Bywater's syndrome

A condition of major shock and renal failure following a crushing injury to skeletal muscle. Features include myoglobinuria and typical lower nephron nephrosis with oliguria or anuria. Pain where trauma has occurred.

Cases commonly occur in catastrophes such as earthquakes or war, where victims have been trapped under fallen masonry. Eric Bywaters and Desmond Beall described the syndrome in 16 civilian victims of the 1941 London Blitz.

It is a reperfusion injury that appears after the release of the crushing pressure. The mechanism is believed to be the release into the bloodstream of toxic chemicals - notably myoglobin, potassium and phosphorus - that are the products of rhabdomyolysis (the breakdown of skeletal muscle damaged by ischemic conditions). The specific action on the kidneys is not fully understood, but may be due in part to nephrotoxic metabolites of myoglobin (Wikipedia).

From the description by Bywaters and Beall:

"The patient has been buried for several hours with pressure on a limb. On admission he looks good except for swelling of the limb, some local anaesthesia and whealing. The haemoglobin, however, is raised, and a few hours later, despite vasoconstriction, made manifest by pallor, coldness and sweating, the blood pressure falls. This is restored to a pre-shock level by (often multiple) transfusions of serum, plasma, or, occasionally, blood. Anxiety may now arise concerning the circulation of the injured limb, which may show diminution of arterial pulsation distally, accompanied by all the changes of incipient gangrene. Signs of renal damage soon appear, and progress, even though the crushed limb be amputated. The urinary output, initially small, owing perhaps to the severity of the shock, diminishes further. The urine contains albumen and many dark brow or black granular casts. These later decrease in number. The patient is alternately drowsy and anxiously aware of the severity of his illness. Slight generalised oedema, thirst and incessant vomiting develop, and the blood pressure often remains slightly raised. The blood urea and potassium, raised at an early stage, become progressively higher and death occurs comparatively suddenly, frequently within a week. Necropsy reveals necrosis of muscle and, in the renal tubules, degenerative changes and casts containing brown pigment."

The condition had previously been observed in victims of the Messina earthquake in 1909, and in German victims of Allied air raids in the first world war.

We thank Joseph Constantin, France, for information submitted.

• Franz Colmers:
  Ueber die durch das Erdbeben in Messina am 28. Dec. 1908 verursachten Verletzungen. Archiv für klinische Chirurgie, 1908, 90: 701.
• Ludwig Frankenthal (1885-1944):
  Über Verschüttungen.
  Virchows Archiv für pathologische Anatomie und Physiologie und für klinische Medizin, Berlin, 1916, 222: 332.
• L. Frankenthal:
  Die Folgen der Verletzungen durch Verschüttung.
  Bruns beiträge zur klinischen Chirurgie, 1918, 109: 572.
• S. L. Baker and E. C. Dodds:
  Obstruction of the Renal Tubules during the Excretion of Haemoglobin.
  The British Journal of Experimental Pathology, Oxford, 1925, 6: 247.
• E. G. L. Bywaters and Desmond Beall:
  Crush injuries with impairment of renal function.
  British Medical Journal, London, 1941, 1: 427-432.
• E. G. L. Bywaters, G. E. Delory, C. Rimington, J. Smiles:
  Myohaemoglobin in the urine of air raid casualties with crushing injury.
  The Biochemical Journal, London, November 1941, 35 (10-11): 1164-1168
• E. G. L. Bywaters and J. H. Dible:
  The Renal Lesion in Traumatic Anuria.
  The Journal of Pathology and Bacteriology, London, 1942, 54, 111.
• E. G. Bywaters, G. Popjak:
  Experimental crushing injury: Peripheral circulatory collapse and other effects of muscle necrosis in the rabbit.
  Surgery, Gynecology & Obstetrics, Chicago, 1942, 75: 612-627.
• M. G. Eggleton:
  Crush Syndrome. British Medical Journal, 1942, 2: 495.
• E. G. L. Bywaters:
  Ischemic Muscle Necrosis.
  Journal of the American Medical Association, Chicago, 1944, 124: 1103.
• E. G. L. Bywaters and J. McMichael:
  Crush Syndrome. In Z. Cope, editor: History of the Second World War: Surgery, page 73. London, Her Majesty's Stationary Office. 1953.