Though the incidents of crush injuries may be low in frequency, major crush injury syndrome is associated with a high mortality rate. In this podcast episode, we sit down with regular guest, Chris Stevenson, to discuss the “why”. We highlight the pathophysiology behind re-perfusion injury and pre- and post-treatment options.
Major Crush Injury/syndrome:
Can happen in as little as 20 mins depending on force and size of muscle group.
Re-perfusion of crushed area can result in massive edema causing hypovolemia as well as release of myoglobin and potassium.
- Myoglobin cast formation and hypovolemia result in renal injury/failure
- Potassium can be elevated to levels causing cardiac toxicity and fatal arrhythmias
Injury is proportionate to the amount of involved muscle, time of compression and amount of force.
Due to the muscle mass involved, lower extremities are more likely cause complications.
Treatment centers around the restoration of volume loss prevention/treatment of renal injury and the management of hyperkalemia.
Renal injury prevention/volume loss:
- Blood products if indicated due to suspected or frank bleeding from injuries.
- Crystalloid volume resuscitation with isotonic fluids: none have shown superiority.
- D5 with 3 amps of bicarb
- Alkalization of urine with sodium bicarb to prevent urine cast formation (casts are more likely in an acidic environment)
While likely not part of pre-hospital care, diuretics may also be used to promote urine output in conjunction with volume resuscitation. Frequently used options include:
No diuretic has shown superiority and each has unique properties that may guide use.
Hyperkalemia: suspected by history or evidenced by changes in ECG
- Calcium-chloride is 3x more potent than gluconate-but ideally is give via central line
- Insulin and D50
Chris Stevenson, AGACNP-BC, RN, EMT-B is Chief Flight Nurse at Virginia State Police Med-Flight and an ACNP at VCU’s Burn Center. Med-Flight operates under part 91. Their primary mission is conducting scenes and inter-facility medevacs, but they are also tasked with SAR and Police missions. Amongst his vast experience, he had the privilege of admitting patients from the 9/11 attack on the Pentagon while working in DC, and he responded to Katrina to support FEMA search operations. He’s done some time in operations as well as management.
Burns K, Cone DC, Portereiko JV. Complex extrication and crush injury. Prehosp Emerg Care. 2010 Apr-Jun;14(2):240-4. doi: 10.3109/10903120903564498. PMID: 20095831.
Gonzalez D. Crush syndrome. Crit Care Med. 2005 Jan;33(1 Suppl):S34-41. doi: 10.1097/01.ccm.0000151065.13564.6f. PMID: 15640677.
Guo X, Wang D, Liu Z. Electrocardiographic changes after injury in a rat model of combined crush injury. Am J Emerg Med. 2013 Dec;31(12):1661-5. doi: 10.1016/j.ajem.2013.08.054. Epub 2013 Oct 4. PMID: 24094864.
Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin. 2004 Jan;20(1):171-92. doi: 10.1016/s0749-0704(03)00091-5. PMID: 14979336.
Sahjian, Michael RN, BSN, CFRN, CCRN, NREMT-P; Frakes, Michael APRN, CCNS, CCRN, CFRN, NREMT-P Crush Injuries, The Nurse Practitioner: September 2007 – Volume 32 – Issue 9 – p 13-18 doi: 10.1097/01.NPR.0000287464.81259.8b
Schwartz DS, Weisner Z, Badar J. Immediate Lower Extremity Tourniquet Application to Delay Onset of Reperfusion Injury after Prolonged Crush Injury. Prehosp Emerg Care. 2015;19(4):544-7. doi: 10.3109/10903127.2015.1005264. Epub 2015 May 13. PMID: 25970809.
Whiffin ANH, Spangler JD, Dhir K, Zhang R, Ferguson JD. Bathroom Entrapment Leading to Cardiac Arrest From Crush Syndrome. Prehosp Emerg Care. 2019 Jan-Feb;23(1):90-93. doi: 10.1080/10903127.2018.1471558. Epub 2018 Aug 17. PMID: 30118356.
Zhang X, Bai X, Zhou Q. First-aid treatments of crush injuries after earthquake: 2 special cases. Am J Emerg Med. 2014 Jul;32(7):817.e3-4. doi: 10.1016/j.ajem.2013.12.062. Epub 2014 Jan 8. PMID: 24534195.