Crush syndrome

Background

Also known as traumatic rhabdomylosis

Criteria

1. Involvement of muscle mass
2. Prolonged compression of 4-6 hours but possible in <1 hr
3. Compromised local circulation

Pathophysiology

• Hypovolemic shock
  • Third spacing of fluids
• Metabolic acidosis
  • Hyperkalemia
  • Hyperphosphatemia
  • Hypocalcemia
  • Rhabdo and Renal Failure

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 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

See Also

• Compartment syndrome
• Rhabdomyolysis
• Disseminated Intravascular Coagulation (DIC)

References

Authors

Ross Donaldson, Neil Young, Ben Isakson