Crush Syndrome: The Most Common Problem Faced by People Rescued Alive from Under Rubble

Days have passed since the earthquake that struck Van on October 23. Among those who managed to survive under the rubble for days, some sadly could not hold on to life after being removed from it, and our joy turned to sorrow in an instant. Most of us could not even understand why our people died on the same day they were pulled out from under the rubble, right after surviving there for hours...

We asked the Internal Medicine specialists at Hisar Hospital Intercontinental about Crush Syndrome, the most important cause of death among people who remain trapped under rubble for a long time and are then extracted.

What Is Crush Syndrome?

Crush syndrome is a series of events that occurs when muscles and soft tissues are crushed by the weight falling on them for various reasons, resulting in the person entering severe organ failure. The most important events seen in this condition are the crushing of muscles, either directly by trauma or as a result of developing tissue swelling (compartment syndrome), and the kidney failure and fluid and electrolyte disturbances that follow.

What Are the Symptoms of Crush Syndrome?

In crush syndrome, both local signs in the traumatized muscles and systemic signs affecting the whole body appear. The main local finding is the condition called compartment syndrome, which develops as a result of crushing and swelling of the muscles caused by trauma. In this case, pain, weakness and firmness of the muscles are the main findings. The skin and subcutaneous tissues over the muscle often appear normal. In other words, the skin looking normal from the outside does not mean that crush syndrome is absent. If this occurs in the arm muscles, for example, a pulse can still be felt in the blood vessels supplying that arm. However, there may be nerve dysfunction and numbness. In addition, signs such as fractures and bleeding may also be detected in the affected area.

The main systemic findings, on the other hand, result from extensive breakdown of muscles (rhabdomyolysis), which releases large amounts of substances such as myoglobin and potassium into the bloodstream. When myoglobin begins to rise in the blood, it starts a process that leads to kidney failure. Kidney failure may develop in about 4 to 50% of classic rhabdomyolysis cases, but in disasters such as earthquakes this rate is much higher. This is a very important determinant of mortality. In the chaos of a disaster, when healthcare conditions are inadequate, it may sometimes not be possible to quickly correct fluid and electrolyte balance or, when necessary, to start hemodialysis. This is a factor that increases the number of deaths. Kidney failure does not develop only in severely injured patients. Sometimes, patients who initially seemed only mildly injured may develop crush syndrome and subsequent kidney failure in the following days. In addition, excess potassium released into the bloodstream from broken-down muscles can affect the heart's function, leading to rhythm disturbances, and even cardiac arrest and sudden death.

Infection is also encountered as another important finding and cause of death. These mostly arise from open wounds caused by the initial trauma or from the surgical sites of fasciotomy performed to treat compartment syndrome.

How Is Crush Syndrome Treated?

Early and rapid action is necessary to prevent the general and kidney-related harmful effects of crush syndrome. Only healthcare teams can intervene in such a patient. When a person trapped under debris is seen to have a free limb, isotonic NaCl (saline) IV fluid should be started at a rate of 1 to 1.5 liters per hour. If there is no way to check electrolyte levels, potassium-containing fluids must never be given. If the complete removal of the earthquake victim from the debris is delayed, fluids should continue to be given according to the victim's condition. Once the earthquake victim is removed from the debris, the first thing to ask is whether they have urinated. For an unconscious patient, check whether they have urinated by inserting a urinary catheter or, at the very least, by checking their underwear. The patient should be taken to hospital as soon as possible and receive adequate fluid and electrolyte replacement, antibiotic treatment, a tetanus vaccine, and fasciotomy, the procedure that releases the muscles from pressure.

How Can I Protect Myself from Crush Syndrome During an Earthquake?

If you are inside a building during an earthquake, you run the risk of being injured and then developing crush syndrome. This risk is lower outside buildings, but it still exists. You can find general precautions for protection on the Turkey Earthquake Foundation website (turkiyedepremvakfi.org.tr). However, data from earthquakes in general show that kitchens and bathrooms are the most suitable places. This is because if you become trapped under rubble, these rooms contain elements that can create a survival triangle, and you may be able to drink water leaking from burst pipes, which can help protect your body from crush syndrome.

Does Crush Syndrome Only Occur in Earthquakes?

Crush syndrome can develop in almost any situation that causes direct or indirect trauma to the muscles. In addition to earthquakes, traumatic causes such as mine collapses, traffic accidents, wars, torture and beatings can also lead to crush syndrome. Apart from trauma, various problems such as infections, certain medications, heatstroke and frostbite can also cause excessive muscle breakdown and lead to crush syndrome.