Should we give priority to plasma exchange and hyperbaric oxygen treatment before deciding on amputation for severe crush injuries?

Murat Tanyıldız, Ömer Özden, Karya Şenköylü, İlker Eren, Aysu Çakar, Laşin Özbek, Aslıcan Çakkalkurt, Ilmay Bilge
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Abstract

Background: The most common medical sequelae after earthquakes are crush injuries and syndromes that require urgent and well-organized care, which further complicates the approach in the face of overstretched resources. The 2023 Kahramanmaraş earthquake, with a magnitude of 7.7, was one of the largest disasters in Türkiye, affecting 11 cities with a population of about 13.5 million people and claiming more than 50,000 deaths. Approximately 4.6 million pediatric patients were affected, with over 500 children undergoing amputations. The overwhelming number of cases rendered further treatment efforts nearly unfeasible.

Cases: Here we present three cases of severe crush injuries in which amputation was initially considered in both primary and our tertiary centers but was prevented by a protocol that included therapeutic plasma exchange (TPE) and intensive hyperbaric oxygen treatments (HBOT). Based on our review of the literature, this appears to be the first case series documenting the use of therapeutic plasma exchange (TPE) in the management of crush injury.

Conclusion: In extremities at risk for amputation, TPE therapy is crucial to preventing disseminated intravascular coagulation, systemic inflammatory response syndrome, and the accompanying multiorgan failure. It has been shown that extremities at risk for amputation due to poor perfusion can be managed confidently during the safe recovery period of daily TPE therapy with frequent HBOT, anticoagulant and vasodilator treatments, frequent wound care to prevent the development of infection, prophylactic antibiotics, vacuum-assisted closure therapy, and debridement when necessary.

我们是否应该优先进行血浆置换和高压氧治疗,然后再决定对严重挤压伤进行截肢?
背景:地震后最常见的医学后遗症是挤压伤和综合征,需要紧急和有组织的护理,这在资源过度紧张的情况下使治疗方法进一步复杂化。2023年发生的7.7级kahramanmaraki地震是乌克兰最大的灾难之一,影响了11个城市,人口约为1 350万,造成5万多人死亡。大约460万儿科患者受到影响,500多名儿童接受截肢手术。压倒性的病例数量使进一步的治疗工作几乎不可行。病例:在这里,我们报告了三例严重挤压伤,其中截肢最初在我们的一级和三级中心都被考虑过,但通过包括治疗性血浆交换(TPE)和强化高压氧治疗(HBOT)的方案来预防。根据我们对文献的回顾,这似乎是第一个记录治疗性血浆置换(TPE)在挤压伤治疗中的应用的病例系列。结论:对于有截肢危险的肢体,TPE治疗对于预防弥散性血管内凝血、全身炎症反应综合征和伴随的多器官功能衰竭至关重要。研究表明,在日常TPE治疗的安全恢复期,通过频繁的HBOT、抗凝和血管扩张剂治疗、频繁的伤口护理以防止感染的发生、预防性抗生素、真空辅助闭合治疗和必要时的清创,可以自信地管理因灌注不良而有截肢风险的肢体。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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