Amputation in crush syndrome: A case report

• Published in: International journal of surgery case reports Vol. 72; pp. 346 - 350
• Main Authors: Arango-Granados, María Camila, Cruz Mendoza, Diego Fernando, Salcedo Cadavid, Alexander Ernesto, García Marín, Alberto Federico
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Ltd 01.01.2020; Elsevier
• Subjects: Amputation; Crush injuries; Crush syndrome; Fasciotomy; Rhabdomyolysis; CS; Amputation; Fasciotomy; Rhabdomyolysis; Crush syndrome; Crush injuries; CPK
• DOI: 10.1016/j.ijscr.2020.05.087
• ISSN: 2210-2612

•Crush syndrome (CS) produces severe electrolyte disorders, circulatory and multiple organ failure due to severe rhabdomyolysis and reperfusion injuries.•To date, the main stem of management is aggressive fluid resuscitation.•Fasciotomy for the treatment of compartment syndromes due to crush injuries is still controversial, and it is still unknown if early amputation has patient-centered benefits.•This case suggests a potential benefit of amputation in patients with CS and progressive deterioration. It also invites to think if this is a decision to consider early in the course of the disease.•The presence of risk factors for poor prognosis and the natural course of the disease can favor amputation despite the apparent viability of the limb and the morbidity of losing of an extremity. Crush syndrome (CS) is a condition with a high morbidity and mortality due to severe electrolyte disorders, circulatory dysfunction and multiple organ failure, secondary to severe rhabdomyolysis and reperfusion injuries. There is controversy about the role of fasciotomy in the treatment of compartment syndromes due to crush injuries and it is still unknown if early amputation has patient-centered benefits. This is a 29-year-old patient whose lower body was trapped for 50 h under a 40-meter landslide. Upon admission the left thigh was edematous and painful. Laboratories revealed a creatinine of 1.58 mg/dL, hyperkalemia, metabolic acidosis, hyperlactatemia and creatinine phosphokinase (CPK) of 88,700 U/L, suggesting CS. Despite fluid and bicarbonate infusion his renal function worsened, CPK rose and left thigh became more tense, so a fasciotomy was performed. He developed a distributive shock refractory to vasopressors, steroids and methylene blue so amputation was proposed. Two hours after amputation the vasopressor support was nearly withdrawn. This case suggests a potential benefit of amputation in patients with CS and progressive deterioration despite aggressive resuscitation. It also invites to think if this is a decision that should be considered before the establishment or in the initial stages of the syndrome, even if the viability of the extremity is still questionable. The presence of risk factors for poor prognosis can favor amputation despite the apparent viability of the limb and the morbidity of losing an extremity.