Treatment of Trauma Crush Patients

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magik20

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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?
 
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.

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?
Click to expand...
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...
 
The myoglobin you don't have to worry about
Click to expand...

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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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.
 
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.
 
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.
 
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.
 
Ah ok! Thanks. I guess I have a long way to go before I know all the medic stuff!
 
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.
 
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.
 
Mannitol is occasionally administered in the ED for rhabdomyolysis after fluid resuscitation to prevent renal failure.
 
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.
 
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.
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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
 
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
 
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.
 
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).
 
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). ----->

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
Click to expand...

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.
 
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?
Click to expand...

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