Double entrapment neuropathy of the ulnar nerve at the elbow and the wrist : double crush syndrome?

BACKGROUND: Double crush syndrome refers to a nerve in the proximal region being compressed, affecting its proximal segment. Instances of this syndrome involving ulnar and cubital canals during ulnar neuropathy are rare. Diagnosis solely through clinical examination is challenging. Although electromyography (EMG) and nerve conduction studies (NCS) can confirm neuropathy, they do not incorporate inching tests at the wrist, hindering diagnosis confirmation. We recently encountered eight cases of suspected double compression of ulnar nerve, reporting these cases along with a literature review. METHODS: The study included 5 males and 2 females, averaging 45.6 years old. Among them, 4 had trauma history, and preoperative McGowan stages varied. Ulnar neuropathy was confirmed in 7 cases at both cubital and ulnar canal locations. Surgery was performed for 4 cases, while conservative treatment continued for 3 cases. RESULTS: In 4 cases with wrist involvement, 2 showed ulnar nerve compression by a fibrous band, and 1 had nodular hyperplasia. Another case displayed ulnar nerve swelling with muscle covering. Among the 4 surgery cases, 2 improved from preoperative McGowan stage IIB to postoperative stage 0, with significant improvement in subjective satisfaction. The remaining 2 cases improved from stage IIB to IIA, respectively, with moderate improvement in subjective satisfaction. In the 3 cases receiving conservative treatment, satisfaction was significant in 1 case and moderate in 2 cases. Overall, there was improvement in hand function across all 7 cases. CONCLUSION: Typical outpatient examinations make it difficult to clearly differentiate the two sites, and EMG tests may not confirm diagnosis. Therefore, if a surgeon lacks suspicion of this condition, diagnosis becomes even more challenging. In cases with less than expected postoperative improvement in clinical symptoms of cubital tunnel syndrome, consideration of double crush syndrome is warranted. Additional tests and detailed EMG tests, including inching tests at the wrist, may be necessary. We aim to raise awareness double crush syndrome with ulnar nerve, reporting a total of 7 cases to support this concept.

Mortality predictors in earthquake victims admitted to intensive care unit in Kahramanmaras earthquakes.

BACKGROUND: The purpose of this study is to report the data for patients followed-up in our intensive care unit due to the 6th February 2023, earthquake in Kahramanmaras, Türkiye, and to investigate parameters affecting mortality. METHODS: The demographic characteristics of patients followed-up in intensive care due to trauma following the earthquake, the treatments administered, developing complications, lengths of stay in the hospital and intensive care, and laboratory data were scanned retrospectively and recorded. These data were then compared between the surviving and non-surviving patients. RESULTS: Twenty-six patients, 13 (50 %) male, were followed-up in our intensive care, 24 (92 %) due to being buried under earthquake debris, and 2 (8 %) due to falling from heights. Increased Sequential Organ Failure Assessment (SOFA) (p = 0.027), higher initial serum potassium (p = 0.043), higher initial serum phosphorus (p = 0.035), higher initial and peak serum magnesium (p = 0.004 and p = 0.001), lower initial and peak bicarbonate (p = 0.021 and p = 0.012) and higher initial and peak serum base deficit values (p = 0.012 and p = 0.009) were associated with mortality. In the subgroup with crush injuries, higher initial and peak serum potassium (p = 0.001 and p = 0.025), higher initial and peak serum magnesium (p = 0.005 and p = 0.004), lower initial and peak bicarbonate (p = 0.019 and p = 0.021) and higher initial and peak serum base deficit values (p = 0.017 and p = 0.025) were associated with mortality. Multiorgan dysfunction failure developed in nine patients, sepsis in seven, dissemine intravascular coagulation in four, and acute respiratory distress syndrome in two. Fasciotomy was performed on 2 (8 %) patients and amputation on 8 (31 %). Extremity injuries were most frequently observed. 10 (38.5 %) of the 12 (46 %) patients developing acute kidney injury required renal replacement therapy. 7 (27 %) patients died during follow-up. In logistic regression analysis, higher SOFA scores, lower initial bicarbonate and BE levels, higher serum initial potassium and magnesium levels were a risk factor for mortality. Higher SOFA scores, lower initial bicarbonate and base deficit and higher initial phosphorus values affected mortality in patients with crush syndrome. CONCLUSION: Not only increased SOFA, serum potassium, serum phosphorus, and serum magnesium, but also decreased bicarbonate, and base deficit were associated with mortality in earthquake victims with crush syndrome in ICU.

Rosmarinic acid plus deferasirox inhibits ferroptosis to alleviate crush syndrome-related AKI via Nrf2/Keap1 pathway.

BACKGROUND: Myoglobin (Mb) induced death of renal tubular epithelial cells (RTECs) is a major pathological factor in crush syndrome-related acute kidney injury (CS-AKI). It is unclear whether ferroptosis is involved and could be a target for treatment. PURPOSE: This study aimed to evaluate the potential therapeutic effects of combining the natural small molecule rosemarinic acid (RA) and the iron chelator deferasirox (Dfe) on CS-AKI through inhibition of ferroptosis. METHODS: Sequencing data were downloaded from the GEO database, and differential expression analysis was performed using the R software limma package. The CS-AKI mouse model was constructed by squeezing the bilateral thighs of mice for 16 h with 1.5 kg weight. TCMK1 and NRK-52E cells were induced with 200 µM Mb and then treated with RA combined with Dfe (Dfe + RA, both were 10 µM). Functional and pathological changes in mouse kidney were evaluated by glomerular filtration rate (GFR) and HE pathology. Immunofluorescence assay was used to detect Mb levels in kidney tissues. The expression levels of ACSL4, GPX4, Keap1, and Nrf2 were analyzed by WB. RESULTS: We found that AKI mice in the GSE44925 cohort highly expressed the ferroptosis markers ACSL4 and PTGS2. CS-AKI mice showed a rapid decrease in GFR, up-regulation of ACSL4 expression in kidney tissue, and down-regulation of GPX4 expression, indicating activation of the ferroptosis pathway. Mb was found to deposit in renal tubules, and it has been proven to cause ferroptosis in TCMK1 and NRK-52E cells in vitro. We found that Dfe had a strong iron ion scavenging effect and inhibited ACSL4 expression. RA could disrupt the interaction between Keap1 andNrf2, stabilize Nrf2, and promote its nuclear translocation, thereby exerting antioxidant effects. The combination of Dfe and RA effectively reversed Mb induced ferroptosis in RTECs. CONCLUSION: In conclusion, we found that RA combined with Dfe attenuated CS-AKI by inhibiting Mb-induced ferroptosis in RTECs via activating the Nrf2/Keap1 pathway.

Surgical and critical care management of earthquake musculoskeletal injuries and crush syndrome: A collective review.

Earthquakes are unpredictable natural disasters causing massive injuries. We aim to review the surgical management of earthquake musculoskeletal injuries and the critical care of crush syndrome. We searched the English literature in PubMed without time restriction to select relevant papers. Retrieved articles were critically appraised and summarized. Open wounds should be cleaned, debrided, receive antibiotics, receive tetanus toxoid unless vaccinated in the last 5 years, and re-debrided as needed. The lower limb affected 48.5% (21.9%-81.4%) of body regions/patients. Fractures occurred in 31.1% (11.3%-78%) of body regions/patients. The most common surgery was open reduction and internal fixation done in 21% (0%-76.6%), followed by plaster of Paris in 18.2% (2.3%-48.8%), and external fixation in 6.6% (1%-13%) of operations/patients. Open fractures should be treated with external fixation. Internal fixation should not be done until the wound becomes clean and the fractured bones are properly covered with skin, skin graft, or flap. Fasciotomies were done in 15% (2.8%-27.2%), while amputations were done in 3.7% (0.4%-11.5%) of body regions/patients. Principles of treating crush syndrome include: (1) administering proper intravenous fluids to maintain adequate urine output, (2) monitoring and managing hyperkalemia, and (3) considering renal replacement therapy in case of volume overload, severe hyperkalemia, severe acidemia, or severe uremia. Low-quality studies addressed indications for fasciotomy, amputation, and hyperbaric oxygen therapy. Prospective data collection on future medical management of earthquake injuries should be part of future disaster preparedness. We hope that this review will carry the essential knowledge needed for properly managing earthquake musculoskeletal injuries and crush syndrome in hospitalized patients.

Advancing crush syndrome management: the potent role of Sodium zirconium cyclosilicate in early hyperkalemia intervention and survival enhancement in a rat model.

Background: Crush Syndrome (CS), a severe trauma resulting from prolonged muscle compression, is commonly seen in large-scale disasters such as earthquakes. It not only causes localized tissue damage but also triggers electrolyte imbalances, particularly hyperkalemia, increasing the risk of early mortality. This study aims to assess the early intervention effects of Sodium Zirconium Cyclosilicate (SZC) on hyperkalemia in rat CS model. Methods: A rat CS model was established using a self-developed multi-channel intelligent small-animal crush injury platform. Rats in the experimental groups were treated with varying doses of SZC before compression and immediately post-decompression. The efficacy of SZC was evaluated by continuous monitoring of blood potassium levels and survival rates. Serum creatinine (Cre) and blood urea nitrogen (BUN) levels were analyzed, and renal damage was assessed through histopathological examination. Results: SZC treatment significantly reduced blood potassium levels and improved survival rates in rats. Compared to the placebo group, the SZC-treated rats showed a significant decrease in blood potassium levels at 6 and 12 h post-decompression, maintaining lower levels at 24 h. Biochemical analysis indicated no significant impact of SZC on renal function, with no notable differences in Cre and BUN levels between groups. Histopathological findings revealed similar levels of renal damage in both groups. Conclusion: SZC demonstrates significant early intervention effects on hyperkalemia in a rat model of crush injury, effectively improving survival rates without adverse effects on renal function. These results provide a new strategic direction for the clinical treatment of Crush Syndrome and lay the foundation for future clinical applications.

From Tragedy to Resilience in a University Hospital: Characteristics of Patients in the Aftermath of the 2023 Turkey Earthquake.

OBJECTIVE: This study focuses on adults affected by the February 2023 Turkey earthquakes, aiming to uncover demographic and clinical traits. METHODS: A retrospective analysis of data from adult patients who sought emergency care between February 6 and February 21, 2023, following the earthquakes, was conducted. RESULTS: Among 3072 patients, 1544 (50.3%) of whom were women, trauma (31.1%) was the most prevalent cause of emergency department presentations. The median age of all patients was 44 y (interquartile range [IQR] 31-61 y). Hatay province accounted for 65.2% of trauma patients as origin. Most of the patients (66.8%) presented to the emergency department by their own means, while this was opposite for trauma patients, of whom 54.5% was transferred by means of Ambulance Service. Half of the total trauma patients were rescued from the debris, and 75.9% sustained limb injuries. Crush syndrome affected 24.7%, and emergency hemodialysis was performed on 9.1%, whereas emergency surgery was performed on 22.8% of all trauma cases. Overall, 10.2% of trauma patients lacked any identification. The rate of emergency department admittions due to respiratory and cardiovascular diseases was higher at the time of the earthquake compared with the previous year (P < 0.001). CONCLUSIONS: The insights gained from this study hold valuable implications for disaster response strategies, emphasizing the importance of preparedness, timely intervention, and comprehensive patient care.

After the Türkiye Earthquake: The Experience of a Pediatric Emergency Department in a University Hospital Distant from the Disaster Area.

INTRODUCTION: Earthquakes rank among the most deadly natural disasters, and children are particularly affected due to their inherent vulnerability. Following an earthquake, there is a substantial increase in visits to emergency services. These visits stem not only from patients seeking care for physical traumas resulting from the earthquake and its subsequent complications, but also from individuals affected by the circumstances created by the disaster. STUDY OBJECTIVE: This study aims to determine the characteristics and outcomes of children who presented to the pediatric emergency department (PED) after the earthquake and to evaluate children who had crush injuries at a referral tertiary university hospital away from the earthquake area. METHODS: The medical records of children who presented to the PED from the earthquake area from February 6 through March 7, 2023 were retrospectively reviewed. Children rescued from under rubble were categorized as Group 1, those affected by earthquake conditions as Group 2, and patients seeking medical attention due to the follow-up of chronic illnesses were considered as Group 3. Patient data, including sociodemographic characteristics, time period under rubble (TPR), laboratory findings, and details of medical and surgical procedures, developing acute kidney injury (AKI), and the requirement for hemodialysis were recorded. RESULTS: A total of 252 children were enrolled in the study, with 52 (20.6%) in Group 1, 180 (71.4%) in Group 2, and 16 (6.0%) in Group 3. The median age was six (IQR = 1.7-12.1) years. In the first group (n = 52), 46 (85.2%) children experienced crush injuries, 25 children (46.3%) developed crush syndrome, and 14 of them (14/25; 56.0%) required dialysis. In the second group, the most common diagnoses were upper respiratory tract infections (n = 69; 37.9%), acute gastroenteritis (n = 23; 12.6%), simple physical trauma (n = 16; 8.8%), and lower respiratory tract infections (n = 13; 7.1%). For children in the third group, pediatric neurology (n = 5; 33.3%), pediatric oncology (n = 4; 25.0%), and pediatric nephrology (n = 3; 18.8%) were the most frequently referred specialties. CONCLUSION: Crush injuries, crush syndrome, and AKI were the most common problems in the early days following the earthquake. Along with these patients, children who were affected by the environmental conditions caused by the earthquake, as well as children with chronic illnesses, also accounted for a significant portion of visits to the PED, even if they were distant from the disaster area.

Reviving the Grasp: A Case Report on a Pioneering Approach to Managing Crush Syndrome and Unveiling the Occult Compartment Syndrome.

A crush injury results directly from a crushing force, while crush syndrome, or traumatic rhabdomyolysis, manifests as systemic consequences stemming from the breakdown of muscle cells. Hand crush injuries present intricate challenges involving damage to multiple structures, tissue loss, and potential digit amputation, often caused by high-energy trauma. Each case demands a unique management plan, with the critical decision between limb salvage and amputation. Early intervention to restore vascularity is pivotal for preserving hand function. The complexity is heightened by the occult compartment syndrome, characterized by increased pressure causing neurovascular compromise without external signs. A patient with an insensate limb due to ipsilateral pan brachial plexus injury (BPI) adds an additional layer of complexity to the management journey, emphasizing the need for a multidisciplinary approach. This case is unique and underscores the importance of prioritizing reconstruction, identifying crush syndrome and the occult compartment syndrome, and employing a strategic, decisive approach that includes various surgical techniques for optimal outcomes in complex hand injuries.

Evaluation of musculoskeletal system injuries after the 2023 Kahramanmaras Turkey earthquakes: Our single-center experience.

INTRODUCTION: This study aimed to retrospectively analyze patients who presented to the orthopedic and traumatology clinic following the 2023 Kahramanmaras earthquakes. PATIENTS AND METHODS: Over a week after the earthquakes, two hundred and sixty patients were consulted at our clinic. Demographic data of the patients, duration of being under the rubble, fracture locations, types of surgeries performed, number of surgical sessions attended by individuals, and early mortality rate within one month were determined. RESULTS: The mean age of the patients was 40.2 ± 22.4 years. One hundred thirty-eight (53.1%) were female, and 122 (46.9%) were male. The average duration of being under the rubble was determined as 27.1 ± 28.0 hours. Sixteen patients died within one month after the earthquake. The one-month mortality rate among patients with orthopedic injuries was 6.15%. Forty-seven fasciotomies were performed in 35 patients, and 22 amputations were performed in 19 patients. The most injured region was the lower extremity (78 cases, 40%). The ratio of external and internal fixation in extremity fractures was 22%. CONCLUSIONS: The management of musculoskeletal injuries can be successful with proper triage and treatment plans. Decisions regarding fasciotomy and amputation in patients with crush syndrome following an earthquake should be individualized. Implant sets should be planned accordingly, especially considering the higher occurrence of lower extremity injuries.

The 2023 Türkiye-Syria earthquakes: analysis of pediatric victims with crush syndrome and acute kidney Injury.

BACKGROUND: On February 6th, 2023, two consecutive earthquakes struck southeastern Türkiye with magnitudes of 7.7 and 7.6, respectively. This study aimed to analyze the clinical and laboratory findings, as well as management of pediatric victims with Crush Syndrome (CS) and Acute Kidney Injury (AKI). METHODS: The study included pediatric earthquake victims who were presented to Mersin University Hospital. Clinical and laboratory characteristics of the patients were collected retrospectively. RESULTS: Among 649 patients, Crush injury (CI), CS and AKI was observed in 157, 59, and 17 patients, respectively. White blood cell count (12,870 [IQR: 9910-18700] vs. 10,545 [IQR: 8355-14057] /µL, P < 0.001), C-reactive protein (51.27 [IQR: 14.80-88.78] vs. 4.59 [1.04-18.25] mg/L, P < 0.001) and myoglobin levels (443.00 [IQR: 198.5-1759.35] vs. 17 [11.8-30.43] ng/ml) were higher in patients with CS, while their sodium (IQR: 134 [131-137] vs. 136 [134-138] mEq/L, P < 0.001) levels were lower compared to non-CS patients. An increase in myoglobin levels was identified as an independent risk factor for developing CS (OR = 1.017 [1.006-1.027]). Intravenous fluid replacement was administered to the patients with CS at a dose of 4000 cc/m2/day. Hypokalemia was observed in 51.9% of the CS patients on the third day. All patients with AKI showed improvement and no deaths were reported. CONCLUSIONS: Hyponatremia and increase in inflammation markers associated with CS may be observed. An increase in myoglobin levels was identified as a risk factor for CS. Hypokalemia may be seen as a complication of vigorous fluid therapy during hospitalization.

Patients With and Without Double Crush Syndrome Achieve Similar Rates of Clinical Improvement Following Carpal Tunnel Release.

BACKGROUND: The purpose of this study is to compare outcomes of carpal tunnel release (CTR) in patients with and without double crush syndrome (DCS), defined as concurrent carpal tunnel syndrome (CTS) and cervical radiculopathy at C5-T1 on preoperative nerve conduction studies. METHODS: Patients with preoperative nerve conduction studies who underwent unilateral, isolated CTR were retrospectively identified. All patients completed preoperative and 3-month postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI), and Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaires, and responded to the anchor question: "Since your treatment, how would you rate your overall function?" (much worse, worse, slightly worse, no change, slightly improved, improved, much improved). Preoperative, postoperative, and changes in scores for UE, PI, and QuickDASH were compared, as were the anchor question responses and rates of achieving the minimal clinically important difference (MCID). RESULTS: Sixty-three patients with DCS and 115 patients with CTS only were included. At 3- to 4-month follow-up, absolute and change in UE, PI, and QuickDASH scores were not statistically different between patients with DCS and CTS. Rates of anchor question response and MCID achievement were comparable for patients with CTS only and DCS on each questionnaire. The MCID achievement ranged from 48.4% to 68.8% in the unmatched cohort and 48.4% to 60% in the matched group. CONCLUSIONS: At 3 to 4 months, patients with DCS experience similar patient-reported symptomatic and functional improvement, and achieve MCID of outcome measures at comparable rates to patients with CTS only. For patients with nerve compression at the carpal tunnel and cervical spine, CTR is a reasonable first step prior to proceeding with cervical spine decompression.

Pediatric kidney care experience after the 2023 Turkey/Syria earthquake.

BACKGROUND/AIMS: Two earthquakes on February 6th, 2023 destroyed ten cities in Türkiye. We report our experience with pediatric victims during these catastrophes, with a focus on crush syndrome related-acute kidney injury (Crush-AKI) and death. METHOD: A web-based software was prepared. Patient demographics, time under rubble (TUR), admission laboratory data, dialysis, and kidney and overall outcomes were asked. RESULTS: 903 injured children (median age: 11.62 years) were evaluated. Mean TUR was 13 h (Interquartile range-IQR: 32.5), max 240 h). 31 of 32 patients with a TUR of >120 h survived. The patient who rescued after ten days survived.Two-thirds of the patients were given 50 mEq/L sodium-bicarbonate in 0.45% sodium-chloride solution on admission day. 58% of patients were given intravenous fluid (IVF) at a volume of 2000-3000 mL/m2 body surface area (BSA), 40% of 3000-4000 mL/m2 BSA, and only 2% of >4000 mL/m2 BSA. 425 patients had surgeries, 48 suffered from major bleeding. Amputations were recorded in 96 patients. Eighty-two and 66 patients required ventilator and inotropic support, respectively.Crush-AKI developed in 314 patients (36% of all patients). 189 patients were dialyzed. Age > 15 years, creatine phosphokinase (CK)≥20 950 U/L, TUR≥10 h, and the first-day IVF volume < 3000-4000 mL/m2 BSA were associated with Crush-AKI development. 22 deaths were recorded, 20 of 22 occurred in patients with Crush-AKI and within the first 4 days of admission. All patients admitted after 7 days survived. CONCLUSIONS: This is the most extensive pediatric kidney disaster data after an earthquake. Serum CK level was significantly associated with Crush-AKI at the levels of >20 950 U/L, but not with death. Adolescent age and initial IVF of less than 3000-4000 mL/m2 BSA were also asscoiated with Crush-AKI. Given that mildly injured victims can survive longer periods in the disaster field, we suggest uninterrupted rescue activity for at least 10 days.

Factors affecting the mortality of February earthquakes victims in Türkiye.

OBJECTIVE: >50,000 people died in the February 2023 earthquakes in Türkiye. The aim of this study was to identify the factors affecting mortality rates of the trauma patients who were presented to the emergency department (ED) after the earthquake and provide suggestions for better preparedness strategies for future natural disasters. METHODS: This retrospective, cross-sectional study encompassed data from 955 trauma patients out of 3072 patients aged 18 years and above who sought assistance in the ED. Patients were divided into two groups: the survivor group and the exitus group. Age, gender, the city where patients came from, type of presentation, injured organ systems and mechanisms of injury, laboratory findings, the diagnoses in the ED, time spent in the ED, surgical intervention, and hemodialysis sessions were analyzed. The characteristics of those who could not be identified at the presentation to the ED were subjected to additional analysis. RESULTS: Out of 955 patients, 75.9% had extremity injuries, with crushing injuries (23.6%) being predominant. There were no significant differences in age or gender between the survivor and exitus groups (p = 0.776, p = 0.522), nor in the province of admission (p = 0.249). Clinical factors indicated that the exitus group were more likely to lack identification documents (29.6%), have spent longer trapped under debris, and have a higher frequency of ambulance transportation. Injuries such as chest and abdominal trauma, specific injury types, and amputation or open wounds were notably more frequent in the exitus group. Diagnoses revealed that metabolic causes were more common in exitus group (p < 0.001). While no significant difference existed in the need for emergency surgical intervention (p = 0.939), a higher frequency of emergency hemodialysis was observed among exitus group (p = 0.001). Laboratory findings indicated higher levels of various markers and lower calcium, base excess, and pH levels among those in the exitus group. CONCLUSION: In the aftermath of a devastating earthquake, this study underscores the formidable challenges faced by healthcare systems during natural disasters. To prepare for future disasters, healthcare systems must enhance resilience, develop rapid identification techniques, and adopt a holistic patient care approach.

Prehospital management of earthquake crush injuries: A collective review.

Earthquakes are natural disasters which can destroy the rural and urban infrastructure causing a high toll of injuries and death without advanced notice. We aim to review the prehospital medical management of earthquake crush injuries in the field. PubMed was searched using general terms including rhabdomyolysis, crush injury, and earthquake in English language without time restriction. Selected articles were critically evaluated by three experts in disaster medicine, emergency medicine, and critical care. The medical response to earthquakes includes: (1) search and rescue; (2) triage and initial stabilization; (3) definitive care; and (4) evacuation. Long-term, continuous pressure on muscles causes crush injury. Ischemia-reperfusion injury following the relieving of muscle compression may cause metabolic changes and rhabdomyolysis depending on the time of extrication. Sodium and water enter the cell causing cell swelling and hypovolemia, while potassium and myoglobin are released into the circulation. This may cause sudden cardiac arrest, acute extremity compartment syndrome, and acute kidney injury. Recognizing these conditions and treating them timely and properly in the field will save many patients. Majority of emergency physicians who have worked in the field of the recent Kahramanmaras 2023, Turkey, earthquakes, have acknowledged their lack of knowledge and experience in managing earthquake crush injuries. We hope that this collective review will cover the essential knowledge needed for properly managing seriously crushed injured patients in the earthquake field.

Factors predicting kidney replacement therapy in pediatric earthquake victims with crush syndrome in the first week following rescue.

Crush syndrome due to traumatic rhabdomyolysis is one of the most significant problems to occur following earthquakes. On February 6, 2023, millions of people in Turkey were affected by two consecutive Kahramanmaras earthquakes. The present study reports the analysis of clinical and laboratory findings of crush syndrome in pediatric earthquake victims admitted to our hospital from our region where the earthquake had a devastating effect. Clinical and laboratory findings concerning earthquake victims with crush syndrome were analyzed within the first week to determine what factors are predictive of kidney replacement therapy (KRT). The data of patients were retrospectively collected from medical records. A total of 310 children were admitted as earthquake victims to the pediatric emergency department. Ninety-seven (31%) of these patients had crush syndrome. Fifty-three (55%) of those with crush syndrome were female. The mean age was 10.9 ± 4.7 years, and the mean time under the rubble was 30.6 ± 23.8 h. Twenty-two patients (23%) required KRT. Hemodialysis was applied to 16 (73%) of them, and hemodiafiltration was applied to the other six (27%) in the pediatric intensive care unit. Regarding creatine kinase (CK) levels, the area under the receiver operating characteristic (ROC) curve (AUC) for predicting KRT was 0.905 (95% confidence interval [CI] 0.848-0.963; p < 0.001). The optimal cut-off value was 40,000 U/L with a sensitivity of 86% and a specificity of 83%. In terms of the percentage of body area crushed, the AUC for predicting KRT was 0.907 (95% CI 0.838-0.976; p < 0.001). The optimal cut-off value was 30% with a sensitivity of 86% and a specificity of 88%. Multiple logistic regression analysis showed that each 10% increase in body area crushed (OR 4.16, 95% CI 1.58-10.93, p = 0.004) and 1 mg/dl increase in the serum phosphorus level (OR 4.19, 95% CI 1.71-10.28, p = 0.002) were significant risk factors for dialysis treatment. CONCLUSIONS: Crush syndrome and kidney problems are common following disasters like earthquakes. Clinical and laboratory findings at admission can predict dialysis requirement in earthquake victims. While CK elevation, body area crushed percentage, and increased phosphorus level were predictive of dialysis treatment, time under the rubble was not. Even if the patients were under the rubble for a short time, acute kidney injury (AKI) may develop as a result of severe hypovolemia due to crush injuries, and patients may need KRT. WHAT IS KNOWN: •Crush syndrome after earthquakes needs to be treated carefully in victims and can cause AKI and mortality when not treated timely and appropriately. WHAT IS NEW: •CK level elevation, body area crushed percentage, and increased phosphorus level are predictive of dialysis treatment. •The time under the rubble may not be predictive of dialysis requirement.

The Evaluation of Different Treatment Approaches in Patients With Earthquake-Related Crush Syndrome.

BACKGROUND: On February 6, 2023, an earthquake occurred in Kahramanmaras, Turkey, resulting in loss of life, injuries, and the displacement of thousands of people. The aim of this study is to determine the factors affecting amputation and fasciotomy decisions in patients with crush syndrome, along with clinical laboratory parameters. MATERIALS AND METHODS: The study included patients over 18 years of age who presented with crush injuries and exhibited systemic symptoms. Inclusion criteria comprised patients with creatine kinase (CK) levels exceeding 1,000 IU/L, oliguria (urine output less than 400 mL per day), elevated blood urea nitrogen (BUN) levels surpassing 40 mg/dL, serum creatinine exceeding 1.5 mg/dL, potassium levels over 6 mEq/L, phosphorus levels surpassing 8 mg/dL, and serum calcium levels below 8 mg/dL. Multiple parameters were evaluated, including blood glucose, serum sodium, potassium, calcium, phosphorus, BUN, creatinine, uric acid, CK, albumin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, direct bilirubin, prothrombin time (international normalized ratio (INR)), urinalysis, C-reactive protein (CRP), venous blood gas, ECG, and chest radiography. RESULTS: Following the Maras earthquake, a total of 3,184 patients were admitted to our hospital within the first seven days. Out of these patients, 2,216 received outpatient treatment, 639 were hospitalized in the general ward, and 128 were admitted to the intensive care unit. Among the admitted patients, 237 were diagnosed with crush syndrome, with 126 being male and 111 being female. The average duration of being trapped under debris was eight hours, ranging from four to 36 hours. In the study population, extremity trauma was observed in 84 patients, thoracic trauma in 32 patients, and abdominal trauma in 20 patients. Erythrocyte replacement was administered to 123 patients, while fresh frozen plasma was given to 69 patients, for a total of 1008 units utilized. Mannitol infusions were provided to 58 patients, while bicarbonate infusions were administered to 116 patients. Among the cohort, 71 patients underwent dialysis, with nine of them receiving hemodialysis along with mannitol. Additionally, 67 patients experienced stage 3 acute kidney injury, and 41 patients were deceased. None of the patients required permanent hemodialysis. CONCLUSION: Earthquakes are considered to be one of nature's most significant and inevitable disasters. While it is impossible to prevent them, effective management strategies are crucial in mitigating the ensuing chaos and reducing casualties. In order to achieve this, it is imperative to draw lessons from past seismic events and apply appropriate treatment protocols to the affected individuals.

Progress in the Diagnostic and Predictive Evaluation of Crush Syndrome.

Crush syndrome (CS), also known as traumatic rhabdomyolysis, is a syndrome with a wide clinical spectrum; it is caused by external compression, which often occurs in earthquakes, wars, and traffic accidents, especially in large-scale disasters. Crush syndrome is the second leading cause of death after direct trauma in earthquakes. A series of clinical complications caused by crush syndrome, including hyperkalemia, myoglobinuria, and, in particular, acute kidney injury (AKI), is the main cause of death in crush syndrome. The early diagnosis of crush syndrome, the correct evaluation of its severity, and accurate predictions of a poor prognosis can provide personalized suggestions for rescuers to carry out early treatments and reduce mortality. This review summarizes various methods for the diagnostic and predictive evaluation of crush syndrome, including urine dipstick tests for a large number of victims, traditional and emerging biomarkers, imaging-assisted diagnostic methods, and developed evaluation models, with the aim of providing materials for scholars in this research field.

[Acute deltoid compartment syndrome]. / Cas clinique. Syndrome de loge aigu du deltoïde.

In this article, we present a rare type of acute compartment syndrome affecting the deltoid muscle, which occurred after a crush syndrome in a patient discovered at home in a stuporous state. Although compartment syndromes are not rare, certain circumstances cause unusual consequences and localizations, shoulder impotence in the present case. The importance of an early diagnosis is obvious to avoid the risk of irreversible lesions. We describe predisposing circumstances and provide a brief review of the pathophysiology of this syndrome.

Nous présentons un type rare de syndrome de loge aigu touchant le deltoïde apparu après un crush syndrome chez un patient découvert au domicile dans un état stuporeux. Bien que les syndromes de loge ne soient pas rares au sens large du terme, certaines circonstances provoquent des conséquences et localisations inhabituelles, une impotence de l'épaule dans le cas rapporté. L'importance de réaliser un diagnostic précoce est évidente au risque de laisser évoluer des lésions irréversibles. Nous décrivons les circonstances favorisantes et présentons un bref rappel concernant la physiopathologie de ce syndrome.

The prevalence of double- and multiple crush syndromes in patients surgically treated for peripheral nerve compression in the upper limb.

OBJECTIVE: The double crush syndrome describes a condition characterized by multifocal entrapment of a nerve. In the upper limb, the high prevalence of carpal tunnel syndrome makes it a common diagnosis of assumption in the setting of median neuropathy. More proximal compressions may tend to be overlooked, under-diagnosed and under-treated in the population. This study aims to map the prevalence of peripheral upper limb nerve compressions among patients undergoing peripheral nerve decompression. METHODS: A prospective case series was conducted on 183 patients undergoing peripheral nerve decompression in a private hand surgery clinic. Level(s) of nerve compression in the median, ulnar and radial nerves were determined by history and physical examination. The prevalence of each nerve compression syndrome or combination of syndromes was analyzed. RESULTS: A total of 320 upper limbs in 183 patients were analyzed. A double crush of the median nerve at the levels of the lacertus fibrosus and carpal tunnel was identified in 78% of upper limbs with median neuropathy, whereas isolated lacertus syndrome and carpal tunnel syndrome were present in only 5% and 17% of affected limbs respectively. Cubital tunnel syndrome affected 12.5% of upper limbs, and 80% of these had concomitant lacertus and carpal tunnel syndromes, compared to only 7.5% with isolated cubital tunnel syndrome. CONCLUSION: A high prevalence should prompt clinicians towards more routine assessment for double crush syndrome to avoid misdiagnosis, inadequate treatment, recurrence, and revision surgeries.