Southeastern Türkiye has suffered several devastating earthquakes this month, killing over 41,000 people, so crush syndrome has been more relevant than ever before.

Crush syndrome – also known as traumatic rhabdomyolysis or Bywaters' syndrome – is the systemic manifestation caused by a crush injury to skeletal muscle, characterized by significant shock and kidney failure, which can result in organ dysfunction, multisystem organ injury or death.

A crush injury is compression of the arms, legs or other parts of the body that causes muscle swelling and neurological disturbances in the affected areas of the body. When the crush injury pushes systemic manifestations, it becomes crush syndrome. The syndrome commonly occurs in catastrophes such as earthquakes and presents some of the most significant challenges in medicine.

In crush injury cases, it may be possible to free the patient without amputation; however, field amputations may be necessary for drastic situations.

Dr. Hüseyin Sina Coşkun, associate professor at the Orthopedics and Traumatology Department of Samsun Ondokuz Eylül University (OMÜ), was sent to Kahramanmaraş's Elbistan after the second earthquake hit the town on Feb. 6 and said that the severity of crush syndrome depends on a lot of factors.

Coşkun is part of the 40-member medical team that OMÜ's medical faculty sent to the quake-hit region. He said they were doing their best to care for quake victims. "As we started, we encountered numerous fractures and dislocation cases in orthopedic terms," he said.

"Medical conditions like 'crush syndrome,' 'compartment syndrome,' which we regularly encounter in disasters, were quite prevalent."

Compartment syndrome is when increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space. It can be acute or chronic. Compartments of the leg or arm are most commonly involved.

History, effects

Crush syndrome was first reported by a Japanese physician named Seigo Minami in 1923. Minami studied the pathology of three soldiers who died in World War I due to kidney failure. British physician Eric Bywaters later described it in patients during the Blitz – the German bombing campaign against the United Kingdom, in 1940 and 1941, during World War II.

The syndrome is a reperfusion injury that appears after the release of the crushing pressure. The mechanism is believed to be the release into the bloodstream of muscle breakdown products, notably myoglobin, potassium and phosphorus, that are the products of rhabdomyolysis – the breakdown of skeletal muscle damaged by ischemic conditions.

The specific effect on the kidneys is not understood completely but may be partly due to myoglobin nephrotoxic metabolites. The most devastating systemic effects can occur when the crushing pressure is suddenly released, without proper preparation of the patient, causing reperfusion syndrome. In addition to tissue directly suffering from the crushing itself, tissue is then subjected to sudden reoxygenation in the limbs and extremities. Without proper care, a patient administered pain relief may be cheerful during recovery and die shortly after that. This sudden failure is called the "smiling death."

Symptoms include the five Ps: pain, pallor, paresthesias – pins and needles, paralysis and pulselessness.

Severity

Coşkun stated that "crush syndrome" is a medical condition that occurs as a result of situations such as being crushed, collisions, being stuck under rubble, being hit and being immobile for a long time. He also pointed out that it is frequently seen in people who come out from under collapsed structures and wreckage.

"It is a medical condition that we frequently see, especially in people under the rubble for a certain period. Just as every doctor had some knowledge of infectious diseases related to COVID-19 during the pandemic; 'crush syndrome' is a syndrome that should be well known by all doctors now. Although it is mostly related to orthopedics and nephrology departments, everyone must know its vitality for the patient," Coşkun told Demirören News Agency (DHA).

"'Crush syndrome' can lead to extremity losses, as well as secondary losses and deaths with kidney damage. Its severity depends on many factors. It varies depending on the time spent under the debris, the amount of muscle destroyed and the extent of the destruction. (For) its treatment, (you need) a good nephrologist, if necessary, the patient should be taken to dialysis, even more than once, and treated with fluids aggressively," he said.

'Earthquake sentinels'

Expressing that he experienced the 1999 earthquake – which killed nearly 20,000 people – in Istanbul, Coşkun stated that he knew the quake psychology very well. He also said that hospital staff had to stay in the hospital with their spouses, children and families because their houses were destroyed in the earthquakes in Kahramanmaraş.

"While we were responding to earthquake victims, the children portrayed us as 'earthquake sentinels.' We hung the pictures on the doors of our rooms. The houses of the doctors (and) nurses were damaged in the earthquake, and they brought their families to the hospital. Those pictures made by the children made us very emotional."