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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

Crush Injuries

crush injury
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
Incidence
  • Lower extremities = 74%
  • Upper Extremities = 10%
  • Trunk = 9%

Crush injury with amputation,

El Salvador earthquake (1987)

Crush Injuries

crush syndrome
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 syndrome5
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

slide7

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
Components of Crush Syndrome
  • Local tissue injury
  • Organ dysfunction
  • Metabolic abnormalities

Crush Injuries

metabolic abnormalities
Metabolic Abnormalities
  • Acidosis (low blood pH levels)
  • Hyperkalemia (high potassium levels)
  • Hypocalcemia (low calcium levels)

Crush Injuries

key principles
Key Principles:
  • ADEQUATE FLUID RESUSCITATION is critical in treating victims of crush injury.
  • Ideal resuscitation fluid: Normal Saline

Crush Injuries

secondary treatment modalities
Secondary Treatment Modalities
  • Bicarbonate
  • Mannitol (no proven benefits but no significant deleterious effects)

Crush Injuries

goals of fluid therapy
Goals of Fluid Therapy:
  • Prevent tubular precipitation of myoglobin
  • Decrease risk of hyperkalemia
  • Correct acidemia

Crush Injuries

treatment alert
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 alert17
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
Key Principle:
  • Risk of acute deterioration and death with sudden release of pressure on the involved extremity (REPERFUSION SYNDROME).

Crush Injuries

reperfusion syndrome
Reperfusion Syndrome
  • Acute hypovolemia
  • Metabolic abnormalities

Crush Injuries

treatment alert20
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 alert21
TREATMENT ALERT!
  • Delays of hydration for longer than 12 hours increase the incidence of renal failure.

Crush Injuries

compartment syndrome
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 syndrome24
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
RISK ALERT!
  • Peripheral pulses may be present in the early stages of limb ischemia.

Crush Injuries

field observation
Field Observation…
  • The cardinal symptom of compartment syndrome is pain out of proportion to apparent injuries.

Crush Injuries

upper extremity compartment syndrome
Upper Extremity Compartment Syndrome
  • Forearm and hand are at highest risk.

Crush Injuries

lower extremity compartment syndrome
Lower Extremity Compartment Syndrome
  • Anterior and lateral compartments of the lower leg (calf) are at highest risk.

Crush Injuries

fasciotomy
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

early mortality in crush syndrome
Early Mortality in Crush Syndrome
  • Hypovolemia
  • Hyperkalemia

Crush Injuries

late mortality in crush syndrome
Late Mortality in Crush Syndrome
  • Sepsis
  • Multiple Organ Failure

Crush Injuries

factors impacting mortality and morbidity
Factors Impacting Mortality and Morbidity:
  • Severity of the crush injury
  • Timing of treatment
  • Initial treatment provided to the victim

Crush Injuries

questions
Questions…

Crush Injuries

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