Crush injuries
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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

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CRUSH INJURIES

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


Incidence

  • Lower extremities = 74%

  • Upper Extremities = 10%

  • Trunk = 9%

Crush injury with amputation,

El Salvador earthquake (1987)

Crush Injuries


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


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


Crush injury of pelvis with secondary crush syndrome

Crush Syndrome Common in Earthquakes

Crush Injuries


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


Components of Crush Syndrome

  • Local tissue injury

  • Organ dysfunction

  • Metabolic abnormalities

Crush Injuries


Crush Injuries


Metabolic Abnormalities

  • Acidosis (low blood pH levels)

  • Hyperkalemia (high potassium levels)

  • Hypocalcemia (low calcium levels)

Crush Injuries


Definitive Management of Crush Syndrome

Crush Injuries


Key Principles:

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

  • Ideal resuscitation fluid: Normal Saline

Crush Injuries


Secondary Treatment Modalities

  • Bicarbonate

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

Crush Injuries


Goals of Fluid Therapy:

  • Prevent tubular precipitation of myoglobin

  • Decrease risk of hyperkalemia

  • Correct acidemia

Crush Injuries


Prehospital Considerations in the Management of Victims with Crush Injuries

Crush Injuries


TREATMENT ALERT!

  • 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


TREATMENT ALERT!

  • 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


Key Principle:

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

Crush Injuries


Reperfusion Syndrome

  • Acute hypovolemia

  • Metabolic abnormalities

Crush Injuries


TREATMENT ALERT!

  • Metabolic abnormalities

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

    • Hyperkalemia: Calcium, sodium bicarbonate, insulin/D5W

    • Hypocalcemia: Calcium

Crush Injuries


TREATMENT ALERT!

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

Crush Injuries


Late Treatment: Dialysis

Crush Injuries


Compartment Syndrome

  • 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


Compartment Syndrome

  • 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


RISK ALERT!

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

Crush Injuries


Field Observation…

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

Crush Injuries


Upper Extremity Compartment Syndrome

  • Forearm and hand are at highest risk.

Crush Injuries


Lower Extremity Compartment Syndrome

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

Crush Injuries


Fasciotomy

  • 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


Lower Extremity Fasciotomies

Crush Injuries


Early Mortality in Crush Syndrome

  • Hypovolemia

  • Hyperkalemia

Crush Injuries


Late Mortality in Crush Syndrome

  • Sepsis

  • Multiple Organ Failure

Crush Injuries


Factors Impacting Mortality and Morbidity:

  • Severity of the crush injury

  • Timing of treatment

  • Initial treatment provided to the victim

Crush Injuries


Questions…

Crush Injuries


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