Thermal radiopathy combined with transverse muscle dissolution syndrome and forearm fascia syndrome 1 case.

Heat-shooting disease (HS) is caused by high temperature and humidity environment, mainly manifested in the serious increase of the core temperature of the human body (usually 40 degrees C) and the central nervous system dysfunction (delirium, aggressiveness, convulsions, coma, etc.), accompanied by a group of clinical syndromes with severe internal environmental disorders of the organism and extensive damage to tissue organs.
HS can cause many serious complications, such as clotting dysfunction, multi-organ failure, dispersal in-vascular clotting, transverse myolysis syndrome (RM) and so on.
RM refers to a group of clinical syndromes caused by various causes of transverse muscle damage, which causes enzymes, ions and small molecules in muscle cells to enter the outer blood.
RM can cause acute renal dysfunction (AKI), electrolyte disorders, severe heart rate disorders, etc., is one of the important causes of death.
HS combined RM when the disease is serious, the prognosm is poor, need active treatment.
RM in addition to causing AKI, but also can cause fascia syndrome (OCS) or in the case of limb pressure induced OCS, need to cut early to reduce pressure, cut after the incuss needs to be properly handled to avoid infection.
the emergence of RM and OCS at the same time, not only prompt the patient to be critically ill, but also increase the difficulty of treatment, clinically need to actively deal with, save the patient's life.
this paper reports on the diagnosis and treatment of 1 case of HS combined RM and OCS patients, with the aim of providing some reference for the treatment of such patients.
clinical data patient, male, 59 years old, sanitation worker.
hospital before 2h in the high temperature environment was found unconscious, accompanied by limb convulsions, urinary retention, urination incontinence.
rushed to a nearby hospital after the emergence of high fever, convulsions, after treatment into our hospital emergency department treatment.
admitted to hospital: body temperature 38.6 degrees C, pulse 110 times /min, breathing 25 times/min, blood pressure 151/73mmHg, confusion, should not be called, convulsions, double pupils, etc. large, diameter about 2mm, Hearing double lung breathing sound thick, smell and a little dry and wet tone, heart rhythm, heart rate 110 times / min, no noise, abdominal softness, residual body can not cooperate, bowel chirping 4 times / min, double upper limb slightly swollen, double lower limbs no puffiness.
laboratory examination results are as follows.
blood routine: white blood cells 15.7 x 109/L, neutral granulocytes 12.78 x 109/L, neutral granulocyte percentage 84.1, hemoglobin 86g/L, plateplate 187 x 109/L.
biopics: total protein 40.4g/L, albumin 19.2g/L, white/ball ratio 0.91, blood creatinine 86.8μmol/L, blood sugar 12.04 mmol/L, Na-133.3mmol/L, Ca2-1.84mmol/L, crea acid kinase 1600U/L, lactic acid dehydrogenase 677U/L.
blood gas analysis (oxygen absorption status, oxygen concentration 45%):pH7.46, CO2 pressure 26.4mmHg, oxygen pressure 172mmHg, total CO2 19.3mmol/L, standard bicarbonate 20.9mmol/L, actual bicarbonate 18.5mmol/L, anion clearance 5.1mmol/L; crea acid Kinase isoenzyme 16.43 ng/mL, hypersensitive titrogen T190.8pg/L, myoglobin-gt;3000 ng/mL, N-end-pre-brain sodium peptide 1674pg/mL, calcitonin 5.70 ng/mL; clotting function D-djubin 1.24mg/L, fibrotin 4.91/Lg.
electrostatic chart: sinus titration.
clinical diagnosis: (1) HS; (2) RM; (3) type I. respiratory failure; (4) ion disorder; (5) diabetes; (6) hypertension in the fascia chamber of the upper extremities.
therapy admitted to hospital, in the improvement of the relevant examination at the same time, to physical cooling, breath tube intubation ventilator auxiliary ventilation (synchronous intermittent command ventilation mode, oxygen absorption concentration of 45%, moisture volume 500mL, exhalation is pressing 5cm water column, oxygen saturation remained at 98%), propofol and Medacron sedation, butofino tanthalies, sodium propionate pumping, Infusion white virus inactivated frozen plasma to improve clotting, infusion filter white blood cell suspension to improve anemia, Meropenan anti-infection, Ulladir blood pressure control, omepracyte inhibition, nutritional heart muscle, wake-up and other treatment, while the right collarbone under the venous puncture tube monitoring center venous blood pressure, common vein puncture continuous kidney replacement therapy (CRRT) (continuous static-venous blood transfusion mode).
the second day of hospitalization, the patient's left upper limb swelling increased, accompanied by blisters appear, consider the left upper limb OCS is likely.
line bed next to the limb cut decompression drainage, postoperative wound with oil yarn filled drainage, can touch the artery throbbing;
the 4th day of hospitalization, the patient's left limb swelling than before saw no significant relief, more blood seepage at the intlow, blisters on the surface of the skin, the implementation of vacuum negative pressure closed drainage (VSD) membrane cover, after surgery continued VSD, the rest of the treatment before.
7th day of hospitalization, the patient's consciousness recovers.
the 8th day of hospitalization, the patient was removed from the ventilator and replaced with a nasal catheter to absorb oxygen, continued infusion of leachate leachate virus inactivated frozen plasma and white blood cell suspension to improve blood clotting function and anemia;
10th day of hospitalization, the swelling of the patient's two-sided limbs gradually eased.
the 11th day of hospitalization, the patient's mind is clear, the condition is stable, line VSD after 7d, remove VSD, upper arm decompression indicing healing well, left forearm and hand back side indigestion see yellow seepage, to clean, reduce the stitching, and then line VSD, continuous flushing.
the 24th day of hospitalization, the patient's hand back side indentation healed, left forearm side indentation did not heal, scarring, after clean-up again line VSD cover, continuous flushing.
the 31st day of hospitalization, the removal of VSD, indicing healing well, strong fists, discharged from the hospital to go home to recuperate.
the pathophysiology of HS and RM and the diagnosis of HS is a critical disease with severe elevated body temperature and dysfunction of the central nervous system, which is mainly manifested in aggressiveness, delirium, convulsions, coma, etc.
depending on the labor factor, HS can be divided into classic HS and labor HS.
Classic HS is mainly caused by the hypothermia dysfunction and heat dissipation in high temperature environment, mainly in the elderly, children and people with basic diseases, while labor-type HS is mainly caused by high-intensity physical activity in high temperature, high humidity environment, high-risk groups for the army officers and soldiers, young adults and athletes.
HS pathogenesis and pathophysiology are mainly the body's thermal regulation dysfunction and related thermal damage, clotting dysfunction and immunomodulation dysfunction, and several factors interact to eventually lead to systemic inflammatory response and multi-organ dysfunction.
RM refers to a group of clinical syndromes caused by various causes of transverse muscle damage, which causes enzymes, ions and small molecules in muscle cells to enter the outer blood.
RM-causing factors can be broadly divided into physical and non-physical factors, including extrusion and trauma, movement and muscle over-activity, and non-physical factors mainly include drugs, poisons, infections, electrolyte disorders, autoimmune diseases and so on.
normal enzymes (e.g. myoglobin, lactic acid dehydrogenase, creatinine kinase, etc.) in transverse muscle cells when RM occurs, a large number of blood, causing a series of bio-chemical indicators to change, which is an important basis for diagnosis of RM.
RM diagnosis mainly includes eynamic diagnosis, RM diagnosis and its complication diagnosis 3 aspects, mainly based on ;(: (1) the presence of the cause of RM;
most common complications of RM are AKI, the incidence rate is about 13% to 50%, the incidence of AKI after the death rate of up to 20% to 50%.
AKI should be highly suspected of the following conditions after the exclusion of primary kidney disease: less urine, no urine, hemouria nitrogen ,14.3mmol/L, blood creatinine . . . 176.8 . L, blood uric acid, 475.8 mol/L, blood potassium, 6mmol/L, blood phosphorus, 2.6mmol/L, blood calcium, slt;2mmol/L.
suspected RM clinically, blood, urinary myoglobin and creatinine kinase should be examined, and kidney function, electrolytes and other tests should be carried out to determine whether there is damage to renal function.
the cause of RM in this case is HS, which is a non-physical factor, and the patient's blood creatoic kinase 1600U/L (-gt;1000U/L), creatoic kinase isoenzyme 16.43 ng/mL (normal upper limit 3.4 times), lactic acid dehydrogenase 677U/L (normal upper limit 1.09 times), high sensitivity T190.8pg/mL (normal upper limit 13.6x), myoglobin 3000g/mL (normal upper limit 41.67x), N-frontal sodium peptide 1674pg/mL (normal upper limit 5.58x), K-4.38mmol/L, blood creatinine 86.8 μmol/L.
clinical performance and medical history of patients, HS combined RM diagnosis was established, while blisters and skin color changes appeared in the patient's limbs, and OCS diagnosis was established.
, the treatment of this case is mainly focused on the comprehensive treatment of HS, RM and OCS.
treatment of HS, RM and related complications mainly includes on-site treatment and hospital treatment.
treatment mainly includes leaving the high-heat environment, stabilizing the air channel, breathing, temperature measurement, physical cooling and so on.
hospital treatment measures mainly include a variety of measures combined cooling, sedation, oxygen, protection of brain function, CRRT, anticoagulant therapy, anti-inflammatory treatment, intestinal nutrition and so on.
RM treatment principle is to remove the cause as soon as possible, early to give a large number of rehydration fluids and alkaline urine treatment, prevention and treatment of critical complications, the key to treatment is early fluid resuscitation, correction of low blood volume, prevention of AKI.
for OCS, the most effective method is to cut open decompression, after incussion care recommended VSD technology.
from the principles of HS and RM treatment, whether it is pure HS, pure RM, or HS combined RM, CRRT is an important and very effective treatment.
AKI did not occur when the patient was admitted to the hospital, and the whole treatment process of blood K-plus, blood creatinine are in the normal range, the main reason is that the patient immediately after hospitalization began to implement CRRT, effectively prevent the occurrence of AKI.
In addition, about 1 week after the implementation of CRRT treatment, hemoglobin, N-end-frontal sodium peptides, creatinase isoenzyme, calcitonin primary significantly decreased, indicating that early implementation of CRRT can effectively remove harmful substances, to prevent AKI and multi-organ dysfunction is of great significance.
CRRT can achieve two main purposes with the help of in vitro circulation technology: first, to effectively cool down, and second, to remove harmful substances from the body and maintain environmental stability in the body.
CRRT therapy can effectively remove hemoglobin, cremoglobin, interferon-alpha, leuriocyte mesothrin (IL)-1, IL-2 and other substances, breaking the vicious circle of HS from systemic inflammatory response to dispersal intracvascular clotting, multi-organ dysfunction and AKI.
, although there is no uniform standard for the timing of CRRT implementation, a large number of studies have recommended the early implementation of CRRT, especially before renal damage.
Wang Used CRRT to treat 35 RM patients, the results showed that the amount of myoglobin and hyperfiltration in CRRT treatment 2h can be significantly reduced, after treatment 6 and 8h its concentration decreased significantly, which shows that early CRRT can effectively remove myoglobin, to avoid the occurrence of AKI.
For what CRRT mode to adopt, currently mainly includes continuous static-venous blood filtration and continuous static-intravenous hemodialysis filter 2 modes, both can effectively remove hemoglobin, but continuous static-vein blood filter on the removal of blood creatinine is better, and continuous static-intravenous hemodialysis filter to clear IL-6, IL-8 and other small molecules of the clearance rate is higher.
But studies such as Chen Gang showed that the survival rates of 15, 28 and 60d were not significantly different in patients treated with RM in two modes of continuous static-intravenous blood filtration and continuous static-intravenous hemodialysis.
, both clinical models can be used to treat RM patients.
addition, in this case, the patient OCS decompression indulation care using VSD technology, for the patient's incuss situation has been implemented 3 times VSD, the final intive healing, the function of the patient limb remains good.
VSD technology is mainly through polyurethane film (bio-semi-permeable membrane) and polyethylene ethanol hydrated seaweed salt foam (VSD dressing) to create continuous negative pressure drainage, a variety of oozing and inflammatory factors in a timely manner excluded from the body, can effectively control wound infection, promote wound healing, reduce complications and so on.
is the timely removal of necrotasia and smooth drain, thereby accelerating the wound healing.
in summary, for patients with HS combined RM, the early implementation of CRRT can effectively prevent AKI and multi-organ dysfunction;
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