THE CRITICAL IMPACT OF A CRUSH INJURY

L. Mirea , R. Ungureanu , R. Florescu, R. Marin , A. Bogdan , A. Gherca , M. Tiglis ,

1 1 2 2 2 2

J. Fulga , M. Costache , M. Vladut , R. Reff , I. Grintescu , O. Lupescu , I.M. Grintescu

2 2 2 2 1 1 1

1. Carol Davila University of Medicine - Bucharest

2. Clinical Emergency Hospital - Bucharest

Background: Treatment: surgical procedures using Comments:

47 yo man admitted in the Emergency
Unit
irreversible lower limb ischemia due to
severe crush injury after an
occupational accident
OR: above-knee amputation of the
lower right limb because of an
irreversible avulsion of the femoral
neurovascular bundle and severe crush
injuries of the lower limb
ICU: extremely severe condition
requiring mechanical ventilation and
management of shock
Clinical signs: hypovolemic shock
unresponsive to fluid replacement and
blood transfusion, hypothermia,
oliguria, with hemorrhagic soaked
amputation stump dressing and
important scrotal swelling
Methods:
Full body CT scan: low density in the
anterior muscular compartment of the
thigh, bladder, scrotal and pelvic
hematoma, without any bone fractures.
Angiography: occlusion of the femoral artery
in the proximal third segment.
Standard lab tests: severe anemia (2.3
g/dl), thrombocytopenia, leukocytosis,
severe coagulopathy (INR 9.91),
rhabdomyolysis syndrome (CK 76000
U/L), hyperkalemia, severe metabolic
acidosis.
modern hemostasis techniques, massive
blood transfusion and derivative, fluid
replacement, vasopressor and inotrope
support, antibiotics and renal substitution
therapy - the general condition improved
significantly and after 13 days the patient
was extubated.
On the 6th day - convulsive crisis
followed by ischemic stroke in the
frontoparietal area.
Clinical signs: left facial paralysis and
hemiplegia (heparin and anticonvulsant
therapy with remission of the clinical
signs).
After three months - bronchopneumonia
complicated with massive pleural
effusion. After three days, the patient was
readmitted in the ICU with dilative
cardiomyopathy with severe systolic
dysfunction (EF 15%) and exertion.
The patient developed mixed anxiety
depressive disorder after four months of
being hospitalized.
1. Sever bleeding despite repeated
attempts at surgical hemostasis -
TRAUMA INDUCED
COAGULOPATHY - intrinsic
dysregulation contributing to further
blood loss and eventually evolving
into a procoagulant state.
Mechanisms: consumption, platelet
dysfunction, hyperfibrinolysis,
anticoagulation + blood dilution
(volemic resuscitation), hypothermia
and acidosis.
2. Stroke despite thromboprophylaxis -
procoagulant later state in TIC and
suspicion of hereditary thrombotic
disorder (mild protein C deficiency).
3. Dilative Cardiomyopathy - sepsis
induced, having the 3 well known
characteristics: LV dilatation,
depressed EF (endotoxins, cytokines
and NO), recovery in 7-10 days.
Supposed mechanisms: decreased
myofibril response to Ca2+,
mithocondrial dysfunction,
downregulation of beta-adrenergic
receptors.
Despite being a severely injured patient
(severe hemorrhagic shock, septic
shock with multiple organ
dysfunction, stroke and dilative
cardiomyopathy) he was discharged
from the Clinical Emergency Hospital
of Bucharest 4 months later, with
physical and psychological sequelae
but with a satisfactory functional
outcome.

Conclusion:

After severe trauma injury, in order to prevent MSOF and death, high standard intensive care should be initiated immediately. Despite fluid
replacement, massive blood transfusion and repeated hemostasis surgical procedures, the blood pressure and the hemoglobin level
were low for the first few days leading to late ischemic events. A particular aspect of this case was the unpredictable evolution, the
patient losing not only his lower limb, but a significant amount of heart function.

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