Role of physiotherapy in the rehabilitation of survivors of the Kiss nightclub tragedy in Santa Maria, Brazil

On 27 January 2013, a fire in Kiss nightclub, Santa Maria, Brazil caused 1000 injuries and 242 deaths due to carbon monoxide (CO) and hydrogen cyanide (HCN) poisoning. This was the second highest death toll due to fire in Brazilian history. Survivors were exposed to HCN gas produced when fire consumed the soundproofing foam in the ceiling. In addition to severe smoke inhalation injury, the survivors had musculoskeletal disorders and burns.

CO is an asphyxiant, colourless, odourless, tasteless and non-irritating gas [1] produced by the incomplete combustion of hydrocarbons [2], [3]. A CO concentration of 1% is sufficient to cause serious injury because CO is absorbed rapidly by the pulmonary epithelium and has high affinity for haemoglobin (up to 200 to 250 times higher than that of O₂) [3]. CO poisoning accounts for 80% of all smoke-inhalation-related deaths, most of which occur within 24hours of exposure [4].

HCN is produced by the incomplete combustion of carbonaceous and nitrogenous materials, including cotton, silk, wood, paper, plastics, sponges, acrylics and synthetic polymers [5], [6]. The recycling of pyrolysis products in enclosed spaces increases the rate of HCN formation, and lack of ventilation in the environment can increase the rate up to 10 fold. Ingestion of HCN products produces metabolic acidosis, which is also seen in burns patients during resuscitation [7]. Systemic toxicity following inhalation of CO or HCN particularly affects those organ systems most sensitive to low oxygen levels: the nervous, cardiovascular and respiratory systems [8].

Studies have shown that respiratory injury resulting from inhalation of smoke or chemical products of combustion is associated with significant morbidity and mortality. Even in isolation, inhalation injury can be associated with longstanding pulmonary dysfunction [9]. Survivors of acute CO poisoning experience excess mortality compared with the general population [10]. However, it is important to note that the long-term respiratory effects caused by HCN smoke inhalation remain poorly understood.

In terms of neurological effects, survivors may suffer brain damage due to a direct effect of the poison on nerve cells, a lack of oxygen or insufficient blood circulation. Examples of long-term neurological effects caused by HCN poisoning include personality changes, memory loss and disturbances in movement (both voluntary and involuntary movement disorders); some damage may be permanent [8].

To date, there is no evidence about the effects of HCN inhalation on the musculoskeletal system in humans.

Based on these studies [8], [9], [10], a group of professors are working alongside a multidisciplinary team at the Integrated Centre for Victims of Accidents in the University Hospital of Santa Maria of the Federal University of Santa Maria. Such work is taking place at the present time with the continuity of rehabilitation care to the victims. The University Hospital of Santa Maria was designated by the Brazilian Ministry of Health as a reference centre and follow-up care, with multidisciplinary care team of all those involved directly and indirectly for a minimum of 5 years.

This group is also conducting pulmonary, neurological and musculoskeletal functional assessments (standardised questionnaire and physical examination) of all individuals (those who were hospitalised and subsequently discharged, those who were not admitted but who also inhaled toxic chemicals, those who live in the environs of the nightclub, firefighters, etc.) through a protocol designed specifically for this purpose. To date, 259 individuals [115 females, 144 males, mean (SD) age 27 (10) years, mean (SD) body mass index 23.55 (5.99)kg/m²] have been evaluated, and approximately 70% have clinical evidence of functional impairment that indicates rehabilitation. The most common respiratory symptoms and signs in smoke-inhalation victims are: dry and productive cough (40%), alteration of respiratory rhythm (31%), fatigue (21%), breathlessness (20%), dyspnoea (17%) and chest pain (13%). Some individuals also have neurological symptoms such as persistent headache (13%), memory loss (10%) and paresthesia (15%). Musculoskeletal lesions (20%) and extensive cutaneous burns (23%) have also been observed. The burn injuries are important because rehabilitation for these patients starts from the day of injury, lasts for several years and requires multidisciplinary efforts. A comprehensive rehabilitation programme is essential to decrease patients’ post-traumatic effects and improve functional independence [11].

These preliminary results emphasise the important role of long-term physiotherapy follow-up in the rehabilitation of survivors of the Kiss nightclub tragedy, and may support the future development of strategies to optimise functional recovery of survivors after disasters involving smoke inhalation injury caused by fires in enclosed spaces, HCN poisoning and CO poisoning.

Role of physiotherapy in the rehabilitation of survivors of the Kiss nightclub tragedy in Santa Maria, Brazil Pysiotherapy - December 2013 (Vol. 99, Issue 4, Pages 269-270, DOI: 10.1016/j.physio.2013.07.001)