TRAUMATIC TOXICOSIS (Greek trauma, traumatos wound, damage; toxicosis; these.: a syndrome of long crush, a krash-syndrome, a syndrome of crush, a syndrome of traumatic compression, crush a syndrome) — the peculiar morbid condition developing at injured long (4 — 8 hours and more) crushes of soft tissues of extremities fragments of the destroyed buildings, constructions, blocks of soil at collapses in mines, etc.
Local a wedge, manifestations of extensive damages from crush are described by N. I. Pirogov. Later from crush reported Kalmers about an injury (Calmers, 1909), Franken-tal (L. Frankenthal, 1916), G. Kyut-tner (1918). The albuminuria at victims of crush was described by Bossar (Bossar, 1882), and «nephrite with an albuminuria and a hamaturia» is noted by Zilberstern (P. Silberstern, 1909). Morfol. changes in kidneys of victims are studied by Gakkardt (Hackardt,
1917); Levin (A. Levin, 1919); Mines (S. Minami, 1923). The general reaction of an organism in response to release of victims from under ruins and recovery of blood circulation in the affected extremity is described Kenya (E. And. V. A. Quenu,
1918) as toxemic shock.
T. t. (krash-eindry) as specific reaction of an organism to long crush of extremities fragments of the buildings destroyed during the bombing of the English cities was described in 1941 by Bayuo-ters and Bill (E. G. L. By waters,
D. Beall). A. Ya. Pytel (1945) called this state a syndrome of crush and traumatic compression of extremities. H. N. Elansky, observing this state at victims during an earthquake in Ashgabat, called it traumatic toxicosis. Results of pilot studies and studying wedge, pictures T. t. at victims allowed M. I. Kuzin to establish direct dependence between extensiveness and duration of crush and weight of a current of it patol. states.
At destruction of the cities as a result of earthquakes long crush of extremities with characteristic signs of T. t. it was observed at 3,5 — 5% of victims. At the same time crush of the lower extremities was noted more often (79,9%), than upper (14%), simultaneous damage of top and bottom extremities — in 6,1%.
At long crush as at any mechanical injury, the organism is influenced by three factors: painful (destructive, according to I. P. Pavlov) the irritation causing a difficult complex to it-rogumoralnykh and the neuroendocrinal frustration characteristic of a heavy stress (see); the traumatic toxaemia (see) caused by absorption of toxic products of an autolysis of fabrics from the center of defeat; plazmo-and blood loss, connected with hypostasis and hemorrhages in a zone of crushed or it is long ischemic fabrics. Initial changes in an organism are similar to a picture of heavy traumatic hypovolemic shock (see), later changes — to a picture of an acute renal failure (see).
As a result of generalization wedge, observations by Bayuoters, H. N. Elansky, A. Ya. Pytel put forward the toxemic theory of a pathogeny of T. t. Really, main manifestations of T. t. arise through a nek-swarm time after elimination of a compression and recovery of a blood-groove in the damaged part of a body. Muscular tissue of the injured extremity, according to Bayuoters, in several hours after recovery of a blood-groove loses 75% of a myoglobin and phosphorus, 70% of creatine, 66% of potassium, to-rye together with products of an autolysis of muscular tissue (peptides, proteolytic enzymes) come to a blood channel and cause so-called toxemic shock.
Plazmopoter at T. t. reaches the considerable sizes, leading to a pachemia and considerable reduction of volume of the circulating blood. According to experimental data, plazmopoterya (at the expense of hypostasis of fabrics) reaches 3 — 4,7% of body weight, or more than 30% of volume of the circulating blood. It gave the grounds to explain a wedge, a picture T. t. plazmo-loss. At the same time a toxaemia and plazmopoterya explain only the nek-ry important parties of a pathogeny, disregarding neuro and reflex and neurohumoral factors, to-rye begin to influence an organism even before elimination of a compression, i.e. prior to absorption of toxic products and a massive plazmopotera. Long (more than 8 hours) crush of extremities at animals with the spinal cord (switching off of reaction to pain stimulation) crossed for 3 — 7 days before proceeds much easier, than at animals with the unimpaired spinal cord. Long pain stimulation reduces adaptive and protective mechanisms, does an organism more sensitive to a plaz-mopoter and to absorption of toxicants.
The neuroreflex factor, shock and a hypoxia also play an essential role in the mechanism of development of an acute renal failure. Long pain stimulation causes a vasospasm of cortical substance of a kidney and restriction of glomerular filtering. The blood stream in kidneys in these conditions is made preferential through vessels of marrow. The toxicants coming to a blood channel after elimination of a prelum strengthen a vasospasm and ischemia of cortical substance of a kidney, leads edges to dystrophic changes of an epithelium of the gyrose tubules extremely sensitive to a long hypoxia. The myoglobin circulating in blood is allocated with kidneys (see the Myoglobinuria). At acid reaction of urine it drops out in a deposit, corks gyrose tubules and has the expressed nephrotoxic effect. Due to the described processes permeability of capillaries in a kidney sharply increases. In urine appear protein, cylinders, erythrocytes. The acute renal failure proceeds the heavier, than the zone of the crushed (ischemic) muscles is more extensive; its weight depends also on duration of crush.
At a pathoanatomical research hypodermic cellulose and muscles of the affected extremity are edematous on a section, the centers of an imbibition blood in places are visible. Sites of normal muscular tissue alternate with the pale yellow centers of a necrosis, there are hemorrhages in perineuriums and adventitias of vessels. Microscopically in the crushed muscular tissue the coagulative necrosis is noted (see). The normal muscle fibers which kept cross striation alternate with the fibers which lost normal structure. Lungs are edematous, full-blooded. The plethora of abdominal organs, hemorrhages in a mucous membrane of small curvature of a stomach, a duodenum, in initial and terminal departments of a small bowel is noted. Kidneys of the usual sizes or are slightly increased, cortical substance their dry, pale yellow color, brain — plethoric, dark red. Microscopically find the changes characteristic of the acute toksiko-tshfektsionny damage of kidneys which is observed not only at T. t., but also at massive hemolysis, dehydration, the expressed intoxication.
Wedge, current of T. t. divide into 3 periods: early (till 3rd day)
with dominance of the phenomena of shock; intermediate (from the 3rd to 8 — the 12th day) with dominance of an acute renal failure; late (with 8 — the 12th day up to 1 — 2 month), or the period of recovery, with dominance of local symptoms.
The early period is characterized by signs of hypovolemic traumatic shock. Victims complain of pains and impossibility of movements in the injured extremity, weakness, nausea, thirst. The injured extremity begins to swell quickly, its volume increases, fabrics get ligneous density owing to hypostasis of muscles and sharp tension of myshech-but-fascial cases. On skin in a zone of crush hemorrhages, grazes, bubbles filled with serous or hemorrhagic liquid are visible. The movements in joints are impossible because of the pains caused by injury of muscles and nervous trunks. Sensitivity in a zone of damage and to distal departments of an extremity is lost. The pulsation of vessels in distal departments of an extremity weakens in process of increase of hypostasis, a prelum of vessels and their spasm. The ABP decreases depending on weight and duration of crush. The pachemia is noted: the hematocrit and a hemoglobin content, reduced volume of the circulating blood are raised, the number of erythrocytes and leukocytes is increased. In blood the maintenance of K+, P+, myoglobin is sharply increased (myoglobinemia). The initial alkalosis is replaced by acidosis (see. Acid-base balance). Gradually the content of urea and creatinine in blood increases. Signs of the expressed hypercoagulation and initial signs of the disseminated intravascular blood coagulation come to light (see. Hemorrhagic diathesis). The amount of the emitted urine sharply decreases from the very beginning of a disease, making 50 — 300 ml a day. Urine gets the varnish-red coloring caused by allocation of a myoglobin and the hemoglobin coming to a blood stream from the crushed muscles. Becomes later urine than dark-brown. In urine the squirrel (6 — 12 °/00), and in draft — cylinders and the tsilindropodobny brownish tape-like educations similar to molds of gyrose tubules is a lot of. They contain about a shelled epithelium, glybk of an amorphous myoglobin, crystals of a gamatin.
The correct treatment allows to bring the patient out of serious condition. At untimely and defective treatment victims perish already in the early period from acute cardiovascular insufficiency (see) and intoxications (see).
In the intermediate period, after elimination of the phenomena of shock, the condition of patients gradually improves. Pains abate a little, the ABP is normalized or raises a little. Pulse is speeded up, body temperature is usually increased to 37,5 — 38,5 °. Still is available about Liguria (see) or an anury (see). At a blood analysis find a hyperpotassemia (see), a hyperphosphatemia (see Fosfatemiya), hypercoagulation, increase in content of urea, residual nitrogen and creatine. To 4 — to the 5th day there are expressed symptoms of uraemia (see), edges develops also at those patients, at to-rykh in the early period there were no expressed symptoms of shock. At an easy current of T. t. the acute renal failure is expressed not so sharply and quite often passes under the influence of conservative treatment. In a zone of the greatest crush the centers of a necrosis of skin appear; rejection of nekrotizirovanny fabrics leads to formation of wounds, their infection, developing of phlegmon is possible (see).
Late period of T. t. it is characterized by dominance of local symptoms over the general. Function of kidneys is gradually recovered, normalized water and electrolytic balance, hypostasis of the injured extremity completely disappears. On this background an atrophy of muscles in a zone of damage, rigidity in joints, contractures come to light. Due to the development of ischemic neuritis, to-ry it is noted more than at a half of patients with damage upper and approximately at V3 with injury of the lower extremities, pains, burning with a kau-zalgichesky shade, develop.
In the early period of T. t. treatment is directed to elimination of traumatic hypovolemic shock, in the intermediate period — to overcoming an acute renal failure, in the late period the main attention is paid by therapies of local disturbances (wounds, contractures, restriction of mobility in joints, traumatic neuritis). Antishock actions consist in elimination of a hypovolemia: administration of blood-substituting liquids (see) — Polyglucinum, Haemodesum, a laktasol, 5% of solution of glucose; maintenance of datum level of the ABP; corrections of acid-base equilibrium; parenteral food; elimination of a giperkoakulyation (intravenous administration of heparin); introduction of Trasylolum, kontrik of l and or similar drugs, inhalation of oxygen is reasonable. Favorable action on a renal hemodynamics and distribution of potassium renders administration of hydroxybutyrate of sodium (30 — 40 mg on 1 kg of weight). After recovery of volume of the circulating blood further infusional therapy (see) is carried out taking into account losses of water and electrolytes under control of an hourly and daily urine. Inside within
2 — 3 days it is recommended to give hydro-sodium carbonate on 2 — 4 g every 4 hour for maintenance of alkali reaction of urine.
Attempts to reduce intake of potassium and toxicants in a blood channel by carrying out partial perfusion (see) the injured extremity are insufficiently effective since receipt of toxic products continues within several days continuously. Hemosorption is more effective (see t. 10, additional materials), if necessary — repeated. At the correct selection of sorbents it is possible to reduce the content in blood of potassium, phosphorus and nek-ry toxicants. Use of a plasma exchange is useful (see) with the managed hemodilution and stimulation of a diuresis introduction of 10% P ~ Ra of a mannitol. Perinephric novocainic blockade (see) is ineffective.
Lampasny cuts in the field of damage for the purpose of reduction of intoxication due to release of edematous liquid in a bandage in a crust, time apply seldom. The section of fastion providing a decompression of muscles and reduction of their ischemia is more preferable. For the prevention of complications enter antibiotics of a broad spectrum of activity.
At emergence of an acute renal failure — overhydratations — use of a hemodialysis is shown to a sharp hyperpotassemia (more than 7 mekv/l) (see). Other forms of dialysis at T. t. are inefficient. Also fight against respiratory insufficiency (see) and rational treatment of wounds is carried out (see Wounds, wounds). For elimination of rigidity of joints and contractures, and also treatments of traumatic neuritis widely use physical therapy.
Crush or long ischemia of both extremities during 6 hours are in most cases deadly. A lethality at T. t. reaches 30% and more, especially at a heavy acute renal failure.
From among recovered the complete recovery of function of the injured extremity comes approximately at 30% of victims, at the others an atrophy of muscles, contractures, rigidity of joints develop.
On the effects the syndrome of a position prelum — hours-long ischemia of muscles owing to long stay of the person in the forced situation breaking normal blood circulation in extremities is similar to traumatic toxicosis. This syndrome is observed at the persons which are in a condition of a drunkenness at a poisoning with carbon monoxide or nek-ry other poisons.
Stage treatment. In the center of defeat at extraction struck from under blockages, the damaged equipment, ruins of buildings it is necessary to bandage hardly after release of the squeezed extremities their elastic (or usual) bandage and to make an immobilization (see). This measure allows to reduce the speed of receipt in an organism of toxicants from the damaged fabrics and to slow down edematization. Struck enter anesthetics, sedative, cardiacs also evacuate first of all in a prone position. At a stage of rendering the first medical assistance (see) check quality of imposing of hard bandages and an immobilization, if necessary correct them. Provide cooling of an affected extremity (lay over it bubbles with ice, snow, a cold water). Enter antishock, cardiovascular means, antihistaminic drugs, tetanic anatoxin or antitetanic gamma-globulin. Struck are subject to bystreyshy evacuation on stages of rendering the qualified and specialized medical aid (see. Stage treatment), where treatment on the basis of the principles stated above is carried out.
Bibliography: Elansky H. N. O traumatic toxicosis at the massive closed damages of soft tissues, Surgery, No. 1, page 3, 1950; And in and N about in A. Ya., etc. Syndrome of a position prelum, Vestn. hir., t. 119, No. 7, page 80, 1977; Isaev M. R., Korneev A. A. and Kravtsova V. A. Some questions of a pathogeny, clinic and treatment of a syndrome of a long prelum, in the same place, t. 125, No. 8, page 125, 1980; To at z and M. I. Klinik's N, a pathogeny and treatment of a syndrome of long crush. (Traumatic toxicosis, krash syndrome), M., 1959; Kurbatova 3. And. Influence of long crush of soft tissues of an extremity on coagulant system of blood, Ortop. and travmat., No. 4, page 22, 1973; Their M and l h at to M. A., etc. Treatment of patients with a syndrome of a position prelum, Vestn. hir., t. 126, No. 5, page 71, 1981;
Pies N. I. The beginnings of the general field surgery, p.1, M. — L., 1941; P y t e l A. Ya. Sindr of traumatic compression of extremities, its treatment and prevention, Surgery, No. 10, page 3, 1951; Sernyak P. S., Kovalenko N. V. and Oleshchenko N. D. Philosophy of treatment of patients with a syndrome of a long prelum myagky fabrics, Voyen. - medical zhurn., No. 5, page 28, 1978; Bentley G. Jeffreys of T. E. The crush syndrome in coal miners, J. Bone Jt Surg., y. 50, p. 588, 1968; By waters E. G. L. Ischemic muscle necrosis, J. Amer. med. Ass., v. 124, p. 1103, 1944; Chiu D., WangH. H. a. Blumenthal M. R. Creatine phosphokinase release as measure of tourniquet effect on skeletal muscle, Arch. Surg., v. Ill, p. 71, 1976;
Corco ran A. C. a. Page I. A. Crush syndrome, post-traumatic anuria, J. Amer. med. Ass., v. 134, p. 436, 1947;
Muba rak S. Owen C. A. Compartmen-tal syndrome and its relation to the crush syndrome, spectrum of disease, Clin. Orthop., v. 113, p. 81, 1975;
P o-w e r s S.
R. Renal response to systemic trauma, Amer. J. Surg., v. 119, p. 603, 1970; Q u e n u E. De la ioxemie trau-matique a syndrome depressif (shock trau-matique) dans les blessures de guerre, Rev. Chir. (Paris), t. 55, p. 204, 1918; S a n-tangelo M. L. A study of the pathology of the crush syndrome, Surg. Gynec. Obstet., at. 154, p. 372, 1982; S with h r e i-b e r S. N., LiebowitzM. R. a. Bernstein L. H. Limb compression and renal impairment (crush syndrome) of following narcotic and sedative overdose, J. Bone Jt Surg., v. 54, p. 1683, 1972; Suchy T., To o n e with n at B. i. L a h o-ra k K. Crush syndrom, Rozhl. Chir., sv. 60, s. 522, 1981; Tructa J. o. Studies of the renal circulation, Oxford, 1947. M. I. Kuzin.