TREATMENTOFCRUSHCASUALTIESFOLLOWINGMASSDISASTERSWord文档格式.docx

TREATMENTOFCRUSHCASUALTIESFOLLOWINGMASSDISASTERSWord文档格式.docx

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III.2.Generalapproachtothevictimimmediatelyafterrescue

III.3.Approachtooligo-anuricvictims

III.4.Approachtovictimswithsomeurinaryoutput

III.5.Othermeasures

II.Secondlinetreatmentofcrushsyndromecasualties（approachtothecasualtiesatthefieldhospitalsoratthemomentofadmissiontotheemergencyward）

IV.1.Generalapproachatadmissiontohospitals

IV.2.Medicaltreatmentatadmissiontohospitals

IV.2.A.Treatmentofhyperkalemia

IV.2.B.Treatmentofhypocalcemia

IV.2.C.Fluidresuscitation

V.Thirdlinetreatmentofcrushsyndromecasualties（TreatmentofARFduringtheclinicalcourse）

V.1.Treatmentintheoliguricperiod

V.1.A.Conservativetreatment

V.1.B.Dialyticinterventions

V.2.Treatmentinthepolyuricperiod

I.

eitheratthefieldorinfield

diagnosis;

hence,therapyis

First-lineapproachtothecasualtiesatthedisasterfield

Thisprotocoldescribestherapeuticinterventionsintheveryearlyperiodofthedisaster,hospitals.Duetodifficultaccesstolaboratories,clinicalfindingsaremaindeterminantsofessentiallydirectedbythesefindings.

Theveryfirstconcernshouldbeselfsafetywhenapproachingdamagedinfrastructure,becausetherecanbedangeroffurthercollapse.Hence,itisstrictlydiscouragedthatmedicalorparamedicalrescuerswouldattempttoextricatevictimsbythemselvesfrompartially/totallycollapsedbuildings.Ifarescueworkerwouldlocateatrappedvictim,itisrecommendedtoseekforhelpfromexperiencedrescueteams,andifthisappearsimpossible,fromotherrescueworkersorpublictohelpsurvivingvictims,ifany.

Itshouldbeconsideredthatvictimscanstillberescuedalivefromundertherubbleeven5daysormoreafterthedisaster（Sever,2001;

San,1993）.Manyofthesecasualtiesmaysufferfromcrushsyndrome,whichnecessitatestoactrapidlyandaggressivelytopreventrenaland/orothersystemiccomplications.

Toachievethis,thefollowingrulesshouldbeconsidered:

（1）Ifanalivevictimisdetectedatthedisasterfield,anattemptshouldbemadetofindaveininanyofthelimbs,ifpossiblewhenshe/heisstillundertherubble.Afterplacinganintravenouslineaninfusionofisotonicsalineatarateof1liter/h（10to15millilitersperkilogramperhour）shouldbeinitiated.

（2）Usually,anaverageof45–90min.issufficienttototallydisengagethecasualty;

fluidadministrationshouldbecontinuedoverthisentireperiod.Theamountoffluidstobegivenshouldbeadaptedaccordinglyifrescueactivitiestakelonger（sometimes4–8hrs）.

Oncethecasualtyisextricatedfromtherubble,initiallyvitalsignsshouldbechecked;

thetypeoftraumashouldbeidentified;

anda“primarysurvey”shouldbeperformed.（seeunder“Terminologyrelated

todiagnostic/therapeuticinterventions”page:

4）

Ifinitialobservationrevealsthatthepatientisalert,talking,well-orientedandmovingallextremities,thenthereisnodoubtthatshe/hehaspatentairwaysandisbreathingwell,thatoxygeniscirculatingtothebrainandthatshe/hedoesnothaveamajorcentralneurologicalinjury.Inthatcase,andiftheABCDEsdonotrevealmajorlesions,routinetreatmentcanbestarted,asdescribedbelow.

Ifthepatientisnonresponsive（andifshe/heissufferingfromvisible,potentiallyfatal–mostlypenetrating–traumas）,she/heshouldbetreatedaccordingtolocalconditions.Inmassivedisasters,onlythecaseswithatleasta50%chanceofsurvivalaretreatedinthefield;

inotherwords,veryseverely

woundedandhopelesscasesareneglected（PepeandKvetan）.However,ifthedisasterisnotmassiveandifthereisanadequatenumberofhealthcarepersonnel,thenprotectionoftheairwaywithachinliftorjawthrustisindicated.Ifthepatientisbleeding,attemptsshouldbemadetostopbloodlossesbysimpleinterventions（tourniquets,compressionbandages,sutures,etc.）.Also,helpshouldbecalledforandattemptsshouldbeconsideredtotransportthepatienttothenearesthealthcarefacilityattheearliestconvenience.

Fortheroutinemedicaltreatmentofcrushinjuries,itshouldbecheckedwhetherthevictimproducesurineornot.Ifavailable,anindwellingbladdercathetershouldbeinserted[especiallytounconsciouscasualtiesand/ortovictimswhosufferfrompelvic/abdominaltrauma]toverifyurineproduction.Ifnocatheterisavailable,theunderpantsofthecasualtyshouldbechecked;

ifanyhumidityisdetected,itcanbeassumedthatthereisurineproduction.Thesmellofurinemaybeanotherusefulindicator.

Inthecasualtieswhocannotproduceurine,featuresofhypovolemia（i.e.hypotension;

weakandrapidpulse;

cold,moist,cyanoticandpaleextremities）shouldbesearchedfor.Iftheabove-mentionedsymptomsareevident,thepotentialcauseofhypovolemiashouldbesought;

ifthepatientisbleedingbloodlossesshouldbestoppedasdescribedabove.Simultaneously,themostappropriatetherapy,i.e.

bloodtransfusionshouldbestarted;

ifthelatterisnotavailable,plasma,humanalbumin,orcolloidssuchasdextranorHAESshouldbeadministered.Ifnoneoftheseproductsareavailable,salineoranyotherintravenousfluidcanbeadministered,withtheexceptionofpotassium-containingfluidsthatshouldneverbeadministeredunlesshyperkalemiaandimminentriskforacuterenalfailure（ARF）havebeenexcluded.

ItshouldbeconsideredthatfatalhyperkalemiacanbeseenincrushpatientsevenwithoutARF.

Excessiveamountsoffluidaccumulationintheextremitiesofthecasualtieswithcompartmentsyndromeshouldbeconsidered.Inthiscase,muchmorefluidisrequiredthanintheusual（non-crush）traumavictims.

Inthecasualtieswhocanpassevensmallamountsofurine,intravenousfluidsshouldbecontinuedatarateof1liter/h.Preferablefluidatthisstageishypotonic（half-isotonic）saline.Adding50mEqofsodiumbicarbonatetoeachsecondorthirdliterofhypotonicsaline（usually200–300mEqintotalforthefirstday）

willmaintainurinarypHabove6.5,whichpreventsintra-tubulardepositionofmyoglobinanduricacid.Ifurinaryflowexceeds20ml/hr.,50mlof20%mannitolshouldbeaddedtothissolution[mannitolatadosageof1to2gr/kg（overall120gram）perdayandatarateof5gr/hr]（Sever,2006）.Thiscombinationwillbereferredtoasmannitol-alkalinesolutionhereafter.

However,mannitolshouldnotbeusedinanuriccasualties!

Urineoutputshouldbecloselymonitoredasthisprotocolisinitiated.Anurse,amedicalstudent,orifnotavailable,anyvolunteershouldbeassignedtofollowthecourse.Theaimistoincreaseurineflowtomorethan300ml/h.Mannitol-alkalinesolutioncanbeappliedindosesofupto12liters/daytoanadultweighing75kgandwithanappropriateurinaryresponse,ifpossibilitiestomonitorareavailable.Ingeneral,upto8litersofurinaryoutputcanbeexpectedfor12litersofthissolution（Better,1990）.Forvictimswithalowerorhigherbodyweight,administeredvolumeshouldbeadaptedproportionally.Apositivefluidbalanceisalwaysnecessaryincrushsyndromecasualtiessinceextremeamountsoffluidscandiffuseintothedamagedmuscles.Therefore,itisreasonabletoadminister4–4.5litersmorefluidthanwhatcorrespondstothetotallossesoftheprevious24-hourperiod.

Thisprotocolshouldbecontinueduntilmyoglobinuriadisappears（practicallyuntilnormalizationoftheurinarycolor）,whichusuallyoccurswithin2-3daysfollowingthetrauma.Subsequently,mannitol-alkalineinfusioncanbegraduallyreducedandthendiscontinued.

Ontheotherhand,ifthecasualtycannotbewatchedcloselyduetochaoticdisasterconditions,mannitol-alkalinesolutionshouldbeappliedlessaggressively（i.e.4–6liters/day）,toavoidinadvertentvolumeoverload,especiallyinoldervictims,whocannotpassadequatevolumesofurine（Vanholder,2000）.

Anysolutionshouldbeadministeredatanevenlowerratethan3–6liters/daytoanuricvictims,inordertoavoidvolumeoverload,hypertensionandacuteleftcardiacfailure.Ideally,anattemptshouldbemadetoindividualizethefluidvolumeforeachcasualty;

forthispurpose,acentralvenouspressure（CVP）cathetershouldbepositionedattheearliestconvenienceinthevictimswithoutthoraxtraumaoracuterespiratorydistresssyndrome（ARDS）.Then,itbecomespossibletomanagethefluidadministrationmoreobjectively.

Incrushcasualties,oneofthemostfrequentandoftenfatalmedicalcomplicationsishyperkalemia.

Manycasualtiesdieduetothisproblematthedisasterfield,duringtransport,orearlyafteradmissiontothehospital.Fordecreasingtherisk,especiallythevictimswithahighpossibilityofhyperkalemia（malecasualtieswithseveremusculartrauma）shouldbetreatedempirically（Sever,2002）.Thiscanbedonebyinitiatingoralkayexalate（ifthecasualtyisabletotakeoralmedication）atadosageof15to30g.atthedisasterfield,combinedwith1/3ofthesameamountofsorbitoltoavoidintestinalobstruction.Whenindicated,acuteantihyperkalemictreatmentshouldbeadministeredinthefieldhospitalsorintheemergencycareunitsofregularhospitalsasdescribedinthefollowingsections（pages:

11,14）.

Administeringso-calledvasodilator（orrenal）dosesofdopaminefortheprophylaxisofARFisuseless.Benef