Crush Syndrome
OVERVIEW
- prolonged ischaemic and muscular damage -> rhabdomyolysis and reperfusion injury on release
- limb often initially numb with a peripheral pulse -> rapid swelling with compartment syndrome
MANAGEMENT (otherwise healthy adult)
Field
- full monitoring
- IV N/S 1L/hr prior to extrication
- post extrication: 500mL N/S alternating with 500mL 5% glucose (per hour)
Hospital
- add 50mEqu of NaHCO3 to every second 500mL glucose (maintain urinary pH > 6.5)
- once urine flow established add 2g/kg of 20% mannitol (ever give more than 200g/day and never administer in established anuria)
- aim for urine flow 8L/day (will require 12 L/day)
- if HCO3 produces pH > 7.45 -> give acetazolamide 500mg
- continue until myoglobin disappears from urine
Limb care
- splint joints in a functional position
- active and passive movement as soon as pain allows
- contractures and paralysis dealt with late reconstructive surgery
Fasciotomies
- recommended within 6 hours of a compartment syndrome BUT NOT when muscle is already dead (which is inevitable in crush compartment syndrome)
- often done -> significant increase in bleeding, coagulopathy, sepsis and mortality
- in closed injuries -> there is no place for fasciotomies
- only indicated if a distal pulse is absent and when major artery and systemic hypotension have been excluded
- necrosis and severe infection sets in 2-5 days post injury -> must be amputated
Hyperbaric O2
- reduces oedema
- floods ECF with O2
COMPLICATIONS
- hypovolaemia
- hyperkalaemia
- hypocalcaemia
- metabolic acidosis
- acute myoglobinuric renal failure
- acute muscle-crush compartment syndrome
- death
References and Links
Journal articles
- Gonzalez D. Crush syndrome. Crit Care Med. 2005 Jan;33(1 Suppl):S34-41. Review. PubMed PMID: 15640677.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
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Within this paper was the recommendation for NS over LR. However I do not think this is correct. Please see the reference below from PulmCrit. Therein a decent argument is made, with lit backing showing efflux of K+ from cells due to the acidic nature of NS:
“the primary reason that this myth is wrong [NS being better than LR for hyperK+] has to do with potassium shifting between the cells and the extracellular fluid. About 98% of the potassium in the body is present inside the cells, with an intracellular potassium concentration of ~140 mEq/L. Therefore, even a tiny shift of potassium out of the cellular compartment will have a major effect on extracellular potassium levels. NS causes a non-anion gap metabolic acidosis, which shifts potassium out of cells, thereby increasing the potassium level. On the other hand, LR does not cause an acidosis, but instead may have a mild alkalinizing effect given that it contains the equivalent of 28 mEq/L of bicarbonate. Potassium shifts have a greater effect on the serum potassium than the actual concentration of potassium in the infused solution. ”
“a prospective, randomized, double-blind controlled trial of NS versus LR among 52 patients undergoing renal transplant surgery. The mean change in serum potassium during the procedure was +0.5 mEq/L in the NS group compared to -0.5 mEq/L in the LR group (p < 0.001; figure below). Patients in the NS group also had lower pH levels following surgery. ”
https://emcrit.org/pulmcrit/myth-busting-lactated-ringers-is-safe-in-hyperkalemia-and-is-superior-to-ns/