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Crush syndrome
From WikEM
(Redirected from Crush injury)
Contents
Background
Also known as traumatic rhabdomylosis
Criteria
- Involvement of muscle mass
- Prolonged compression of 4-6 hours but possible in <1 hr
- Compromised local circulation
Pathophysiology
- Hypovolemic shock
- Third spacing of fluids
- Metabolic acidosis
Clinical Features
- Skin trauma or local signs of compression over a muscle mass
- Erythema, ecchymosis, bullae, abrasion
- Tense muscle mass
Differential Diagnosis
Extremity trauma
- Peripheral nerve injury
- Vascular injury
- Tendon injury
- Laceration
- Fracture
- Open joint injury
- Crush syndrome
- Compartment syndrome
- Rhabdomyolysis
- Contusion
- Myositis ossificans
Evaluation
Work Up
- CBC
- Chem 10
- CK
- Urine dip and UA
- Strict I&Os
- ECG
- Imaging as indicated by injury
- Compartment pressure monitoring for suspected Compartment syndrome
Results
One or more of these should be found in the right clinical setting
- Myoglobinuria and/or hematuria
- Peak CK (typically >10,000)
- Oliguria (<400ml/24hrs)
- Elevated BUN (>40)
- Elevated creatinine (>2.0)
- Elevated uric acid (>8)
- Hyperkalemia (>6)
- Hyperphosphotemia (>8)
- Hypocalcemia (<8)
Management
Prehospital Protocol for Entrapment Lasting >4hrs or Suspicion of Hyperkalemia
Should begin BEFORE extrication
- Cardiac monitoring
- Hydration (~NS 1.5 L/hr)
- Pain control
- Albuterol neb
- Calcium chloride
- 1 gram slow IV push over 60 sec
- Sodium bicarbonate
- Flush IV with NS (prevent precipitation), then
- 1mEq/kg added to 1L of normal saline, run IV wide open just prior to extrication
- Release compression
- In the field, use of tourniquet before extrication is controversial
ED Management
- ATLS
- Aggressive IVF
- Treat Hyperkalemia with typical management
Extended Management
- 250ml IV bolus q15min until UOP is 2ml/kg/hr
- Lasix or Mannitol for forced diuresis
- Acetazolamide for pH >7.5
Disposition
- ICU
- Intermediate Care or Floor for minor cases
