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Crush-Related Injury after Disasters
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     To the Editor: The review of crush injuries by Sever et al. (March 9 issue)1 does not mention the hyperkalemic response to succinylcholine that is associated with these injuries.2 Crush injuries and other pathologic conditions (e.g., burns, prolonged immobilization, nondepolarizing neuromuscular blockade, and severe infection) seem to be associated with up-regulation of the acetylcholine receptor, manifested by an increased number of receptors, increased sensitivity of the receptors to agonists, and increased distribution of receptors beyond the neuromuscular junction. This results in a massive release of potassium on the administration of succinylcholine and in hyperkalemia, causing cardiac arrest.

    Persons with crush injuries may also have some of the other conditions associated with the hyperkalemic response. These conditions may independently increase the risk of cardiac arrest.

    Patients receiving care for crush-related injuries may require intubation on several occasions, such as ventilatory support in the intensive care unit, for surgical procedures, and during transport. The clinical course of the hyperkalemic response has not been well established, but it would be prudent to avoid the administration of succinylcholine beginning about two days after injury and continuing until about a year later.

    Robert E. Kettler, M.D.

    Medical College of Wisconsin

    Milwaukee, WI 53226

    References

    Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med 2006;354:1052-1063.

    Martyn JAJ, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology 2006;104:158-169.

    To the Editor: We would like to emphasize two points that were not included in the article by Sever et al. The number of actual crush-related injuries after a disaster is probably far higher than reported in the official publications. According to our experience with the rescue teams sent to Turkey and India after the earthquakes there, large numbers of casualties were not evaluated for crush injuries.

    Sever et al. wrote that early fluid administration in the field is needed. Rapid evacuation is also very important. Furthermore, rescue techniques themselves may play an important role in the outcome of casualties. In January 2006, a five-story building in Nairobi collapsed. The Israeli Home Front Command forces used special techniques called tunneling and scalping (i.e., carefully removing layer after layer of debris with the use of heavy instruments). By means of these techniques it was possible to evacuate a man who was buried under the building for more than one day. This specialized technique was not previously available in Kenya. We believe that international cooperation and the use of special evacuation techniques might play an important role in preventing crush injury.

    Ariel Rokach, M.D., M.H.A.

    Yaron Bar-Dayan, M.D., M.H.A.

    Israeli Home Front Command

    02673 Ramla, Israel

    bardayan@netvision.net.il

    The authors reply: We agree with the comments of Rokach and Bar-Dayan. The main reasons for incomplete information are the chaotic circumstances after a disaster, the heavy workload, panic, and incomplete patient records.1 However, despite these drawbacks, crush injuries after the Marmara earthquake, in Turkey, which formed the main basis for our article, were documented in as much detail as possible regarding the fate of the injured persons, their profile, and any nephrologic problems, thanks to the high rate of response to questionnaires that were sent to the reference hospitals immediately after the disaster. This high response rate made it possible to understand the sequence of events after disasters of great magnitude and helped us develop logistic coordination, as presented in the article.

    We also agree that rapid evacuation of the victims is important. As we noted in our article, "after a disaster, rapid transport systems should be devised, if feasible, to evacuate injured persons from the epicenter."

    Kettler is correct that the hyperkalemic response to succinylcholine was not mentioned in our article, but it was not our aim to provide a detailed technical description of how to treat persons with crush-related injuries. The primary focus of our article was to provide conceptual information about lifesaving aspects of the medical care that is related to renal rescue, as well as the global and local logistics that are needed to support such action. Hence, owing to space limitations, it was impossible to include all details about the many key interventions required in disaster conditions; this information can be found elsewhere.2,3 However, we thank Kettler for emphasizing the importance of hyperkalemia in patients with crush injuries. In one of our articles on the Marmara earthquake, we reported that the risk of fatal hyperkalemia continues even after hospitalization and that early detection and treatment of hyperkalemia may improve the final outcome of disaster victims with renal damage.4

    Mehmet Sukru Sever, M.D.

    Istanbul School of Medicine

    34390 Istanbul, Turkey

    severm@hotmail.com

    Raymond Vanholder, M.D., Ph.D.

    Norbert Lameire, M.D., Ph.D.

    University Hospital

    B-9000 Ghent, Belgium

    References

    Sever MS, Erek E, Vanholder R, et al. The Marmara earthquake: epidemiological analysis of the victims with nephrological problems. Kidney Int 2001;60:1114-1123.

    Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. J Am Soc Nephrol 2000;11:1553-1561.

    Slater MS, Mullins RJ. Rhabdomyolysis and myoglobinuric renal failure in trauma and surgical patients: a review. J Am Coll Surg 1998;186:693-716.

    Sever MS, Erek E, Vanholder R, et al. Serum potassium in the crush syndrome victims of the Marmara disaster. Clin Nephrol 2003;59:326-333.