stabilized for the often lengthy extrication process. In Armenia, more than 50 person-hours were frequently required to extricate one trapped person (Noji, 1989a). Once the person has been extricated, an infusion of sodium bicarbonate, calcium chloride or gluconate, insulin, and glucose may be immediately necessary to control the influx of potassium. After the person’s intravascular volume status has been stabilized, forced mannitol-alkaline diuresis therapy for prophylaxis against hyperkalemia and acute renal failure should be started (Better and Stein, 1990). Rapid attention to these pathophysiologic changes can prevent the development of systemic complications of crush syndrome, including acute renal failure (Ron and Taitelman, 1984). Other procedures have been used to prevent the systemic complications of crushing from developing. Some disaster experts recommend applying an arterial tourniquet above the trapped limp as a temporary measure to prevent crush syndrome. The rationale for using tourniquets is to prevent the release of harmful substances such as myoglobin and potassium into the central circulation. Although there is potential for irreversible ischemic and neurological damage to still viable proximal tissue, this procedure may be the best procedure in certain situations. No data are available, however, on its efficacy. Rescue personnel must also be able to recognize and
Noji
Ren Fail Downloaded from informahealthcare.com by University of Toronto on 11/23/14 For personal use only.
248
treat other problems of prolonged limb compression such as compartment syndrome. Such conditions cannot wait until the victim has been completely extricated and transported to a treatment area. If extrication cannot be effected by any other means, the entrapped extremity must be amputated in situ. Contingency plans must be in place to ensure that wellequipped, self-sufficient personnel with experience in rescuing people after buildings collapse are deployed immediately after an earthquake. Such plans are critical to avoid high mortality rates among those trapped (Noji, 1989b). On-site medical and rescue teams should work closely with the critical care and renal dialysis teams who will be caring for the trapped person after rescue. The logistics of large-scale emergency hemodialysis operations are discussed by Drs. Kim Solez and Allan Collins in their accompanying papers. Regarding supplies and the maintenance of equipment for emergency hemodialysis, it is important to provide adequate training to local health care workers in earthquake-affected regions who will ultimately be responsible for the continued operation and maintenance of hemodialysis equipment. For example, less than 2 months after the Armenian earthquake, only 28 of 103 dialysis machines were still operational (Van der Reljden and Van der Neut, 1989). Finally, we need more research on more effective ways to prevent or treat traumatic rhabdomyolysis and its associated systemic complications such as acute renal failure. For example, the efficacy of replacing fluids intravenously in situ and of applying arterial tourniquets to trapped limbs during extrication requires thorough evaluation.
CONCLUSION Within minutes to hours after injured people are extricated from collapsed buildings, many die of a combination of shock, hyperkalemia, hypocalcemia, and cardiac arrhythmias. Some of those deaths and some deaths that occur later because of acute renal failure can be prevented by early, aggressive volume replacement, preferably during the extrication process. Members of rescue teams should be trained to recognize and promptly treat the problems associated with prolonged limb compression, and they should carry the appropriate fluids and medications to treat the complications of traumatic rhabdomyolysis.
Address for reprints: Eric K. Noji MD, MPH, EHHE/NCEHIC MS: F28, Centers for Disease Control, 1600 Clifton Road, NE, Atlanta, GA 30333.
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