汶川地震挤压综合征患者肌肉挤压伤的特点

The characteristic of muscle injury caused by crush syndrome in Wenchuan earthquake

目的分析汶川地震挤压综合征患者肌肉挤压伤的特点。方法回顾性分析2008年5月12日汶川地震后成都军区总医院收治的挤压综合征患者8例，男女各4例；年龄25-45岁，平均35．4岁。压埋时间9-152h，平均52h。均行筋膜切开手术，截肢者6例8肢。8例患者均行连续肾脏替代治疗。2例死于颅脑出血及肠穿孔。术后发生ARDS2例，DIC1例，气性坏疽1例。结果汶川地震肌肉挤压伤的特点：（1）挤压时间超长，导致急性肾衰；（2）挤压伤因皮肤破损轻微而被误诊，延误病情；（3）受压深层肌肉常比浅层肌肉损伤更严重；（4）肌肉坏死区多发且呈不规律分布；（5）早期坏死组织与正常肌肉混杂造成治疗困难；（6）创面在坏死组织脱落后，可有继发性出血。结论汶川地震中肌肉挤压伤有其自身特点。治疗中应注意观察，发现肌肉肿胀应行切开减压引流。创面易发生突发性出血及感染。隐匿的肌肉坏死区肌肉溶解、感染是长期发热的主要原因。肢体MR检查有助于发现病灶、及时处理肌肉坏死区。连续肾脏替代治疗是治疗挤压综合征的有效手段。

Objective To analyze the features of muscle ischemic injury in patients with crush syn- drome due to be trapped under the rubble for a super long time in the Wenchuan earthquake. Methods Eight patients were identified with crush syndrome from 1070 hospitalized patients after Wenchuan earth- quake in May 12, 2008, including 4 males and 4 females, with the mean age of 35.4 years （range, 25-45 years）. The trapping time ranged from 9 to 152 hours, with an average of 52 hours. Six cases （eight limbs） were amputated due to acute renal failure caused by crush syndrome. Eight patients were treated with continuous renal replacement treatment （CRRT）. Two cases died of cerebral hemorrhage and intestinal perforation. One was diagnosed gas gangrene. The mechanisms of the crush syndrome were also analyzed. The muscula- ture necrosis differed after trap condition and time were notified and noted. Results The characteristics of muscle crush injury were described below, l）The ultra long trapping time leading to acute renal failure. 2） The patients with crush injury might be easily ignored due to the mild skin damaged. 3）Deep muscles re- vealed more severe injury than the superficial muscles. 4）The muscle necrosis took place in multiple com- partments and areas. 5）h was difficult to identify and resect the muscles of early necrosis mixed with the normal musculature. 6） A secondary hemorrhage might occur after necrotic tissues falling from the wounds. Conclusion According to the features of the muscle crush injury in the Wenchuan earthquake, the crushed limbs should be operated for extended decompression and debridment after indicated swellings. The more subterranean necrosis might cause infection even weeks after the injury signaled by that the patient had an unexplainable fever. The decompressed area should be left open. MR examination was helpful to identify early muscle necrosis. If a crush syndrome is suspected the CRRT application was beneficial in life save and limb salvage except for the decompression surgery.