Long-term compartment syndrome (LCS). Providing first aid. Compression Long-term compartment syndrome emergency care

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Crash syndrome in the modern medical understanding is a symptomatic complex that develops with prolonged disruption of systemic circulation in soft tissues due to external pressure exerted on them. Quite often this pathology is also called Bywaters syndrome.

In addition to local problems, it is characterized by broad systemic pathological changes, including renal failure, hyperkalemia and so on. What actions should be taken in case prolonged compression limbs? How does compartment syndrome develop? You will read about this and much more in our article.

First aid for compartment syndrome

Basic principles of providing first first aid for long-term compression syndrome (crash syndrome) includes:

Proper analysis of rubble. When providing first aid, objects that cause compression must be lifted in parts, while quickly bandaging the limb with an elastic bandage in order to prevent the rapid development of shock and at the same time not to prolong the process of squeezing the arterial structures;
Use of cold. Damaged areas are covered with bottles of cold water, ice and so on. It is advisable to place something soft under the limbs - for example, a blanket or clothing;
Fastest possible transportation. The victim must be transported to the nearest department without fail. intensive care any hospital;
Drink plenty of fluids. May be given during transportation with the addition baking soda, which will neutralize negative effect for the kidneys. Such a procedure for providing assistance is only possible if there are no obvious symptoms of damage internal organs, the stomach is soft, and the person has retained all reflexes, including swallowing.

What not to do when providing assistance:

Abruptly release the person from compression. Such a procedure will provoke an immediate shock and the development of the most acute negative consequences;
Apply a tourniquet. During first aid, applying a tourniquet is justified only in cases where there is obvious non-viability of the limb or there is severe open bleeding. In all other situations, such a remedy will only prolong the compartment syndrome and ensure the appearance of more severe forms of the problem;

Use medications.“Field” therapy for crash syndrome (except for anti-shock) does not have the desired effect, since real help can be provided to a person only in intensive care conditions, often with direct surgical intervention;
Do not transport the person to the hospital. Regardless of the circumstances, the victim must be redirected to the hospital for a comprehensive diagnosis and execution, necessary measures, which will not allow a potential crash syndrome to develop, even in situations where a person feels satisfactory after release and can walk, since most symptoms develop later.

Dr. Komarovsky will tell you how to provide first aid to children with compression of their limbs:

Emergency assistance to the victim

As part of the provision of primary emergency medical care Most often, classical antishock therapy is performed.

Traumatic shock with prolonged compartment syndrome develops after severe forms corresponding pathology and incorrect actions to free the person.

Algorithm of actions for providing emergency care for crash syndrome (long-term compression syndrome):

Temporary stop of bleeding. Performed in exceptional cases in the presence of gushing blood;
Relief of pain syndrome. To help with pain, use any available painkillers in injection form;
Correction of gas exchange disorders. Oxygenation, tracheal intubation, other actions;
Resuscitation. When providing emergency care, basic resuscitation actions to restore breathing and heartbeat ();
Relief of shockogenic impulses. A combination of atropine, diazepam and tramadol is used. In addition, intravenous administration of glucocorticosteroids, the use of adrenomimetic drugs, and other drugs are rational. medicines according to symptomatic and vital signs.

What is crash syndrome

Crash syndrome is a special set of symptoms that develops as a consequence of long-term circulatory disorders in various soft tissues of the body - most often in the lower or upper extremities.

Similar pathological processes are diagnosed in victims of various disasters, including building collapses, earthquakes, and so on, as a result of which people find themselves sandwiched between hard surfaces for a long period of time.

Such a compression injury carries not only local risks of open or closed damage structures, fractures, etc., but can lead to short-, medium- and long-term serious consequences for the entire body.

Including leading to consequences associated with impaired functioning of the kidneys, liver, of cardio-vascular system and so on. Crash syndrome has three characteristic features:

Direct compression of the limbs or body, followed by tissue necrosis over a fairly long period of time;
Development of complex swelling together in places of compression at the local level;
The formation of ischemic toxicosis and acute renal failure, as a rule, against the background of long-term compression of the main vessels and main nerves.

As a result, prolonged compression develops

For the first time, crash syndrome was described at the beginning of the 20th century, when soldiers participating in the First World War fell under various rubble, for example, in active street battles.

An accurate interpretation was carried out by British physicians Bywaters in the 40s of the last century: he studied and identified the syndrome as an independent nosological unit.

In the modern era, long-term compression syndrome most often develops as a result of an accident or the inability to get out of the rubble for a long period of time after earthquakes, building collapses, and other natural and man-made disasters.

The modern interpretation of the basic clinical picture of long-term compartment syndrome includes the following circumstances: prolonged exposure to soft fabrics forms the prerequisite for the accumulation of toxic products in the corresponding muscles.

After a sharp release from pressure, these substances in an altered form enter the bloodstream, which causes a sharp acidosis (disorder acid-base balance) and complex, extremely severe hemodynamic disorders (circulatory disorders).

Deep tissue necrosis in clear localizations, temporarily compressed by compression after the disappearance of the basic factor, leads to the entry of decomposition products into the main bloodstream with the development of self-poisoning of the body.

Symptoms of the pathological process

The specific manifestation of crash syndrome depends on the current clinical picture pathological process and direct form, as well as the duration of compression. In general, the following classification applies:

Light form. It represents a pathology on a limb segment, with exposure for no more than 4 hours;
Medium shape. Direct compression of part or all of a single limb for about 6 hours;
Severe form. Pathological effects on several limbs for 6-7 hours;
Extremely severe form. It is characterized by compression of all limbs, sometimes other parts of the body, for 8 hours or more.

Immediately after release, the patient may go into shock. If this does not happen, then starting from the third day after the incident, local complex symptoms begin to appear, from dense swelling, pallor skin and dysfunction of the limb to renal failure, oliguria, anuria and so on.

Early symptoms are almost always erased, however, due to the low effectiveness of delayed treatment, acute clinical manifestations with the rapid development of renal failure can last up to 2 weeks, which sometimes results in fatal outcome in relation to the patient.

If the victim was under the rubble or at the epicenter of the incident for a very long period of time, then Almost immediately after his release, he noted:

Inability to move limbs;
General condition is temporarily satisfactory;
Weakness and nausea;
Only slight tachycardia is noted.

Within a few hours after the event, the following increases rapidly:

Body temperature rises;
The pulse quickens;
Falls sharply arterial pressure;
The skin acquires an uneven purplish-bluish coloration;
Swelling;
Bubbles with serous and serous-hemorrhagic contents form;
Pulsation of peripheral arteries is noted;
All types of sensitivity may be lost;
The amount of urine excreted sharply decreases.

Diagnostic measures

A key feature of diagnosing long-term compartment syndrome in humans is the initial collection of the necessary data that would allow a qualitative and quantitative assessment of both the extent of the pathological process and the duration of its impact on individual areas of the body.

In the vast majority of cases, the first clinical manifestations of an external nature occur after a certain period of time, from several hours to three days.

Without the information described above, it is almost impossible to recognize the presence of pathology, even using instrumental diagnostic techniques, before a clear clinical picture of the development of crash syndrome appears.

Treatment of crash syndrome

Any manifestations and consequences of crash syndrome are treated exclusively in a hospital setting - most often in the intensive care unit. As part of primary care, anti-shock measures are carried out with the administration of analgesics, cardiovascular drugs and blood pressure normalizers. The next stage is intensive infusion therapy, which does not allow the formation and development of acute renal failure.

For moderate and severe degrees of crush syndrome, surgery is prescribed, for example, fasciotomy of the damaged limb, amputation of the distal parts and other measures as necessary.

At the same time, blood circulation is restored. After finishing the most acute period and stabilization of the victim's condition It is recommended to move to the rehabilitation stage, which includes:

Strict drinking regime;
Hemodialysis (method of extrarenal blood purification);
Continuation of infusion therapy;
Plasmapheresis (the procedure for collecting blood, purifying it and returning it back into the bloodstream);
Physiotherapy and exercise therapy.

Possible complication and consequences

With moderate and severe degrees of prolonged compartment syndrome, the prognosis in most cases is unfavorable, and there is a high probability of death in the patient.

Even timely qualified medical care in some cases does not allow the compressed limbs to be kept intact, and the person may remain disabled.

The victim develops the prerequisites for the development of irreversible renal failure with the need for an organ transplant - in the absence of the latter procedure, lifelong hemodialysis is prescribed.

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Long-term compartment syndrome(SDS) occurs in cases where the limbs or torso are pressed down for a long time (more than 2 hours) by some kind of weight (stones, earth).

In 80% of cases, the limbs are compressed, mainly the lower ones. In almost half of the victims, prolonged compartment syndrome is combined with fractures of the limbs and damage to other parts of the body. When compressed chest, abdomen, face and head, if this does not lead to immediate death due to acute asphyxia, preservation of life is possible for a short time, with compression of the limbs - for several hours or more.

As a result of prolonged compression of the soft tissues of the limbs and cessation of blood flow, profound necrobiotic changes develop in the muscles, tissue and skin, up to complete necrosis of the limb. With prolonged exposure to rubble, even rigor mortis of the muscles of the limbs can occur. The development of deep necrobiotic changes in the muscles, accompanied by the release of myoglobin and other toxic products into the blood, is the cause of severe toxic shock. Subsequently, myoglobin settles in the renal tubules, which leads to their final blockade and severe renal failure. Victims in early dates after injury they die from shock, and within the first 7-10 days from renal failure. The severity of the manifestation of SDS depends on the amount of compression: compression of the distal parts of the limbs with a small number of muscles is not accompanied by such severe intoxication as compression of the thigh and lower leg, and can only result in amputation without the development of renal failure. Relatively rarely seen combined injuries, most often when buildings collapse during a fire.

With prolonged compression syndrome, the limb is cold to the touch, the skin is raw, with hematomas and imbibition of blood, often with wounds that do not bleed. If there are fractures, there are characteristic features. With deep ischemia, there is no movement in the limb, tactile and pain sensitivity is sharply reduced or absent, the pulse is distal sections limbs are reduced or not determined. In a later period, swelling of the limb rapidly increases, and unbearable ischemic pain appears. Urine is varnish-red in color due to the admixture of myoglobin and hemoglobin, its amount is reduced.

When compression is released within less than 2 hours from the moment of injury, there are usually no general phenomena, blood flow in the limb is restored, ischemia is observed in the area of individual muscle groups in places of greatest compression.

In the daily practice of trauma departments, patients with long-term compression syndrome are very rare and are victims of industrial injuries - obstructions with earth and stones in trenches, crushing by a car during its repair, if the car falls off the jack, etc. These injuries can be called industrial injuries with a certain stretch , since victims with SDS did this work on their own, without following safety rules. However, in conditions of natural disasters, terrorist attacks and military operations, the SDS can take on the character of a mass catastrophe.

In the domestic literature, the greatest contribution to the development of the problem of long-term compartment syndrome was made by M.V. Kuzin, M.V. Grinev and G.M. Frolov (1994), Yu.V. Groshev et al. (2003), who led the provision of assistance during the catastrophic earthquakes in Ashgabat (1947) and Spitak (1988). A.L. Krichevsky and his school clinically and experimentally studied this syndrome in depth. Research Institute of Emergency Medicine named after. N.V. Sklifosovsky has extensive experience in treating SDS, since after the earthquake in Spitak a visiting team of specialists worked at the source, and then the most seriously injured were transported to Moscow and received further treatment at our institute. The results of this work were summarized by M.V. Zvezdina (1995).

Depending on the area and duration of compression, as well as the force of compression, SDS is classified into mild, moderate and severe. With a mild degree of SDS, the compression period does not exceed 3 hours, the main blood flow of the limb is preserved during compression, and the volume of compression does not exceed the distal segment of the limb. After releasing the compressed part of the limb, there is no decrease in blood pressure, and renal function is slightly impaired in the future.

At medium degree long-term compartment syndrome, usually the lower or upper limb to medium or upper third shoulder or hip, the compression period is 3-6 hours, the compression force is significant with partial shutdown of the main blood flow. After the limb is released, a drop in SBP to 70-80 mm Hg is observed, and oliguria and other renal dysfunction develop within 1-2 weeks after the injury.

A severe degree of long-term compression syndrome occurs in cases where one or more limbs are completely compressed for more than 6 hours with a complete interruption of the main blood flow. In most cases, these patients die at the scene when the limb is released (tourniquet shock). If first aid is provided correctly and in full, then the victims are in severe shock, they quickly develop acute renal failure with anuria. Compressed limbs are usually non-viable, and to save the life of the victim it is necessary to perform amputations proximal to the border of the compression.

Treatment.

General treatment long-term compartment syndrome is the prerogative of specialists in intensive care and renal failure and consists of correction water-salt metabolism, first of all, metabolic acidosis and hyperkalemia, maintaining vital functions, with oligo- and anuria - in artificial hemodialysis.

The tasks of a traumatologist at the resuscitation stage include debridement wounds, open fractures, stabilization (immobilization) of fractures, resolving the issue of amputation and fasciotomy.

Wounds and open fractures are treated according to general surgical rules, without suturing and further wounds are kept open. Immobilization of fractures is performed only extrafocally - on the lower leg and forearm with Ilizarov apparatuses, on the thigh and shoulder - with rod ANF.

At obvious signs disturbances in the main blood flow of the limb, which is observed in severe DFS, after stabilization of hemodynamics (SBP above 90 mm Hg, pulse below 12 per minute for at least 2 hours), amputation is performed. The level of amputation is determined by angiography or by trial incisions, similar to what is done for anaerobic infection. Basically, you have to use the second method, since angiography is not available to most medical institutions, and if it is available, then in conditions of mass admission of victims there is simply no time and energy to perform it. The stump is always left open. If the limb is externally viable in the first period, then massive edema quickly develops, leading to compartment syndrome with the formation of necrosis of muscle tissue in fascial spaces. The only chance in these cases to save the limb is early fasciotomy.

In the intermediate period of SDS (days 4-20), patients continue to be in the intensive care unit, which has hemodialysis facilities. At the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky, the most seriously injured from Armenia were treated in the laboratory of acute hepatic renal failure. During this period there is the most big risk acute renal failure with anuria, high levels of urea, creatinine and potassium in the blood plasma. Necrosis of muscle tissue, skin and fiber, suppuration of wounds and open fractures are formed locally. Infectious complications tend to generalize, resulting in sepsis and the formation of purulent foci in places where there are hematomas, crushed and necrotic tissue.

Necrosis in long-term compartment syndrome is distinguished by the fact that, in addition to the skin and fiber, it involves the underlying muscles. Often the focus of skin necrosis can be small, and the muscle is completely necrotic. Muscle necrosis occurs with intact fascia if fasciotomy has not been performed.

When necrosis forms, one should strive for early necrectomy, since necrotic tissue is an additional source of intoxication and contributes to increased renal failure. Optimal time necrectomy are the first 7 days from the moment of injury. After excision of necrotic skin and tissue tissue, it is necessary to open the fascia and, if there is necrosis of the underlying muscles, excise them. If the muscle is close main vessel limbs, the operation is performed together with an angiosurgeon.

In all cases, one should strive to preserve, if not the entire limb, then perhaps a more distal part of it. After excision, the wounds are kept open in a moist environment using gel dressings. Necrectomy has to be repeated in most patients. After cleaning the wounds and filling them with granulations, autodermoplasty is performed using a split flap. During treatment, contractures in the vicious position should be prevented, for which it is necessary to use Ilizarov apparatuses in most cases. Plaster casts are unsuitable because they exclude access to the wound, quickly become wet with pus and soften.

With the development of sepsis, the tasks of the traumatologist include timely diagnosis and opening of abscesses and phlegmons of the extremities. They form at the site of muscle necrosis, so large incisions are necessary to open the fascia to examine the muscles and remove necrotic areas (or the entire muscle). After this, the wound can be drained with double-lumen drainage from a separate puncture, sutured, and subsequently aspiration-washing treatment according to Kanshin.

With a favorable course, the condition of patients with long-term compartment syndrome gradually stabilizes, the level of creatinine and urea begins to decrease, and urine appears. The restoration of kidney function is preceded by a phase of polyuria, when the victim excretes up to 4-5 liters of low-concentrated urine per day. After reaching normal or slightly higher level urea and creatinine levels, the patient was usually transferred to the trauma department, where the focus was on the treatment of wounds and fractures and active rehabilitation. Some patients require correction of the deformed position of the limbs, most of them require restoration of movements in the joints, training in self-care techniques and walking.

V.A. Sokolov
Multiple and combined injuries

Prolonged compression syndrome (compression) is a massive traumatic injury to soft tissues, often leading to persistent hemodynamic disorders, shock and uremia. This is a traumatic toxicosis that develops in the tissues of the extremities when they are released after prolonged compression. Decay products are released into the blood muscle cells, which are normally excreted by the kidneys. When the kidneys are damaged, they accumulate and clog the renal tubules, which leads to the death of nephrons and the development of acute renal failure.

The variety of clinical signs of the syndrome is due to prolonged soft tissue ischemia, endotoxemia, hyperkalemia and renal dysfunction. This disease is a consequence of accidents: road accidents, earthquakes, destruction of buildings, blockages in mines, man-made disasters, terrorist attacks, landslides, construction work, logging, bombing. The compression force is so great that the victim cannot independently remove the affected limb.

It is possible to develop a special form of the syndrome that affects the limbs of immobilized patients. This is a positional syndrome that develops under the pressure of one’s own body weight on soft tissues. It occurs with severe alcohol intoxication or alcoholic coma. So sick for a long time are in an unnatural position, often lying on an uneven surface. The development of the syndrome is caused by hypoxia and dyscirculatory changes, leading to a decrease in the volume of intravascular fluid and endotoxemia.

The pathology was first described during the First World War by the French surgeon Quenu. He watched an officer whose legs were crushed by a log after the explosion. The limbs below the compression site were dark red, and the wounded man himself felt well during the rescue. When the log was removed from his feet, toxic shock developed, from which the officer died. Several decades later, a scientist from England Bywaters studied in detail pathogenetic factors and the mechanism of development of the syndrome and identified it as a separate nosology.

The syndrome has various causes, complex pathogenesis, requires compulsory treatment And characterized by a high incidence of deaths. It occurs equally often in women and men. A shock-like state develops immediately after the victim is released and blood circulation and lymph flow are restored in the affected parts of the body. The causes of death of patients are: traumatic shock, endogenous toxemia, myoglobinuric nephrosis, cardiac and pulmonary failure. Treatment of the pathology is complex, including detoxification, replacement and antimicrobial therapy, necrectomy or amputation of the affected limb.

Most often, long-term compression syndrome affects people living in regions where active fighting or earthquakes occur frequently. Terrorism is a current problem and the cause of the syndrome.

Crush syndrome is a serious injury, the treatment of which causes many difficulties and difficulties.

Classification

Based on the location of the lesion, compartment syndrome is distinguished:

thoracic region,
abdominal area,
heads,
limbs,
pelvic area.

The syndrome is often accompanied by damage:

vital organs,
bone structures,
articular joints,
arteries and veins,
nerve fibers.

Long-term compartment syndrome is often combined with other ailments:

burns,
frostbite,
exposure to radioactive radiation,
acute poisoning.

Etiopathogenetic links and factors

The main cause of compartment syndrome is mechanical injury received as a result of an accident at work, at home or in war. Compression of body parts occurs during accidents, earthquakes, explosions and other emergency situations.

Long-term compression of soft tissues leads to damage to blood vessels and nerves, the development of ischemia of the affected area and the appearance of areas of necrosis. The syndrome develops a few minutes after the removal of compressive objects and the resumption of lymph and blood supply to the damaged area. That is why first aid is provided directly at the scene of the incident.

Pathogenetic links of the syndrome:

pain shock,
increasing capillary permeability,
release of proteins and plasma from the vascular bed,
disruption of the normal tissue structure,
swelling of tissues,
loss of the liquid part of the blood - plasma,
changes in hemodynamics,
dysfunction of the blood coagulation system,
thrombus formation,
toxemia as a result of tissue breakdown,
penetration of microelements from injured tissues into the blood,
a shift in the acid-base balance towards increasing acidity,
the appearance of myoglobin in the blood and urine,
formation of hematin hydrochloride from methemoglobin,
development of tubular necrosis,
death of kidney cells,
acute uremia,
entry into the systemic circulation of inflammatory mediators,
multiple organ failure.

Vasoconstriction and changes in normal microcirculation in the muscles lead to disruption of sensory stimulation in both the affected and healthy limbs.

Multiple organ failure is characterized by damage to internal organs and systems:

cardiovascular, excretory, respiratory, digestive,
hematopoietic system with the development of anemia, hemolysis of red blood cells, disseminated intravascular coagulation syndrome,
metabolism,
immune system with the development of secondary infection.

The outcome of multiple organ failure in most cases is the death of the patient.

Factors involved in the development of pathology:

toxemia,
plasma loss,
neuro-reflex mechanism.

Pathomorphological changes in long-term compartment syndrome:

The first degree is characterized by swelling and pallor of the skin, no signs of ischemia.
The second degree is tension of edematous tissues, bluishness of the skin, the formation of blisters with purulent exudate, signs of impaired blood and lymph circulation, microthrombosis.
Third degree - “marbling” of the skin, local hypothermia, blisters with blood, gross dyscirculatory changes, venous thrombosis.
Fourth degree – purple skin color, cold and sticky sweat, foci of necrosis.

Symptoms

The symptoms of the pathology depend on the duration of compression of the soft tissues and the area of the lesion.

The compression or first period is characterized by clinical picture shock:

bursting pain in the affected area,
shortness of breath,
signs of general asthenia of the body,
nausea,
paleness of the skin,
drop in blood pressure,
rapid heartbeat,
indifference to current events, lethargy or anxiety, sleep disturbance.

After removing the victim from the rubble, the second period of clinical manifestations begins - toxic. At this time, the swelling in the affected area increases, the skin becomes tense, purple-bluish with many abrasions, bruising, and blisters with blood.

Any movement brings excruciating pain to the victim.
The pulse is weak, thread-like.
Hyperhidrosis.
Loss of sensitivity.
Oliganuria develops.
Proteinuria, leukocyturia, hematuria, myoglobinuria, cylindruria, urine acidification.
In the blood - erythrocytosis, azotemia, blood thickening.
Involuntary release of feces and urine.
Euphoria and loss of consciousness.

The third period is characterized by the development severe complications , which significantly worsen the condition of patients and can lead to death. These include:

kidney dysfunction,
anemia,
uremia with hypoproteinemia,
fever,
vomit,
foci of necrosis,
muscle exposure,
suppuration of wounds and erosions,
lethargy, hysteria, psychosis,
toxic liver damage,
endotoxicosis.

By the end of the first week, uremic intoxication increases and the condition of patients worsens. They have motor restlessness and psychosis, depression gives way to aggressiveness, hemogram parameters change, potassium metabolism is disrupted, and cardiac arrest is possible.

The fourth period is convalescence. In patients, the functioning of internal organs is restored, hemogram and water-electrolyte balance are normalized.

The severity of the clinical manifestations of the syndrome depends on the area of the lesion and the duration of compression:

If the patient's forearm tissues were compressed for 2-3 hours, his condition remains satisfactory, uremia and severe intoxication do not develop. Noted fast recovery victims without consequences or complications.
When a large surface of the human body is compressed for more than six hours, severe endotoxicosis and complete shutdown of the kidneys develop. Without extrarenal blood purification and powerful intensive therapy, the patient may die.

Complications of the syndrome: kidney dysfunction, acute pulmonary failure, hemorrhagic shock, DIC syndrome, secondary infection, acute coronary insufficiency, pneumonia, psychopathy, thromboembolism. Early extraction of victims from the rubble and maximum recovery therapeutic measures increase patients' chances of survival.

Diagnostics

The diagnosis of long-term compression syndrome can be schematically represented as follows:

study of clinical signs of pathology,
obtaining information about the victim’s presence under the rubble,
visual examination of the patient,
physical examination,
direction clinical material to biochemical and microbiological laboratories.

In the pathology clinic, signs of pain, dyspepsia, asthenia, and depression predominate. During the examination, specialists identify pallor or cyanosis of the skin, abrasions and blisters with serous-hemorrhagic contents in the affected area, foci of necrosis, and suppuration of wounds. A physical examination reveals a decrease in blood pressure, tachycardia, edema, fever, and chills. In the late stage - atrophy of viable muscles of the limb and contracture.

Laboratory diagnostics include:

Therapeutic measures

Treatment of the pathology is multicomponent and multistage:

At the first stage, patients are provided with emergency medical care at the scene of the incident.
At the second stage, patients are hospitalized in a hospital in special intensive care vehicles equipped with everything necessary equipment to provide first aid.
The third stage is the treatment of patients in surgery or traumatology by highly qualified specialists.

First aid algorithm:

All victims with prolonged compartment syndrome are hospitalized in a hospital. Drug treatment in the hospital is to prescribe the following groups of drugs:

Extrarenal blood purification is carried out in severe cases when other treatment methods do not produce positive results. If it is not possible to control electrolyte disturbances with medication, pulmonary edema and metabolic acidosis persist, and symptoms of uremia appear, patients are prescribed hemodialysis, ultrafiltration, plasmapheresis, hemosorption, hemodiafiltration, plasmasorption, lymphoplasmasorption. Hyperbaric oxygenation sessions are carried out 1-2 times a day in order to saturate the tissues with oxygen.

Surgical treatment - dissection of the fascia, removal of necrotic tissue, amputation of the limb. In a hospital, it is necessary to strictly observe the rules of asepsis and antiseptics when carrying out diagnostic and treatment procedures, disinfect environmental objects, and keep all premises, equipment and inventory perfectly clean.

Rehabilitation of patients consists of massage, physical therapy, physiotherapeutic techniques and sanatorium-resort treatment. Reconstructive interventions are performed according to indications.

The prognosis of the pathology is determined by the timeliness of medical care, the extent of the lesion, the characteristics of the course of the syndrome, individual characteristics the victim.

Video: about help with long-term compartment syndrome

Landslides, earthquakes, traffic accidents, explosions - these events can cause the development of crash syndrome. This syndrome develops as a result of prolonged compression of the trunk and limbs. There is a violation of blood circulation, oxygen starvation of tissues. A person experiences a decrease in blood pressure, vascular spasms, and lethargy. After release, crash syndrome is determined by a weak pulse, bluish skin, and poor sensitivity.

First aid for long-term compartment syndrome involves ensuring free access of oxygen and calming the victim. You can give him water and painkillers. A person is not suddenly released from pressure factors. A tourniquet is first used in the affected area so that the release is gradual. The syndrome can be mild, moderate, severe or very severe depending on the time of compression.

Prolonged compression of the limbs and torso leads to impaired blood circulation in these areas. Blood does not flow, oxygen starvation of tissues develops, cells die. Necrotic areas release decay products - essentially poison. Dehydration aggravates the condition. The problem becomes more acute the more time passes before help arrives. When blood flow is resumed, cardiac, pulmonary, renal failure. Even without damage to internal organs, fractures or other associated injuries, a favorable outcome with a large area of soft tissue damage tends to zero.

Signs of the syndrome

The clinical picture can be divided into two stages - before the person is freed from the rubble, the compressive object is removed, and after these factors are eliminated.

In the first phase, development occurs traumatic shock. Loss of blood from wounds or plasma due to swelling and muscle crushing leads to a decrease in the total amount of circulating blood, lowering blood pressure. Severe, prolonged pain and panic increase stress. The body begins to fight. To increase gland pressure internal secretion secrete cortisol, adrenaline, and other vasoconstrictor substances.

On the one hand, this helps increase blood pressure, but there is back side– spasm of blood vessels that are already clogged with blood clots. Blood circulation changes, with priority given to the brain, heart, and lungs. All peripheral organs and tissues suffer, including the kidneys, up to anuria. The body cannot cope with the damage, an increase in the amount of endorphins further reduces blood pressure, and indifference and lethargy develop.

After eliminating the compressive factors, symptoms of a disease called crash syndrome, traumatic rhabdomyolysis, and Bywaters syndrome develop. Locally in the affected area, a bluish appearance of the skin is observed, the pulse is difficult to palpate, and in severe cases is completely absent. Then bubbles with liquid appear, sensitivity is weakened. In general, the body shows signs of severe poisoning.

First aid

The procedure for providing first aid to victims of long-term compartment syndrome has two phases.

Phase 1 involves performing certain actions. Before the arrival of rescuers who must free the victim, it is necessary, if possible, to check the victim’s respiratory tract and make sure there is oxygen access. Reassure, morally support the person, say that help is close. You should check for visible damage and touch the stomach. A hard belly indicates injury to internal organs. If the stomach is soft, then there are no violations. In this case, you can and should give the victim drinking plenty of fluids. You can give him water, if you have special rehydration products in your first aid kit, it’s better to feed him with them.

If you have soda, salt and water, mix them (1 tsp per liter of water). This solution is effective against dehydration. The crushed limb must be cooled to slow down the process of cell destruction. To do this, you can use cold water bottles, ice or snow in the cold season. Painkillers and drugs to support the functioning of the cardiovascular system are allowed. Every person can provide emergency first aid.

The beginning of measures to release the compressive object marks the transition to the second phase of assistance for SDS. It seems logical that the sooner you free the victim, the faster relief will come. This is not an entirely correct assumption. Quick release in this case is tantamount to murder, since it is after the compression is removed that intoxication processes begin, affecting the heart, lungs, and kidneys. To prevent this, it is necessary to apply a tourniquet above the affected area. According to the rules, a note must be attached to the tourniquet indicating the time of its application.

The main task is to gradually free the limb from the compressive object and apply a bandage. When providing assistance, applying a bandage for crash syndrome, we replace one compression with another. Therefore, it is better to use an elastic bandage, since a gauze bandage will not create the necessary pressure. If there is no damage to the arteries after ligation, the tourniquet should be removed. Next, the limb is immobilized, that is, fixed with a splint. The administration of potent analgesics and local cooling are indicated. The patient is ready for transportation to a medical facility, which is recommended to be done as quickly as possible.

A complex of correctly, fully and timely first aid for this syndrome, coordinated actions of rescuers and doctors professionally conducting the stages of primary care, increases the likelihood of a successful outcome by 40%. The basic principle of first aid: compressive objects are replaced with compressive bandages.

Degrees and stages of the syndrome

The degree of severity is determined by two criteria:

the weight of the press exerting pressure;
exposure period.

The following stages of the syndrome are distinguished:

mild (compression time – up to 4 hours, with a small affected surface);
medium (compression of one limb for 4-6 hours);
severe (duration of compression – 6-8 hours, localized to one limb, disturbances in the functioning of the kidneys and heart);
very severe (massive body damage, compression for 8 hours or more, traumatic shock, organ failure).

During the course of the disease the following stages are observed:

The first three days are considered the early stage. It is accompanied by symptoms such as pain, the development of traumatic shock, swelling of damaged tissues, the appearance of blisters with serous contents, and impaired sensitivity.
Intermediate conditionally begins on the 4th day and can last until the 20th. The decisive period during which swelling increases, failure of internal organs and acidosis are possible. The patient's condition is serious and unstable.
The recovery stage begins with normalization of kidney function. There is a long-term illness, a large, slowly healing wound surface, necrosis can lead to the development of sepsis.

Long-term compartment syndrome (LCS)- one of the most severe types of injuries that occur during various accidents and natural disasters as a result of rubble, destruction of buildings, and landslides. It is known that after the atomic explosion over Nagasaki, about 20% of the victims had more or less pronounced Clinical signs long-term crush or crush syndrome. The development of a syndrome similar to compartment syndrome is observed after removal of a tourniquet applied to long term. This condition is called crash syndrome or long-term compression syndrome.

When reading large quantity educational literature, I noticed that a tourniquet or twist (analogous to a tourniquet) is mentioned everywhere. I still do not recommend using a tourniquet. This is what our paramedic Elena Bednarskaya, who has extensive experience, writes; and understanding all the difficulties of working with a tourniquet, for a person who is unprepared, or, even worse, who thinks that he is definitely prepared, but in fact, he just read the information on the Internet.

Note “Life Safety. Territory of Rus'".

Due to the fact that evil spirits attack and bomb only residential buildings, people may end up under the rubble. If a person is under a rubble, then long-term compression syndrome is inevitable. This syndrome is considered one of the most severe types of injuries; it can also be complicated by fractures, bleeding, TBI (traumatic brain injury), and other “joys”. Signs of long-term compression syndrome: the damaged limb swells greatly, has an atypical shine for a healthy one, is bluish, cold to the touch, the skin may be covered with blisters, and with prolonged compression, the skin turns black. What to do if you find a person in the rubble? Firstly, the minimum number of people who can provide PMP (first aid) is two. Why two?! The algorithm for providing primary care for long-term compression syndrome involves working in pairs. The algorithm itself is as follows:

First aid is provided at the scene of the incident. Elimination of pain and reduction of psycho-emotional stress in victims at the source of the disaster should be carried out at the first opportunity, even before releasing them from the compressive factor. For the purpose of pain relief, a 2% -1.0 solution of promedol is administered, 50% - 2.0 analgin, sedatives. If there are no signs of damage to the abdominal organs, give 40 - 70% alcohol to drink. If possible, freeing the victim begins with the head and torso. At the same time, they are fighting asphyxia (giving a comfortable position, cleaning the upper respiratory tract, artificial ventilation). Measures are taken to stop external bleeding.

1. do not suddenly lift the object, causing compression, we lift part of it and quickly bandage the limb with an elastic bandage, namely elastic, if not at all, only then with gauze, but this is much worse, i.e. The task is to release the limb in parts and at the moment of release, quickly bandage it. Why is this so? When squeezed, a huge amount of toxins accumulate in damaged tissues, blood supply is disrupted, etc. They abruptly removed the object: all these toxins flow into the muscles, shock develops just before our eyes, so proper and quick dressing can save the victim.

2. apply cold to the injured limb, Just bottles of cold water will do;

3. place soft material under the limb(clothes, blanket, etc.);

4. during transportation, we monitor the condition of the victim;

5. if the stomach is “soft”, i.e. there is no damage to internal organs, we give the victim plenty of warm drink with the addition of baking soda - this will save his kidneys. How is a soft belly different from a “hard” one? You just need to feel the stomach; if there are injuries to internal organs, then the stomach will be very hard.

Experience shows that some people’s lives can be saved even after compression of body parts for several days, while others die after a few hours.

After releasing the victim from the rubble, it is necessary to determine the degree of disruption of the blood supply to the tissues, on which the correctness of further actions to provide medical care depends. This is easy to do if you know the signs of the four degrees of ischemia.

First degree- compensated ischemia, which, despite prolonged compression, did not lead to disruption of blood circulation and metabolism in the compressed limb. With such ischemia, active movements are preserved, i.e. the victim can independently move his fingers and other parts of the compressed limb. There is tactile (touch) and pain sensitivity. We use elastic bandages.

Second degree- uncompensated ischemia. With such ischemia, tactile and pain sensitivity is not determined, there are no active movements, but passive ones are free, i.e. You can bend and straighten your fingers and other parts of the injured limb with light efforts from the helping hand. There is no rigor mortis of the muscles of the compressed limb. We use elastic bandages.

Third degree- ischemia is irreversible. Tactile and pain sensitivity are also absent. Appears main feature- loss of passive movements, rigor mortis of the muscles of the compressed limb is noted. With such ischemia, the tourniquet cannot be removed.

Fourth degree- necrosis (death) of muscles and other tissues, which ends in gangrene. In this case, the tourniquet should not be removed either.

After the issue with the tourniquet is resolved, it is necessary to apply aseptic dressings to the existing wounds and immobilize the limb using standard splints or improvised material. If possible, cover the injured limb with ice packs or cold water heating pads, warm the victim and give him an alkaline drink. After first aid is provided, all measures must be taken to quickly evacuate the victim to medical institution. It is better to transport him lying on a stretcher, preferably accompanied by a medical professional.

REMEMBER! If within 15-20 minutes it was not possible to free the crushed limbs, then you should stop any attempts at liberation and wait for the arrival of rescue services.

REMEMBER! Before the arrival of rescuers and ambulances, you should cover your limbs with ice or snow packs, apply tight bandages (if you have access to them) and provide plenty of warm fluids.

UNDER NO EVENT CAN YOU!

Release pinched limbs

after 15-20 minutes after their compression

without the participation of rescue services.

UNACCEPTABLE!

Release the compressed limb before applying protective tourniquets

and administering large amounts of fluid to victims.

Warm crushed limbs.

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GUNSHOT WOUNDS

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