# Treatment of Trauma Crush Patients



## magik20 (Sep 14, 2009)

we had a scenario the other day about a patient crushed in a car accident pinned against a dumpster ( real call that my instructor was on )

Ive been thinking about this call for a while as a "what would I do" scenario.

2 large bore IV's, treatment of shock while the Fire Department works on extrication of the victim, etc.

But really, what can you do ( both pre and during hospital ) for such a victim?

As soon as the crush injury is relived, they usually crash rapidly if not from hypovelmia its from lack of blood carrying oxygen to the heart / brain.

would sedating such a patient help maintain a lower heart rate in hopes of saving the patients ability to carry oxygen?  Is ( not like its around here anyways ) a oxygen carrying solution the only real way to keep the patient perfused from the internal hemorrhage?


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## akflightmedic (Sep 14, 2009)

The second one is pretty good.
\

http://mediccom.org/public/tadmat/training/NDMS/Crush.pdf

http://www.ncemsf.org/about/conf2003/lectures/bittenbender_crush.pdf

http://www.wnysmart.org/References/Medical Subjects/Crush_injury_syndrome.pdf


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## Akulahawk (Sep 14, 2009)

magik20 said:


> we had a scenario the other day about a patient crushed in a car accident pinned against a dumpster ( real call that my instructor was on )
> 
> Ive been thinking about this call for a while as a "what would I do" scenario.
> 
> ...


They crash rapidly because of hyperkalemia, rhabdomyolysis, and adidosis..

Relieving the compression "returns" the compressed area to circulation. When that happens, the potassium, lactic acid, and myoglobin that has built up the stagnant blood rushes into the central circulation. The myoglobin you don't have to worry about... but the patient might later require dialysis due to kidney failure from it. The hyperkalemia and acidosis is something that can kill the patient right NOW. So you treat that with additional buffering (bicarb) and albuterol (drives K+ back into the cells), and fluid - to dilute all that stuff that much more. 

Inhospital treatment may include dialysis, damage control surgery, further meds to control hyperkalemia, and attempts to keep the blood in a normal pH range... Beyond that, I am not certain as I do not work in a hospital... nor have I followed crush injury patients...


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## ResTech (Sep 14, 2009)

> The myoglobin you don't have to worry about



Large fluid boluses to prevent the myoglobin from inflicting damage to the kidneys is just as important as the calcium chloride and sodium bicarb. Agree?

I'll definitely have to spend some time tonight researching the albuterol and crush injuries... we were never told that during our Trauma course. I scanned over those links... definitely looks like some good info... good reading material for bedtime... thanks!


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## Akulahawk (Sep 14, 2009)

The fluid boluses will dilute the myoglobin, but beyond that, there's currently nothing that you can do in the field to address that. As far as I know, we don't have anything that can bind to myoglobin and prevent it from damaging the kidneys... and administering something that does  prior to release from compression would limit damage from the myoglobin that gets into the bloodstream.

The reason I say you don't have to worry about it is that definitive treatment for that won't occur until the patient reaches the hospital.


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## Smash (Sep 14, 2009)

One of hte main pathological features of crush injury, and crush injury syndrome is the massive amount of third spacing of fluid causing shock, as well as myoglobin sequestering more fluid and clogging the kidneys and electrolyte imbalances as noted.  

Generally speaking they need aggressive fluid resuscitation, and it should really start happening before they are released.

Lots of fluid, lots of fluid.  We want to dilute them a fair bit if they are going to be hyperkalemic (depending on what injuries they have this may or may not be practical), and we need to ensure that adequate thoughput is maintained to flush the kidneys.  Depending on the where and the who you may want/be able to place a catheter as soon as practical to ensure adequate output (about 10 times 'normal').  

You may want to buffer with bicarb if they are hyperkalemic, and this will also help decrease the amount of myoglobin precipitated by the kidneys as well as hopefully working on some of the acidosis that will be present.

Albuterol is probably not going to be that effective in the prehospital setting unless you are going to give it IV as it really won't be getting in in the doses you want it too, although it probably won't hurt so may be worth a try.

Furosemide may also be appropriate in the hyperkalemic patient to increase elimination of potassium, but again, due consideration must be given to what injuries they have, their fluid balance and so on before we go pushing it in and drying them out more.

Fluids, fluids, fluids, fluids, fluids, fluids, fluids, fluids, fluids, fluids.

Don't forget too, that while you may see crush injury in your trauma patient, you are far more likely to see crush injury syndrome in your little old lady who has been supine on the floor all night post fall and #NOF.  Crush injury syndrome takes time to develop (it is a function of time under compression and size of muscle compressed), so a little old (or big old) elderly person who has been lying on their back all night will have 'crushed' their buttocks and legs far more than the trapped patient who has been there 20 minutes.


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## lightsandsirens5 (Sep 14, 2009)

Ahhhh.....the greatful dead syndrome.....

Or I guess more accurately: Compartment Syndrome (Right Medics?)

They told us in high angle rescue and also strutural colapse/confined space rescue that it is mainly caused by acidosis. On an interesting note, we also learned that just 10 minutes of dead hang in a harness (eg. an injured rock climber) can cause enough acid buildup to cause serious problems when the pressure is released unless some kind of buffer is introduced to the pts body.


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## Smash (Sep 14, 2009)

Compartment syndrome can be a complication of crush injury (or suspension) but is not the same thing as crush injury syndrome.  Compartment syndrome can also occur from non-crush type injuries.  I have personally seen it from a small calibre GSW to the calf, as well as from isolated blows to the arm or leg.

Abdominal compartment syndrome commonly occurs from non-traumatic pathololgies (and can occur post-trauma of course) and is a very nasty and often fatal (if unrecognized) cause of mortality in some patients.


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## lightsandsirens5 (Sep 14, 2009)

Ah ok! Thanks. I guess I have a long way to go before I know all the medic stuff!


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## Akulahawk (Sep 14, 2009)

Compartment Syndromes are a specific type of crush injury. You typically see it occur in limbs, and in particular, locations in those limbs that amount to a closed box. Muscles are bundled in groups and surrounded by fascia. Fascia is a type of tissue that doesn't stretch very much. The fascia creates a fluid (and pressure) compartment. Anything that attempts to change the volume within the compartment (swelling, bleeding, etc.) will increase pressure within that compartment. If the pressure gets too high, blood flow through the capillary beds stop. As this happens, the tissues will necessarily switch to an anaerobic metabolism, the byproduct of which is Lactic Acid, and you'll sense the buildup as pain. The increasing pressure also triggers the nociceptors within the compartment, causing you to sense even more pain. You'll become very sensitive to movement and touch. Along the way, you'll get some surface numbness and paresthesias as any nerves in the area become compressed and become less and less effective in relaying any impulses. If a major artery runs through the compartment, you won't see distal pulses diminish until pressure through the compartment increases to the point where it starts encroaching into the distolic BP... but you'd have to watch for that... and that's a very late sign. 

At that point, about the only treatment is an emergent fasciotomy. Basically, the surgeon or EP ends up having to release the pressure by accessing and opening the compartment.


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## mycrofft (Sep 14, 2009)

*HOw many have actually seen one? (That's my new mantra)*

The force causing such a crush is likely to do other things as well, such as broken ribs, torn vessels, concussions, contused or ruptured bowel, torn diahphragm, positional asphyxia, etc. Oh, and death.

These types of injuries have a place in EMS lore because of the Greek Tragedy aspect...unrecoverable configuration and talking to the last.


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## LucidResq (Sep 14, 2009)

Mannitol is occasionally administered in the ED for rhabdomyolysis after fluid resuscitation to prevent renal failure.


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## fma08 (Sep 14, 2009)

I may be wrong and someone may have mentioned this as I only skimmed over the posts for now, but it was my understanding that crush or compartment syndrome usually takes a little time to develop before being relieved from the situation. The OP didn't mention the time frame from when accident occurred to when extrication occurred. Just curious anyway.


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## Jon (Sep 14, 2009)

lightsandsirens5 said:


> Ahhhh.....the greatful dead syndrome.....
> 
> Or I guess more accurately: Compartment Syndrome (Right Medics?)
> 
> They told us in high angle rescue and also strutural colapse/confined space rescue that it is mainly caused by acidosis. On an interesting note, we also learned that just 10 minutes of dead hang in a harness (eg. an injured rock climber) can cause enough acid buildup to cause serious problems when the pressure is released unless some kind of buffer is introduced to the pts body.


Harness / fall position causing problems is in this month's EMS magazine - good article.

Are you talking about crush syndrome, or the unique situations where injury is so great that the patient bleeds out after being moved?

Jon


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## Melclin (Sep 15, 2009)

Apparently the most common cause of crush injury (at least here) is actually drug and alcohol intoxication and the associated "lying flat on your arse for yonks" as we Aussies would say.

Consensus statement made on behalf of the Royal College of Surgeons that forms the centre piece for our crush injury curriculum (so you know its good, but you'll need journal access). ----->

Greaves I, Porter K. Consensus statement on crush injury and crush
syndrome. Accident and Emergency Nursing. 2004;12:47–52.

http://www.journals.elsevierhealth.com/periodicals/yaaen/article/PIIS0965230203000754/abstract


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## mycrofft (Sep 15, 2009)

*Common Crushes and Space Suits*

In th U.S. a "common" venue for surviveable (and lethal) crushes is agricultural machinery, notably corn augers and front end loaders.

NASA had trouble developing its first spacesuits because when suspended (not crushed) the test guys hanging in the harnesses were experiencing decreased venous return from their lower body, causing disorientation and syncope before any regional anaerobic effects. It is observed that head-up crucifixions could have a similar effect.

Also, think emboli.


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## lightsandsirens5 (Sep 15, 2009)

Jon said:


> Harness / fall position causing problems is in this month's EMS magazine - good article.



Which one? I'd love to get my hands on a copy.


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## 46Young (Sep 15, 2009)

Our crush syndrome protocol begins with spinal motion restriction, O2 admin, maintaining the pt's temp, and care of soft tissue injuries. Extrication and ALS assessment/intervention are to be completed prior to extrication unless immediate lifesaving measures are required.

Next, we perform a 12 lead, remembering that pts suffering from a prolonged entrapment are prone to hyperkalemia, hypoglycemia, and hypothermia. We then establish two large bore IV's. Again, in the absance of immediate life threat, extrication is delayed to deliver treatment:

Prior to release, admin NS 20ml/kg IV wide open, 10gtt set. For prolonged extrication, follow with NS IV Drip at 10ml/kg/hr, 10gtt set.

For entrapment greater than 4 hours, admin. Sodium Bicarb (8.4%) 1mEq/kg IV over 5 minutes to a max dose of 100 mEq. If ECG shows signs of hyperkalemia, admin albuterol 10mg via neb.

Post extrication, continue NS IV drip at 5ml/kg/hr (10gtt/ml set).


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## LucidResq (Sep 15, 2009)

Melclin said:


> Apparently the most common cause of crush injury (at least here) is actually drug and alcohol intoxication and the associated "lying flat on your arse for yonks" as we Aussies would say.
> 
> Consensus statement made on behalf of the Royal College of Surgeons that forms the centre piece for our crush injury curriculum (so you know its good, but you'll need journal access). ----->
> 
> ...



My friend saw this in the ED, sort of. A young man drank himself into unconsciousness and was laying on a couch in the same position, legs over the arm rest for 8+ hours. He ended up having both amputated at about knee level.


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## lightsandsirens5 (Sep 16, 2009)

Jon said:


> Are you talking about crush syndrome, or the unique situations where injury is so great that the patient bleeds out after being moved?



Ummmmmm.......I guess I dunno. Which is which?:blush:


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## Akulahawk (Sep 16, 2009)

mycrofft said:


> *In th U.S. a "common" venue for surviveable (and lethal) crushes is agricultural machinery, notably corn augers and front end loaders.*
> 
> NASA had trouble developing its first spacesuits because when suspended (not crushed) the test guys hanging in the harnesses were experiencing decreased venous return from their lower body, causing disorientation and syncope before any regional anaerobic effects. It is observed that head-up crucifixions could have a similar effect.
> 
> Also, think emboli.


Tractor roll-overs fit in that category...


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## Jon (Sep 16, 2009)

lightsandsirens5 said:


> Ummmmmm.......I guess I dunno. Which is which?:blush:



Well... crush syndrome has been talked about already.

Occasionally, you hear stories, like this one, perhaps, where the trauma is so bad that once the vehicle, etc is removed, the Pt. can no longer be hemodynamically stable. There was one out my way many years ago, involving a rail car at a steel mill. Pt. was crushed above the waist... responders determined there was no chance of survival because of the nature of the injury. Pt. was CAO, maintaining adequate BP. Story goes that family was brought in, etc... not 100% sure on accuracy, but I've heard it from a number of older folks that were around during that time frame.


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## Melclin (Sep 16, 2009)

46Young said:


> For entrapment greater than 4 hours, admin. Sodium Bicarb (8.4%) 1mEq/kg IV over 5 minutes to a max dose of 100 mEq. If ECG shows signs of hyperkalemia, admin albuterol 10mg via neb.



Interesting that you say albuterol. It makes good physiological sense, but as far as I can tell, its not used here. 

Do you have HR considerations for administration?...surely if they're pre-arrest a b2 agonist will make things worse (^Mv02,^automaticity,^conduction velocity). 

B2 agonists have also been associated with ^lactate and metabolic acidosis... both in high IV and lower inhaled doses. Seems like you'd want to avoid that in a crush injury pt.

Stratakos G, Kolomenidis J, Routsi C, et al. Transient lactic acidosis as a side effect of inhaled salbutamol. Chest 2002;122:385–6 [http://www.chestjournal.org/content/122/1/385.full#cited-by]

This is a more recent study showing the ^lactate but journal access is required:
G J Rodrigo, C Rodrigo. Elevated plasma lactate level associated with high dose inhaled albuterol therapy in acute severe asthma Emerg. Med. J. June 1, 2005 22:404-408

I realise this is in asthma and pre-labour, and also that an imminent cardiac arrest from hyperkalemia would take priority over lactate levels, but food for thought anyway.


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## mycrofft (Sep 16, 2009)

*Romanticized but possible.*

_"Pt. was CAO, maintaining adequate BP. Story goes that family was brought in, etc... not 100% sure on accuracy, but I've heard it from a number of older folks that were around during that time frame"._

I have heard about this in the NY subway ("Reader's Digest", I think), an MVA ("E.R." TV show), and maybe "Population:485". Never met anyone in person who's seen it. I did work with guys who responded to arms in corn augers, the pinch between auger and pipe served as a tourniquet. Not sure I'd eat Korncheks for a while after that.

For our cityfolks, a corn auger is a big pipe with what appears to be a monstrous screw which rotates and moves corn along the pipe much like an Archimedian screw pump. Clearance between the auger and the tube is close to avoid losing corn, and sometimes it needs unjamming...


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## magik20 (Sep 16, 2009)

Jon said:


> Well... crush syndrome has been talked about already.
> 
> Occasionally, you hear stories, like this one, perhaps, where the trauma is so bad that once the vehicle, etc is removed, the Pt. can no longer be hemodynamically stable. There was one out my way many years ago, involving a rail car at a steel mill. Pt. was crushed above the waist... responders determined there was no chance of survival because of the nature of the injury. Pt. was CAO, maintaining adequate BP. Story goes that family was brought in, etc... not 100% sure on accuracy, but I've heard it from a number of older folks that were around during that time frame.



I have heard a few such stories, but I am hoping that our advancements in the field are to the point that we will be able to save such patients with agressive actions and correct procedures.

Reading that 1st article about earthquake and crush victims by Dr.****son seems like a very promising way of treating and saving victims of such injuries


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## mycrofft (Sep 16, 2009)

*Maybe, but here's another fly in the UNG*

Of those cases where crush/entrapment was for any significant length of time but the pt survived, what was the outcome? If it means living with no legs, urotoma, colostoma, partial bowel, permanent nonunion fx of pelvis/ribs, sequential infections of different organs and systems, mental sequelae from the incident plus multiple general anesthesias...no thanks.


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## magik20 (Sep 16, 2009)

mycrofft said:


> Of those cases where crush/entrapment was for any significant length of time but the pt survived, what was the outcome? If it means living with no legs, urotoma, colostoma, partial bowel, permanent nonunion fx of pelvis/ribs, sequential infections of different organs and systems, mental sequelae from the incident plus multiple general anesthesias...no thanks.



The cases Dr.****son referenced were not specific per say on the quality of life in his examples, but one thing he referenced often was renal failure in those cases.

Jan. 17 1995 Kobe Japan
41,000 Injured, 5,000 died.
very little early treatment
54% of victims developed acute renal failure
*11% of victims who recieved more then 6L per day of fluid developed renal failure.*

Seemingly a huge huge statistic, and maybe a reason for foley's to be administed in the field to ensure renal failure doesnt occur?


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## grich242 (Sep 16, 2009)

I agree k.i.s.s.  we can't treat trauma definitively in the field. Thats the surgeon's job. While acidosis compartment syndrome and myoglobin may be concerns they are probably not the most immeadiate life threat.and how do you know what the labs are? as far as sedation most meds drop bp"s (at least the ones we carry) and if your pt has one they may not for long. remember the golden hour etc and let the hospital worry about the definitive treatments. lots of fluid and early activation of a trauma team are about all you can do. plus if you wind up hanging something like dopamine then you need volume replacement first.

The reason I say you don't have to worry about it is that definitive treatment for that won't occur until the patient reaches the hospital.[/QUOTE]


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## Smash (Sep 17, 2009)

Nor can the trauma surgeon definitively treat crush injury syndrome in the OR while the patient is still trapped in the field.  By it's very nature crush injury syndrome IS something that we need to have more than a passing knowledge of as it will be us who have to deal with the sequelae.

This is particularly the case given the high incidence of crush injury in rural areas; with prolonged entrapments and long transport times to hospital medics will (and do) see the effects of crush injury syndrome in the field.  If the patient is to have the best chance at a good outcome we need to be prepared to manage all aspects of the injury and the subsequent pathology.


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## grich242 (Sep 17, 2009)

I didn't mean to imply or infer that definitive  treatments were not important considerations weather we can treat them or not. more education on any subject especially patho- phys of things we encounter is always a good idea. I just meant that in my experience (and its not rural) there are usually more pressing life threatening concerns, and yes with extended transport times you would definitely consider things like compartment syndrome. I also believe that it is in the best interest of the patient to leave some matters to be treated by definitive care when a proper diagnosis can be made. treating things like acdosis based on a field impression works good as long as you are right.which goes right back to having more education......


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## RyRyTheFlyGuy13 (Sep 25, 2009)

Akulahawk said:


> They crash rapidly because of hyperkalemia, rhabdomyolysis, and adidosis..
> 
> Relieving the compression "returns" the compressed area to circulation. When that happens, the potassium, lactic acid, and myoglobin that has built up the stagnant blood rushes into the central circulation. The myoglobin you don't have to worry about... but the patient might later require dialysis due to kidney failure from it. The hyperkalemia and acidosis is something that can kill the patient right NOW. So you treat that with additional buffering (bicarb) and albuterol (drives K+ back into the cells), and fluid - to dilute all that stuff that much more.
> 
> Inhospital treatment may include dialysis, damage control surgery, further meds to control hyperkalemia, and attempts to keep the blood in a normal pH range... Beyond that, I am not certain as I do not work in a hospital... nor have I followed crush injury patients...




Thanks you I was just about to say something. Furthermore, in some places they give D50 along with insulin. Potassium and dextrose transport together, the insulin brings both back into tissue decreasing levels in the blood stream. With all these interventions, major or prolonged crush injury calls usually don't turn out well unfortunately.


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## RyRyTheFlyGuy13 (Sep 25, 2009)

*sedationg of these patient?*

One of the previous posts asked if sedation of these patients would be beneficial.. well you may want to review contraindications of most of the sedatives in use.. One of the big ones is hypotension. To give something to a person who is hypertensive in the first place would send the patient into cardiogenic collapse and shock. You would be making the container too big for the pump ( as well as slowing the pump down depending on the med you give) which would cause another life threatening event on top of the hyperkalemia that causes heart problems in the first place. These problems in turn deprive the brain of oxygen, not good. multiple system collapse. Diluting the patient is important, but if you see peaked T waves in your 12 lead beware. Pull out all the stops. Sodium Bicarb, Calcium, Albuterol, glucose and insulin, and diuretics and transport to a hospital with dialysis.


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