Crush injury and AKI
in Disasters:
Lessons learned and
applied
For the Renal Disaster Relief Task Force
(RDRTF)
International Society of Nephrology (ISN)
Médecins Sans Frontières (MSF)
R Vanholder, Ghent, Belgium
MSS Sever, Istanbul, Turkey
N Lameire, Ghent, Belgium
Management of crush-related
injuries after disasters
M Sever, R Vanholder, N Lameire
N Engl J Med, 10, 1052-1063, 2006
1
DISASTER
Sudden calamities
producing extensive
damage, loss and
distress
• Natural
– Earthquakes
– Landslides
– Avalanches
– Hurricanes
– Tornadoes
• Man-made
– War
– Mining
– Tunnel collapse
– Terrorism, torture
GLOBAL SEISMIC HAZARD MAP
• Californian fault
• The whole Mediterranean
• South-East Asia
• The Far-East
• Tehran Science, 2000; 288: 661-5.
2
MAN-MADE DISASTERS
Sudden collapse of an eight-story building:
80% die instantly
10% minor injuries
7/10 develop
10% major injuries
Crush syndrome
Ron et al, Arch Intern Med, 1984
3
Crush syndrome =
muscular destruction
after trauma
Rhabdomyolysis =
Disintegration of striated
muscles with release of
muscular content
Myoglobulin =
18,000 D oxygen carrier,
filtered by the glomerulus,
may obstruct the tubules
Crush Syndrome History
First described in
German literature in
victims of Messina
earthquake of 1909
WW I Germans
noted traumatic
rhabdomyolysis
(military medical
literature)
4
Original Charts Oscillometry
Leg Volume
Urinary volume
Bywaters and Beall, BMJ, 1, 427-432, 1941
5
Morphologic changes of Heme
protein toxicity
Zager et a, KI, 49, 314-326, 1996
PATHO-PHYSIOLOGY: GENERAL ASPECTS
H2O
Ca++
Bilirubin
Myoglobin
Nucleotides
Uric acid
K+
Phosphorus
Acids
Vanholder et al, JASN, 11, 1553-1561, 2000
6
FOLLOWING DISASTERS:
CRUSH SYNDROME
the second most frequent cause of death
(following direct trauma) Ukai, Ren Fail,1997
RENAL DISASTER
Solez et al, KI, 1993
THE ARMENIAN EARTHQUAKE
• Death toll: 25,000 ?
• Crush cases: 600 ?
• Many crush pts. died due to lack of dialysis
Help not effective
Need for preplanned logistic organization
RENAL DISASTER RELIEF TASK FORCE
Solez et al, KI, 1993
7
The natural disaster is the catastrophe
that everyone sees. People rarely see the
arrival of overmanned, unorganized
assistance groups, each with its own
game plan, whose first question is “ where
do we eat and sleep?”
Pierre Pradier
Directeur- Général
Médeçins du Monde
8
RENAL DISASTER RELIEF
TASK FORCE (RDRTF): AIMS
• To offer material and personnel support in
any mass disaster where renal problems
are prevalent
• The RDRTF has lists of volunteers
(nephrologists/intensivists, nurses,
technicians)
• The RDRTF has a stock of hardware
(dialysis machines, RO-systems) to be
dispatched in case of disasters
MAJOR LOGISTIC STEPS FOLLOWING AN EARTHQUAKE
US Geological services – earthquake detection
GLOBAL COORDINATION (A)
Chairman RDRTF
Initial estimation of number of Advance scouting
crush syndrome victims nephrologic team
Local key person
Reporting local conditions /
assessing magnitude of the problem
LOCAL COORDINATION (B)
Anticipation of the needs for support
(i.e. medications, blood products)
Inform RDRTF Branch Chairman (international support)
Inform local authorities (national support)
Support is offered, if needed
9
MAJOR POINTS OF
ATTENTION FOR TASK FORCE
INTERVENTIONS
SEVERITY ASSESSMENT
• Intensity of the disaster
• Population density of the region,
Many factors contributive • Structural characteristics of buildings
• Timing (moment) of disaster
• Efficacy of rescue activities
Noji et al., 1990; Nadjafi et al., 1997
Gujarat Earthquake: Bam Earthquake: September 11 terrorism
Death: 19,727, Cr.:35 Death: 26,000; Cr.: 124 Death: >3,000; Cr.: 1
Viroja et al, WCN Abstracts, 2001 Argani et al, JASN, 2004 Goldfarb and Chung, Am J Med, 2002
10
RATIO DIALYZED/DEATHS (x 1,000)
Location Country Year Ratio
Spitak Armenia 1988 9.0-15.4
Northern Iran Iran 1990 3.9
Kobe Japan 1995 24.6
Marmara Turkey 1999 28.1
Chi-Chi Taiwan 1999 13.3
Gujarat India 2001 1.7
Boumerdes Algeria 2003 6.6
Bam Iran 2003 3.7
Kashmir Pakistan 2005 2.4
Yogyakarta Indonesia 2006 <0.1
MEDICAL INTERVENTIONS AT THE DISASTER FIELD
(For Prophylaxis of Crush Syndrome)
EARLY FLUID ADMINISTRATION
IS OF VITAL IMPORTANCE !
(1 L / hr saline)
• After the rescue alkaline solution
• Adequate urine response ⇒ + mannitol 8 - 12 L/day
• Less aggressively (4 - 6 L/day) if monitoring indufficient
• CVP measurements
Better and Stein, NEJM, 1990 Vanholder et al, Kidney Int, 2000
11
STATUS OF LOCAL HEALTH FACILITIES /
TRANSPORT POSSIBILITIES - I
Hospitals are damaged
• Field hospitals??
“de novo dialysis units” • Not useful for crush?
⇒ impractical
STATUS OF LOCAL HEALTH FACILITIES /
TRANSPORT POSSIBILITIES - II
• Aftershocks may further damage hospitals
• Keeping positions open for untransportable cases
• Locally treated patients have a higher risk of mortality
Kuwagata et al, 1997
Transport of victims in disaster conditions may be problematic
Administer potassium binders before transportation !
12
Supplementation of
MEDICAL MATERIAL and PERSONNEL
International relief ≠ functional help
• Guatemalan e. ⇒ 90% drugs useless (unsorted) Seaman, Injury, 1990
• Armenian e. ⇒ 70% useless (expired or damaged) Auiter, Lancet, 1990
International personnel support ⇒ useful or harmful
Local / Global integrated responses are mandatory !
13
29° 30° 31°
Black Sea
41° 41°
Izmit Adapazari
Marmara
Sea
Yalova Gölcük
17.08.1999 Izmit eartquake (Mw=7.4)
Bursa
5
4
40° 40°
29° 30° 31°
Source : Dr. Sahin Akkargan, Istanbul University
EVOLUTION PATIENT POPULATION
800
700
600 ARF without dialysis
500
Number of patients
400
300
On dialysis
200
Discharged
100
Deceased
0
08/17/99 08/24/99 08/31/99 09/07/99 09/14/99
Time, days
Vanholder et al, KI, 59, 783-791, 2001
14
QUESTIONNAIRE
• Questionnaire on 63 clinical or
biochemical questions
• Distributed over 35 hospitals having
treated rhabdomyolysis patients
• Initiative: Turkish Society of Nephrology,
International Society of Nephrology (ISN)
• Data analysis: MS Sever, E Erek
• Data on 639 single patients
EPIDEMIOLOGY – AGE DISTRIBUTION
Age distribution of the inhabitants
Age distribution of the victims with nephrological problems
30
25
% inhabitants and victims
20
15
10
5
0
0-9 10-19 20-29 30-39 40-49 50-59 ≥60
Age groups, years
Sever, Erek, Vanholder et al, KI, 60, 1114-1123, 2001
15
INTERMITTENT HEMODIALYSIS during
THE MARMARA EARTHQUAKE
• HD sessions: 11±8 140 No of HD sessions Days on HD support
• HD support: 13±9 120
100
Patients
80
Daily dialysis 60
40
20
5137 sessions 0
1-5 6-10 11-15 16-20 21-25 26-30 31-50
of HD No. of HD sessions / days of HD support
Sever et al, KI, 2002
BAM (IRAN): DECEMBER 2003
16
Complications between ARF and non-
ARF patients in the BAM earthquake
Non-ARF % ARF % P-value
Sepsis 2/367 0.5 19/164 11.6 < 0.001
DIC 1/369 0.3 12/164 7.3 < 0.001
ARDS 5/368 1.4 15/164 9.1 <0.001
Fasciotomy 7/365 1.9 63/162 38.9 < 0.001
Amputation 2/368 0.5 10/164 6.1 < 0.001
Death 7/366 1.9 21/165 12.7 < 0.001
Hatamizadeh et al, Am J Kidney Dis, in press
KASHMIR (PAKISTAN): 8 OCTOBER
2005
17
KASHMIR: OFFERED HELP
RDRTF
• Personnel help • Material help
– Doctors – Dialysis machines
(nephrologists/intensivi – Reverse osmosis
sts) machines
– Dialysis nurses – Dialyzers
– Dialysis technicians – Blood lines
• Logistic advice – Central vein catheters
• Medical/technical – Drugs
information • Kayexalate
• Heparin
• Training
• Psychologic support
INTERVENTIONS
• Iran, March, 1997: Material support
• Moldova, March, 1999: Material support
• Macedonia, May, 1999: Evacuation chronic patients
• Macedonia/Kosova, July, 1999: Material support
• Turkey, August, 1999: Major intervention
• Kosova, February, 2000: Educational support
• India, January, 2001: Scouting
• Turkey, May, 2003: Material support
• Algeria, May, 2003: Scouting
• Iran, December, 2004: Major intervention
• Luisiana, August, 2005: Advisory role
• Pakistan, October 2005: Major intervention
• Poland, January, 2006: Advisory role
• Indonesia, May, 2006: Scouting
• Lebanon, July, 2006: Material support
18