Treatment of Trauma Crush Patients

[Akulahawk]

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...

 

[Jon]

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.

 

[Melclin]

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.

 

[mycrofft]

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...

 

[magik20]

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

 

[mycrofft]

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.

 

[magik20]

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?

 

[grich242]

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]

 

[Smash]

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.

 

[grich242]

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......

 

[RyRyTheFlyGuy13]

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.

 

[RyRyTheFlyGuy13]

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.