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Crush syndrome (CS) a form of traumatic rhabdomyolysis, can have fatal consequences often because the early manifestations are not recognised and there are delays in appropriate treatment. Recent publications on CS in the Emergency Medicine Journal have reported cases following earthquakes in China.1 2 These studies highlighted the prolonged exposure of patients to crushing injuries before getting in-hospital medical care. The main features of the earthquake victims from the studies in China were the development of compartment syndrome and associated sepsis from damaged limbs. Most of these patients were exposed for more than 24 h before receiving treatment.2 The key feature for the successful management of CS is early recognition and aggressive fluid treatment, as well as appropriate surgical intervention when required (eg, fasciotomy).
Another cause for CS and associated rhabdomyolysis, very seldom seen in the literature, is assault. In Kwazulu Natal, South Africa, this is most commonly a result of interpersonal violence, as a consequence of beatings meted out by the community to perpetrators of crimes. An observational study conducted at Ngwelezane Hospital in Kwazulu Natal recruited 65 patients presenting with CS over a 7-month period. All patients presented to the emergency department within 24 h of injury. Weapons used included fists, metal bars, sticks and sjamboks (a type of traditional leather whip). In contrast to the crush victims of earthquakes, compartment syndrome and sepsis were not a feature in any of these patients. The most common adverse feature with potentially fatal consequences was renal failure (one death was reported). Unlike the patients in the Wenchuan earthquake1 where 81% received haemodialysis, no patient in our study received dialysis, either because it was not indicated or because the service was unavailable. This suggests that prolonged exposure to crushing injuries, the severity of injury and delays in treatment may be indicators of renal failure and haemodialysis in these patients.
Our experience has shown that CS is often under-recognised in the early stages, especially in the assault category of patients. Following CS guidelines based on the International Society of Nephrology Renal Disaster Relief Taskforce3 improved the early diagnosis of CS and the initiation of early aggressive fluids, successfully reducing the complications of myoglobin-associated renal failure. This is especially important in an environment where dialysis is not widely available. The same situation applies to earthquake victims where less exposure time to the trauma, early presentation to the hospital and appropriate early surgical interventions can result in a significant reduction of mortality.
Footnotes
Competing interests None.
Ethics approval This study was conducted with the approval of the Ngwelezane Hospital local ethics committee.
Provenance and peer review Not commissioned; externally peer reviewed.