Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis

Article Abstract:

Rhabdomyolysis, the destruction of skeletal muscle, is a common consequence of earthquakes, when people are crushed and trapped for hours or even days without water. Massive crush injury produces rhabdomyolysis, myoglobinuria (presence of muscle protein in the urine), and renal (kidney) failure. Stretching of tissue and changes in ionic balances across cell membranes lead to cell damage, and pressure changes within the muscle itself result in cell swelling. Since the swelling muscle is enclosed in less distensible fibrous sheaths, the circulation within the muscle can stop entirely, leading to extensive damage from insufficient blood supply (ischemia). Early treatment should focus on replacement of the fluid lost from the muscle cells. Since the urinary bladder may remain unaffected, it is possible to underestimate the full extent of damage; but a delay of only a few hours in restoring proper hydration can result in acute kidney failure. Kidney function is also impaired by increases in phosphate, uric acid crystals, and clots in the organ itself. Effective treatment can completely reverse these effects, however, if begun aggressively and in time. Specific suggestions are provided, including the importance of beginning to infuse saline as soon as a limb has been freed, even if the person remains trapped. The injured limb should be managed conservatively, without surgery, especially exploratory surgery, whenever possible. Opening potential routes of infection in limbs that may have an inadequate blood supply is dangerous. When surgery is necessary, living muscle should be distinguished from dead muscle with electrical stimulation, since visual impression can be misleading. Two groups of men rescued three years apart had very different outcomes because of the treatment they received: none of the members of the group who were treated as outlined developed acute renal failure. All members of the other group, however, developed acute renal failure. Continuing to search for survivors for at least five days after a disaster is important, since people have recovered after burial under rubble for that long. Maintaining communication networks is critical for coordinating emergency medical care, and hemodialysis equipment (for filtering blood to rid it of toxic elements that build up after acute injury) should be maintained in a state of readiness. It appears that, with appropriate planning and knowledge, rhabdomyolysis can be managed in a manner that need not lead to kidney failure or permanent damage. (Consumer Summary produced by Reliance Medical Information, Inc.)

Care and treatment, Management, Disaster victims, Rhabdomyolysis

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Quality of primary care in England with the introduction of pay for performance

Article Abstract:

The quality of primary care in England before and after the introduction of pay-for-performance program is assessed. The analysis has suggested that financial incentives have affected the professional behavior and the patients have received higher-quality care in geographic areas where performance measures and monitoring are established.

Product quality, Personnel administration, HEALTH SERVICES, England, Human resource management, Health care industry, Quality management, Company personnel management, Pay for performance

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