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CRUSH INJURIES Crush Injury Compression of body parts causing localized muscle and nerve damage. Frequent injury seen in both natural (earthquakes, tornadoes, etc.) and man-made (bombings, industrial accidents, etc.) disasters. ©2010 Trauma and Disaster Institute Crush Injuries

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CRUSH INJURIES

Crush Injuries


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Crush Injury

  • Compression of body parts causing localized muscle and nerve damage.

  • Frequent injury seen in both natural (earthquakes, tornadoes, etc.) and man-made (bombings, industrial accidents, etc.) disasters.

©2010 Trauma and Disaster Institute

Crush Injuries


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Incidence

  • Lower extremities = 74%

  • Upper Extremities = 10%

  • Trunk = 9%

Crush injury with amputation,

El Salvador earthquake (1987)

Crush Injuries


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Crush Syndrome

  • “Crush syndrome” first recorded in bombing of London during WWII.

  • 5 people who were crushed presented in shock with swollen extremities and dark urine.

  • All later died from renal failure.

Crush Injuries


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Crush Syndrome

  • Localized crush injury with systemic manifestations

  • Systemic effects caused by traumatic rhabdomyolysis (muscle breakdown) and the release of toxic muscle cell components and electrolytes into the circulatory system

Crush Injuries


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Crush injury of pelvis with secondary crush syndrome

Crush Syndrome Common in Earthquakes

Crush Injuries


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Earthquakes

  • Incidence of crush injury is 2-15% (historical data).

  • ~ 50% develop acute renal failure.

  • ~ 50% of those with acute renal failure need dialysis.

  • > 50% of casualties require fasciotomies.

Crush Injuries


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Components of Crush Syndrome

  • Local tissue injury

  • Organ dysfunction

  • Metabolic abnormalities

Crush Injuries



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Metabolic Abnormalities

  • Acidosis (low blood pH levels)

  • Hyperkalemia (high potassium levels)

  • Hypocalcemia (low calcium levels)

Crush Injuries



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Key Principles:

  • ADEQUATE FLUID RESUSCITATION is critical in treating victims of crush injury.

  • Ideal resuscitation fluid: Normal Saline

Crush Injuries


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Secondary Treatment Modalities

  • Bicarbonate

  • Mannitol (no proven benefits but no significant deleterious effects)

Crush Injuries


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Goals of Fluid Therapy:

  • Prevent tubular precipitation of myoglobin

  • Decrease risk of hyperkalemia

  • Correct acidemia

Crush Injuries



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TREATMENT ALERT! Crush Injuries

  • Pretreat casualties with prolonged crush (> 4 hrs), as well as those with abnormal neurological or vascular exams

  • 1-2 liters Normal Saline BEFORE releasing crush object whenever possible!

Crush Injuries


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TREATMENT ALERT! Crush Injuries

  • If not possible to pretreat, consider applying tourniquet to crushed limbs and maintain until IV fluid administration is initiated.

Combat Application Tourniquet (CAT)

Crush Injuries


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Key Principle: Crush Injuries

  • Risk of acute deterioration and death with sudden release of pressure on the involved extremity (REPERFUSION SYNDROME).

Crush Injuries


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Reperfusion Syndrome Crush Injuries

  • Acute hypovolemia

  • Metabolic abnormalities

Crush Injuries


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TREATMENT ALERT! Crush Injuries

  • Metabolic abnormalities

    • Acidosis: IV sodium bicarbonate to prevent myoglobin deposits in kidneys

    • Hyperkalemia: Calcium, sodium bicarbonate, insulin/D5W

    • Hypocalcemia: Calcium

Crush Injuries


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TREATMENT ALERT! Crush Injuries

  • Delays of hydration for longer than 12 hours increase the incidence of renal failure.

Crush Injuries


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Late Treatment: Dialysis Crush Injuries

Crush Injuries


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Compartment Syndrome Crush Injuries

  • Following traumatic injury, the muscles within a compartment can swell, causing irreversible damage to nerves, vascular structures, and muscles.

  • Compartment syndrome is a medical emergency.

Crush Injuries


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Compartment Syndrome Crush Injuries

  • Consider the possibility of a compartment syndrome in all patients with significant crush injury.

  • Compartment syndrome reported with trapping times less than 1 hour.

  • Fracture not mandatory for compartment syndrome to develop.

Crush Injuries


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RISK ALERT! Crush Injuries

  • Peripheral pulses may be present in the early stages of limb ischemia.

Crush Injuries


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Field Observation… Crush Injuries

  • The cardinal symptom of compartment syndrome is pain out of proportion to apparent injuries.

Crush Injuries


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Upper Extremity Compartment Syndrome Crush Injuries

  • Forearm and hand are at highest risk.

Crush Injuries


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Lower Extremity Compartment Syndrome Crush Injuries

  • Anterior and lateral compartments of the lower leg (calf) are at highest risk.

Crush Injuries


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Fasciotomy Crush Injuries

  • The decision to undertake fasciotomy should be made based on a high index of suspicion of a compartment syndrome in patients with complex extremity injuries.

  • Err on the side of early fasciotomy.

Crush Injuries


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Lower Extremity Fasciotomies Crush Injuries

Crush Injuries


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Early Crush Injuries Mortality in Crush Syndrome

  • Hypovolemia

  • Hyperkalemia

Crush Injuries


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Late Crush Injuries Mortality in Crush Syndrome

  • Sepsis

  • Multiple Organ Failure

Crush Injuries


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Factors Impacting Mortality and Morbidity: Crush Injuries

  • Severity of the crush injury

  • Timing of treatment

  • Initial treatment provided to the victim

Crush Injuries


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Questions… Crush Injuries

Crush Injuries


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