Następstwa ran miażdżonych, poza miejscowym uszkodzeniem tkanek, mogą także obejmować poważne zaburzenia systemowe. Jednym z nich jest zespół zmiażdżenia, zwany także zespołem Bywatersa. W przebiegu tego schorzenia dochodzi do upośledzenia funkcji nerek, które może prowadzić do licznych powikłań.
Patofizjologia zespołu zmiażdżenia
W przebiegu zespołu zmiażdżenia na skutek uszkodzenia tkanek spowodowanego naciskiem tępego przedmiotu dochodzi do rabdomiolizy. Jest to zespół objawów chorobowych, który występuje na skutek rozpadu tkanki mięśniowej poprzecznie prążkowanej.
Kiedy tkanka mięśniowa ulega znacznemu naciskowi, dochodzi do uszkodzeń we włóknach mięśniowych. Nacisk powoduje zmniejszenie dopływu krwi do tkanek, a w konsekwencji ich niedokrwienie i śmierć komórek. W uszkodzonych komórkach dochodzi do zaburzenia błon komórkowych. Kiedy źródło nacisku zostaje usunięte, związki nagromadzone w uszkodzonych komórkach zostają uwolnione do systemu. Substancje znajdujące się w środowisku pozakomórkowym (wapń, sód, woda) przemieszczają się do wewnątrz komórki, natomiast z uszkodzonych włókien mięśniowych do środowiska pozakomórkowego uwalnia się mioglobina. Związek ten tworzy konglomeraty w kanalikach nerkowych, co prowadzi do mechanicznej obturacji cewek nerkowych. Skutkiem tego procesu może być rozwój ostrej niewydolności nerek.
Oprócz mioglobiny z uszkodzonych komórek mięśniowych uwalniane są również kwas mlekowy, tromboplastyna, histamina, kinaza keratynowa, kwasy nukleinowe, fosforan i kreatyna, a także potas.
Kwas mlekowy może spowodować wystąpienie kwasicy metabolicznej, zaś potas może wywołać zaburzenia rytmu serca. Uwalnianie histaminy powoduje rozszerzenie naczyń krwionośnych i skurcz oskrzeli, czego skutkiem są duszności i zaburzenia oddechowe. Wiele z uwalnianych związków działa także rozszerzająco na naczynia krwionośne, co może doprowadzić do niedociśnienia.
Diagnostyka
W każdym przypadku, który uwzględnia znaczne uszkodzenie tkanki mięśniowej, należy przewidywać uwalnianie mioglobiny do układu krwionośnego. Z tego powodu w procesie diagnozowania zespołu Bywatersa bardzo istotne jest oznaczenie poziomu tego związku w surowicy krwi i w moczu.
Innym zalecanym do wykonania badaniem jest marker fosfokinazy kreatynowej. Związek ten jest uwalniany w przypadku każdego uszkodzenia tkanki mięśniowej, natomiast w przebiegu rabdomiolizy urazowej jego poziomy są niezwykle wysoki.
Terapia zespołu zmiażdżenia
Bezpośrednio po wystąpieniu urazu należy jak najszybciej usunąć obiekt wywołujący nacisk na tkanki. Początkowe postępowanie terapeutyczne powinno obejmować intensywne nawadnianie w celu zwalczania hipowolemii i zapobiegania ostrej niewydolności nerek spowodowanej rabdomiolizą. Opóźnienie w zastosowaniu resuscytacji płynami może zwiększyć ryzyko niewydolności nerek o 50 proc. Jeżeli pomimo terapii płynami zaburzenia funkcji nerek się pogłębiają, konieczne może być wprowadzenie dializ.
Zalecane jest także monitorowanie pacjenta elektrokardiografem na obecność objawów hiperkaliemii. Należy również pamiętać, że rozległe uszkodzenie tkanek może stać się przyczyną zakażenia i sepsy.
Źródła: https://www.nursingcenter.com/, https://www.jems.com/, https://www.ncbi.nlm.nih.gov/, https://portal.abczdrowie.pl/
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Dlaczego wankomycyna nie jest właściwym wyborem w leczeniu zakażeń skóry i tkanek miękkich?
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