On February 6, 2023, centered in the province of Kahramanmaraş, southerrn Turkey, two major earthquakes occurred with magnitudes of 7.7 and 7.6 on the Richter scale, with a 9-hour interval between them. These earthquakes resulted in tremendous number of deaths and injuries in 11 cities in the region. In events like these, dead-at-scene rates (coded black in disaster triage situations) are high, and additionally, crush syndrome (CS) is frequently encountered in patients rescued from the debris [1].
CS, also known as traumatic rhabdomyolysis, is most commonly seen in earthquakes, wars, mining accidents, landslides, volcanic eruptions, motor vehicle accidents, and multiple trauma victims, especially those who are trapped for a considerable time, which may result in CS and compartment syndrome [2]. Additionally, CS can be encountered in the emergency department (ED) for routine reasons such as poisoning, stroke, and falls [3]. Theoretically, any situation that results in prolonged immobilization can lead to the development of CS [4].
CS is a clinical condition in which the symptoms and signs are not directly limited to the compressed part and systemic manifestations occur [5]. In CS, injured skeletal muscle cells are destroyed and their contents, including myoglobin, sarcoplasmic proteins (such as creatine kinase, lactate dehydrogenase, aldolase, alanine and aspartate aminotransferase), and electrolytes, are released into the circulation, leading to clinical complications such as myoglobinuria, AKI, electrolyte disturbances (hyperkalemia), hypovolemic shock, disseminated intravascular coagulation, acute respiratory distress syndrome (ARDS), and multiple organ dysfunction syndrome (MODS) [6, 7]. CS affects all vital organs of the body, but damage to the kidneys is the most prominent, and AKI has become a major life-threatening factor for patients with CS [8,9,10,11,12,13]. Clinical manifestations of CS include fever, edema, tachycardia, nausea, vomiting, confusion, anxiety, delirium, tea-colored urine or anuria [14]. The most common clinical feature is the triad of myalgia, myoglobinuria and elevated serum muscle enzyme levels, but the degree and severity of these clinical manifestations vary greatly [15].
CS is the second leading cause of death in earthquakes after direct trauma [2, 7]. It has been reported that the incidence of CS in earthquake victims is as high as 25% and that CS related AKI varies between 0.5% and 25% depending on the intensity of the earthquake and the time spent under the rubble, and more than half of those with AKI require hemodialysis (HD) treatment [16]. The overall mortality rate after an earthquake was found to be 8%, the mortality rate in CS was 21%, and the mortality rate in HD patients was 35% [17]. Another study reported that AKI is seen in approximately 33% of patients who develop rhabdomyolysis and that mortality in these patients can reach up to 50% [18].
Early detection and treatment of AKI are crucial for reducing mortality and morbidity rates [19]. Hence, there is a need for early parameters that can indicate the HD requirement of patients.
Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR) and systemic immune-inflammatory index (SIII) are systemic inflammatory markers that are increasingly used as diagnostic tools and prognosticators in various internal and surgical diseases [20, 21]. The SIII is proposed as a potential marker of systemic inflammation and immune response, with emerging evidence suggesting [22]. Trauma triggers a cascade of immune and inflammatory processes that play in determining the extent of tissue damage, organ dysfunction, and overall prognosis [23]. By leveraging the SIII, can potentially assess the severity of systemic inflammation and immune dysregulation, thus aiding in risk stratification and therapeutic decision-making for multitrauma patients [23]. Due to its easy calculation, cost-effectiveness, reliance on complete blood count parameters only and absence of subjective symptoms, NLR, PLR, LMR and SIII may be effective markers in determining the need for HD in patients developing CS. The study aims to explore the hypothesis.
This study included patients who presented to the education and research hospital operating as a level three trauma center after the earthquakes on February 6, 2023 and diagnosed with CS with clinical and laboratory criteria. The success of complete blood count and biochemistry parameters in determining the need for HD in these patients was evaluated.
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