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I’VE GOT A CRUSH ON YOU! CRUSH INJURIES IN EMS

DON’T BELIEVE THIS MAN….

OBJECTIVES Recognize the differences between Crush Injury and Crush

Syndrome

List at least 2 complications that occur with Crush Syndrome

Understand the interventions performed when treating someone with Crush Syndrome and how they work.

List the three most common areas of the body that are

more susceptible to developing Crush Syndrome

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INJURY SYNDROME

• Cell Disruption/ injury at the point of impact.

• Occurs < 1 hour

•  Systemic effects when muscle is RELEASED from compression

• Occurs after cells have been under pressure >4 hours*

•  Suspect Syndrome with lightening strikes

CRUSHING MECHANISM OF INJURY

Building and Structure Collapse

Bomb Concussions

MVAs’ and Farm Accidents

Assault with blunt weapon

AKA: COMPRESSION SYNDROME

First described by Dr. Minami in 1940

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INVOLVED ANATOMY

Upper Arms

Upper Legs

Thorax and Buttocks

INSIDE A CELL

Potassium ATP (Krebs Cycle… Aaaah! )

Hydrogen (=>acid*) Lactate (=>acid*)

Urea (=>acid*) Phosphate (=>acid*)

*when deprived of oxygen

MYOGLOBIN

The building block of muscle

Doesn’t belong in the bloodstream

“gels up” when it hits acidic urine

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AT THE POINT OF IMPACT…

As the weight presses down ------

As the weight increases ------

As the weight stays pressed down ------

MINUTES LATER…..

Blood flow floods to the injured area

Histamine is released

ONCE THE WEIGHT IS LIFTED…

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“SMILING DEATH”

“In Prolonged entrapment, “smiling death” may occur…….. In this situation, the

trapped person is alert and conversing with rescuers; however, when the entrapped

body part is freed, cardiac arrest is almost instantaneous.”

Emergency Care in the Streets: American Academy of Orthopaedic Surgeons

ISCHEMIC REPERFUSION

Phosphate – vascular calcifications

Acids => more cellular injury

Potassium –Na/K pump => cardiac arrest

HYPERKALEMIA

Usually the thing that kills after the weight has been

lifted….

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TREATMENT OPTIONS….

TOURNIQUETS

Place a tourniquet just proximal to the weight if possible

SALINE

At least 2 large bore IVs’ & SALINE !

Initial Bolus 30 ml/kg

Desired Urine Output: 200-300 ml/hr

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CALCIUM

Calcium Chloride 1 gm IVP over 10-15 minutes

Stablizes the cell wall

Always give FIRST when dealing with hyperkalemia

SODIUM BICARBINATE

1 mEq/kg bolus

Followed by…….

1 amp of bicarb in a 1000 ml bag of NS and infuse wide open

IF the patient survives the initial release of the toxic by-products and makes it to the hospital…

They remain at GREAT risk for

developing RENAL FAILURE with severe morbidity

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RHABDOMYOLYSIS “SKELETAL MUSCLE DEGRADATION”

“Myoglobinemia”

Muscle fibers breakdown

resulting in the dumping of

myoglobin into the bloodstream.

“Myoglobinuria”

The myoglobin gets filtered out

of the blood through the

kidneys into the urine

“MYOGLOBINURIA”

TREATING RHABDOMYOLYSIS

“Aggressive Volume Resuscitation for traumatic rhabdomyolysis is

imperative!”

Desired Urine Output: 200-300 ml/hr

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TREAT THE URINE!

“Normal” myoglobin excretion through the kidneys is 5%

Alkalinize the urine with bicarb and the

excretion rate increases

ALBUTEROL

Drives the potassium into the cell.

10-20 mg is recommended for hyperkalemia

LASIX

Forces Diuresis

Causes Renal Vasodilation

40-120 mgs IVP

Remember!: This stuff will acidify urine

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OTHER TREATMENTS Mannitol

Allopurinol

Hemodialysis

Hyperbaric Oxygenation

OTHER CONSIDERATIONS….

COMPARTMENT SYNDROME

Seen with broken long bones, crush injuries, etc

The fascia don’t stretch to accommodate for swelling

Blood Flow and Nerve Damage Occurs

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COMPARTMENT SYNDROME

Pressure builds up within the ‘compartment’ and compresses

nerves and vessels. Occurs several hours after initial time of

injury.

THE 5 P’S OF COMPARTMENT SYNDROME

Pain Paresthesia

Pallor Pulselessness

Paralysis Poikilothermia

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HARNESS SYNDROME

Seen with repelling, commercial window

washers, parachuters, etc

Leg straps which cross over the femoral veins and arteries compress

the circulation.

I’VE FALLEN AND I CAN’T GET UP!

PASG OR MAST

“The use of PASG has been reported to cause compartment

syndrome and crush injury syndrome”

Journal of Trauma 1984 Issue 24

Pages 1052-1056

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TRUE STORY….

A cattle farmer was found pinned under the rear wheel of his tractor. Estimated to have occurred in the early

afternoon. It is now dusk.

Alert and Oriented, complains of severe back pain and no sensation in his legs.

FIRST RESPONDERS ARRIVE…..

Appears to have Crush Injuries to pelvis and bilateral

lower extremity injuries

Patient still Alert and Oriented and complains only of lower back pain.

ALS units en route urge responders NOT to extricate

until they arrive.

THE REST OF THE STORY……

Due to family’s increasing anxiety and demands, Incident Command

ordered the extrication (ALS not on scene yet…..)

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THE REST OF THE STORY……

Just as the tractor is lifted from the patient, his condition deteriorated rapidly. ALS arrived to find patient

had arrested and never responded to resuscitative efforts.

?QUESTIONS?