Crush Syndrome: A few pearls to remember
to be published in the SC USAR TF-1 Newsletter
Yusuf (JP) Saleeby, MD
Crush Syndrome (CS) has been documented and well known as a serious condition since WWII. The result of a protracted crushing injury to a major limb which can cause catastrophic outcomes if ignored or unanticipated is what should be prevented. Key points in medical management are preventive in the field with prophylactic use of hydration and the preparation for management of electrolyte disturbance. Additional concerns should focus on prevention of acute renal failure as sequelae.
I will attempt to outline in a concise format / algorithm how this syndrome should be recognized. How medical treatment is to be implemented (even prior to extrication and release of injured/trapped limb) and subsequent treatments and follow up.
Crushing or sustained heavy compression on an extremity or other body part causes muscle cell destruction. The cellular breakdown products such as myoglobin, potassium, phosphorus and creatinine enter the blood stream when pressure is released following a ‘’rescue’’. This is termed a reperfusion injury as these products of breakdown effect end organs such as the heart (cardiac dysrhythmia) and kidney (acute renal damage due to rhabdomyolysis). Additionally, subsequent release of crushed extremity will result in hypovolemia and hypotension due to 3rd spacing with resultant shock. This can occur rather rapidly and to save life and limb, quick action should be taken.
Cells start to die immediately after a crushing injury, ischemia under direct pressure occurs within an hour and vascular compromise can start at about four-hours. Suspect crush syndrome to occur in an injury if more than 30-minutes has elapsed. Toxins can circulate for as long as 60-hours after a release. The medical team should be at the scene to asses a victim with the rescue team prior to any release, to be able to implement prophylactic therapies to avert disastrous and untoward effects.
A high index of suspicion should be on the rescuers mind when compression exceeds an hour; large muscle groups are involved; there is lack of good capillary refill or pulses; and the skin is pale, clammy or cool. Also look for evidence of shock (rapid pulse, weakness). There also may be absences of pain, disproportional to the type of injury.
Things we want to avoid in CS: Hypotension, Acute Renal Failure (ARF) and Electrolyte disturbances with Dysrhythmia. During extrication and pre-hospital management: secure airway, O2 therapy and evaluate circulation (ABCs). Establish one or preferably 2 IVs for infusion of LR or NS PRIOR to removal of pressure. Two Liters of fluids are encouraged. To avert hypotension continue aggressive IV fluid resuscitation. Never place ice on the limb; avoid elevating the limb (splint and place in position of comfort/sling).
Pain control with Morphine or Fentanyl per MD’s orders. Keep handy Calcium Chloride/Gluconate, D50 + insulin, & nebulized Albuterol as they all may be helpful for treatment (ECG evidence or clinic suspicion) of hyperkalemia. Bicarbonate for IV administration in IV Fluids may also be indicated to alkalize blood/urine to prevent ARF.
Rapid transport is then indicated in position of comfort, temperature regulated (keep victim warm) and with continued aggressive hydration with IV fluids and cardiac monitoring. Move the crush victim to the closest most appropriate medical center/hospital for continued in-hospital care. For a more in-depth look at Crush Injury/Syndrome go to our SC USAR TF-1 web site and look up the 32 slide PowerPoint lecture on the subject or take the link below.
JP Saleeby, MD is an emergency medicine physician and the medical director for the SC USAR Task Force-1 medical team. He is available for questions at firstname.lastname@example.org