Was it crush syndrome?

Household6

Household6

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59yo male involved in 60mph three car collision. He was trapped for a duration of about 45 minutes by the lower dash on his legs, requiring FD extrication. Broken pelvis, two broken femurs.

I had responded as on-duty EMR, but I was not involved in his care after CCPs landed on scene with the Nine Line. I cared for another patient with minimal injuries.

Now, the 59yo was flown to a level 2 trauma center, where he was listed in serious condition. Upon hot-load, he was quite alert, in good humor, seemed to me that he was doing amazingly well. He was scheduled for surgery the next day. He died on the OR table.

Is 45 minutes long enough to develop toxic and fatal potassium/lactic acid/myoglobin levels from severe muscle breakdown?

Is anyone taught to tourniquet crushed extremities so the trauma center can control the rate at which myoglobin/K is released into the body?

Public photo, published in local paper, taken by media:
3865928_zps386deee4.jpg
 
Crush injury usually takes a while, 2+ hours. The body is pretty resilient. Compartment syndrome may be a concern. Did he have palatable pulses in both distal extremities? If we were relatively close to the hospital, I'd treat with fluid and pain management. For prolonged entrapment, it may be worth starting down the CBADIF algorithm. But, I'm loathe to start affecting any potassium shift without labs.
 
Consider:
  • Undisclosed preexistent condition.
  • Simple blood loss=> vasovagal decomp
  • Fat embolus
  • Undiagnosed internal injury like lacerated liver
  • Undiagnosed "hangman's fx" (C1-C2) aka subclinical decapitation
  • Undiagnosed intracranial bleed due to deceleration/impact/contracoup (Natasha Richardson Syndrome, my own invention; take two tylenol and wake up dead in the morning).
  • Fate.
 
Yea, I would think his outcome the next day was related to something else like was mentioned above.... Hemorrhage, surgical complication, peri operative MI, or other unrecognized injury or not to mention any number of complications related to a chronic illness not knowing his past history...
 
If he'd died within a couple hours of being released from the vehicle, I might suspect crush injury. However, I would also expect that he was entrapped for a bit longer than 2 hours for crush syndrome to occur. There's a reason why the TK is good for 6 hours... While I'm not going to guess what got him, I'm pretty sure it wasn't crush syndrome.

Broken pelvis and a couple of broken femurs tells me that there was a LOT of energy transferred into his body and I would further imagine that those structures weren't the only structures damaged in the crash. There's lots of blood vessels in and around the area. What can easily disrupt those (and more)? Blunt Trauma... as in all that energy left over after smashing 2 femurs and the pelvis, and it's got to go somewhere!!!
 
Household6 said:
59yo male involved in 60mph three car collision. He was trapped for a duration of about 45 minutes by the lower dash on his legs, requiring FD extrication. Broken pelvis, two broken femurs.

I had responded as on-duty EMR, but I was not involved in his care after CCPs landed on scene with the Nine Line. I cared for another patient with minimal injuries.

Now, the 59yo was flown to a level 2 trauma center, where he was listed in serious condition. Upon hot-load, he was quite alert, in good humor, seemed to me that he was doing amazingly well. He was scheduled for surgery the next day. He died on the OR table.

Is 45 minutes long enough to develop toxic and fatal potassium/lactic acid/myoglobin levels from severe muscle breakdown?

Is anyone taught to tourniquet crushed extremities so the trauma center can control the rate at which myoglobin/K is released into the body?

Public photo, published in local paper, taken by media:
Click to expand...

A broken pelvis with bilat broken femurs is a massive injury with a very significant risk of mortality itself, even before accounting for the numerous co-morbidities that could exist in a 59 year old or the possible associated injuries that can't be diagnosed in the field, some of which mycrofft listed.

Crush syndrome normally manifests quickly after the crushed tissue is reperfused.
 
Eh. Damn autocorrect.

... I'll be over here preparing the fava beans and chianti.
 
Bi-lat femur fractures and a pelvis fracture takes a huge amount of force (or some really bad luck). He could have had a whole host of injuries you weren't aware of, in addition to those, and any sort of complications could have resulted in his death.
 
Getting firmly into my armchair...
Fracturing both femurs and the pelvis in an eyes-forward impact suggests someone wasn't wearing their seatbelt.

Magnification of photo may reveal the seatbelt lying at the juncture of the seat back and the seat bottom near the opened door (port side). Airbag also deployed. Steering wheel seems to have telescoped. While the air bag obscures the bottom section of the steering wheel, looks to me as though it were not bent forwards. Windshield is not stellate, so probably not due to forehead. (Hard to be sure, but interior rear view mirror glued to windshield seems to be in place?!).

So, blunt force trauma to the chest and maybe the upper abdomen (diaphragm), as well as higher degree of deceleration because the driver's body was allowed to accelerate for about one foot before hitting the steering wheel/air bag. Greater likelihood of whiplash fx, subcutaneous emphysema/incipient pneumo/haemothorax, great vessel damage (dissection secondary to focused blunt trauma).
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The cases where the injuries are fatal but not immediately rendering the subject unconscious are very dramatic.
:sad:
 
Kicked by a horse not a zebra.
 
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