A crushing experience: the spectrum and outcome of soft-tissue injury and myonephropathic syndrome at an urban South African University hospital.
Kidney failure (Care and treatment)
Creatinine (Health aspects)
Blunt trauma (Diagnosis)
Blunt trauma (Care and treatment)
|Publication:||Name: South African Journal of Surgery Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 South African Medical Association ISSN: 0038-2361|
|Issue:||Date: April, 2011 Source Volume: 49 Source Issue: 2|
|Geographic:||Geographic Scope: South Africa Geographic Code: 6SOUT South Africa|
Objective: The aim of the study was to assess the level of
creatinine kinase (CK) associated with significant renal dysfunction,
the correlation between body surface area (BSA) involved and CK level,
and correlation between BSA injury and renal dysfunction to enable BSA
prediction to identify 'at risk' patients.
Methods and materials: Retrospective review of Tygerberg Hospital Trauma Service patients between January 2003 and December 2005 with a screening CK level >500 U/l. Data were captured on a proforma. BSA was scored charting body surface bruising using a rule-of-nines. The study was approved by the Departmental Research Committee.
Results: 334 records were reviewed. 89% were men, mean age 30 years and average Revised Trauma Score 7.5. Blunt trauma constituted 75%, with blunt force assault 64% of the total. CK of >8 500 U/l predicted renal injury/failure (p<0.01). BSA and CK correlated very well in the blunt group (p<0.01). Linear correlation was found between BSA and the development of renal dysfunction/ failure (p<0.01), with BSA >18% predicting renal impairment. While 83% of patients developed renal risk/injury, only 17% required dialysis. Mortality was 5%. Most deaths were multitrauma MVAs, requiring ICU care and dialysis, and multi-organ dysfunction was the cause of death. The high-CK group (>5 000 U/l) had a worse outcome compared with the low-CK group (500 - 5 000 U/l), with higher peak urea (17.2 mmol/l v.12 mmol/l), peak serum creatinine (2 836 mmol/l v. 140 mmol/l) and rate of renal dysfunction/failure (20% v. 8%). The penetrating group (97% male) included vascular injuries with increased CK due to ischaemia-reperfusion injury and low BSA, mainly due to gunshot wounds (70%). Three patients (10%) developed renal failure and had abnormal CK levels (range 538 - 32 540 U/l). There were 2 deaths in this group and both these gunshot wound patients developed significant rhabdomyolysis with subsequent renal failure and multi-organ failure.
Conclusion and recommendation: Screening CK accurately stratifies patients at risk for myonephropathic syndrome. Early aggressive fluid loading can prevent renal injury/failure. Adjunctive measures have not improved outcome. Patients sustaining vascular and severe extremity injury from penetrating wounds should also be routinely screened.
W Smith, T Hardcastle
Tygerberg Hospital and Stellenbosch University, W Cape
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