Bhaumik Smitha S, Finn Julia, Fleischer Chelsie, Steyn Elmin, Lategan Hendrick J, Dixon Julia M, Maw Anna M, Mould-Millman Nee-Kofi
Department of Emergency Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, United States of America.
Department of Surgical Sciences, Division of Surgery, Stellenbosch University, Cape Town, Western Cape Province, South Africa.
PLoS One. 2025 Sep 2;20(9):e0331596. doi: 10.1371/journal.pone.0331596. eCollection 2025.
Crush syndrome is an important source of morbidity and mortality in resource-constrained settings including earthquake disaster zones, austere military environments, and countries where motor vehicle collisions and interpersonal violence are prevalent. In South Africa and other countries with high rates of community violence, patients develop crush due to a unique form of trauma called community assault, where individuals suspected of wrongdoing are assaulted by multiple persons as a form of mob justice. The purpose of this study is to generate consensus about crush syndrome definitions and endpoints to inform the development of scoring systems appropriate for community assault and usable in resource-limited settings.
This study used in-depth interviews of clinicans from South Africa to determine the challenges associated with crush management in resource-constrained environments. These qualitative findings informed a subsequent Delphi survey process which sought consensus regarding crush definitions, endpoints, and co-variates. Three surveys were administered to an international panel of clinicians with experience managing crush injuries in military, disaster, and civilian clinical environments. There was a pre-established consensus threshold of 75%.
There were 8 interview participants and 15 Delphi participants. These clinicians recommended maintaining a high index of suspicion for crush syndrome as this diagnosis can easily be overlooked in polytrauma patients, and advised early administration of intravenous fluids titrated to urine output and respiratory status. Crush injury was conceptualized as a localized process of muscle injury from trauma, whereas crush syndrome was viewed as the resulting systemic complications including renal failure and hemodynamic instability. Preferred clinical endpoints included acute kidney injury, renal replacement therapy, and need for respiratory support.
This study provided context related to crush injury management in resource-constrained environments. Clinical risk prediction models must account for the unique patient populations and data limitations commonly encountered in these settings.
挤压综合征是在资源有限的环境中导致发病和死亡的一个重要原因，这些环境包括地震灾区、严峻的军事环境以及机动车碰撞和人际暴力频发的国家。在南非和其他社区暴力发生率高的国家，患者因一种名为社区袭击的独特创伤形式而发生挤压伤，即被怀疑有不当行为的个人会遭到多人袭击，这是一种群体惩罚形式。本研究的目的是就挤压综合征的定义和终点达成共识，以为适合社区袭击且可在资源有限环境中使用的评分系统的开发提供参考。
本研究对来自南非的临床医生进行了深入访谈，以确定在资源有限环境中挤压伤管理所面临的挑战。这些定性研究结果为后续的德尔菲调查过程提供了信息，该调查旨在就挤压伤的定义、终点和协变量达成共识。对一个由在军事、灾难和平民临床环境中管理挤压伤有经验的临床医生组成的国际小组进行了三次调查。预先设定的共识阈值为75%。
有8名访谈参与者和15名德尔菲参与者。这些临床医生建议对挤压综合征保持高度怀疑指数，因为在多发伤患者中这个诊断很容易被忽视，并建议根据尿量和呼吸状态早期给予静脉输液。挤压伤被概念化为创伤导致的局部肌肉损伤过程，而挤压综合征则被视为由此产生的全身并发症，包括肾衰竭和血流动力学不稳定。首选的临床终点包括急性肾损伤、肾脏替代治疗以及呼吸支持需求。
本研究提供了与资源有限环境中挤压伤管理相关的背景信息。临床风险预测模型必须考虑到这些环境中常见的独特患者群体和数据限制。
