Crush/Compartment syndrome.

[Mateo_1387]

Flushing the toxins is not "key", but maintaining kidney function is. With all of the electrolyte abnormalities that will be present adding a diuretic would be troublesome.

That is an interesting thought, since Lasix is a potassium wasting diuretic. But we would also have to worry about all the protein breakdown from the crush, other toxins and other electrolytes.

[ccmedoc]

PostPosted: Wed Jun 18, 2008 10:44 pm Post subject:

AZCEP wrote:

Flasurfbum wrote:

AZCEP wrote:

Treatment will depend entirely on how long they are entrapped, and the amount of force that is applied.

Cardiac monitoring will clue you in to the possibility of cellular destruction and the resulting hyperkalemia. If kidney function is maintained, fluid boluses will help to flush the nephrotoxic materials out some.

Rapid transport is key.

So if flushing of the toxins out is key, would lasix be indicated?

Flushing the toxins is not "key", but maintaining kidney function is. With all of the electrolyte abnormalities that will be present adding a diuretic would be troublesome.

That is an interesting thought, since Lasix is a potassium wasting diuretic. But we would also have to worry about all the protein breakdown from the crush, other toxins and other electrolytes.

Diuresis will be necessary for maintaining kidney function..dialysis for the toxins..rapid transport to a facility with dialysis on site would be advantageous....I disagree with the tourniquet..I don't like it..

Attention must also be given to assess for compartment syndrome and fasciotomy performed as necessary..these are not as 'in vogue' as they once were, but when necessary, they can save the limb..

cardiac monitoring is paramount, along with urine output and urine color...both can indicate impending problems..In my experience, Bicarb and calcium chloride are not usually administered without labs...if the patient is suspected hyperkalemic..fluids, insulin, and glucose may be given emperically, along with high dose albuterol..blindly giving bicarb could be considered malpractice, and has not been shown to improve outcomes without high CK levels...as far as I know..

In the absence of dialysis, a foley with fluids and diuretics (loop diuretics preferred) may be indicated after consult with medical direction depending on length of transport and the length of time the patient was trapped...again, not as much for electrolyte control but to keep the kidneys functioning in regards to the rhabdo that is undoubtedly present.....

The rhabdomyolysis is the killer here..

[Ridryder 911]

[blindly giving bicarb could be considered malpractice,

Good thing you are used to newer ACLS, as in the old ACLS guidelines NsHco3 was given routinely every 5 minutes as well as CaCl- for a EMD/PEA rhythm. I agree one has to be be extremely careful, hoever it is not unusual to administer to give a pre-loading dose as well as bicarb drip form in rhabo and other specific conditions such as some OD.'s without having prior baseline labs.

R/r 911

[Kaisu]

My opinion for treatment of crush injury:

- Airway and ventilatory support

- High flow O2

- Aggressive hydration to maintain urinary output (dilution). Note that although crush injury treatment is still controversial, most physicians agree on dilution

- Maintenance of body temperature

- Certainly pain control

- Tourniquet

Most agree on this too – arterial flow and venous return must be prevented

Controversial Treatment

Surgical amputation on site if the individual cannot be freed by removing the compressing force

Sodium bicarbonate to treat hyperkalemia and acidosis

Calcium chloride to treat hypocalcaemia and hyperkalemia

Mannitol and Lasix to maintain urine output and prevent myoglobin (released from damaged muscle) from plugging up the kidneys

I agree that the tourniquet, high flow O2, fluids, pain medications, sodium bicarb and calcium chloride are appropriate pre-hospital treatments, but think that the Mannitol and Lasix can wait for the hospital.

[Spock]

Good comments here. I would add that timing is important. You need to work with the rescue crew so that everything is in place medically before the patient is freed. By that I mean IV's in place and volume loading before releasing the patient. Also, be prepared to intubate as soon as the weight is removed since the patient may arrest or become unresponsive. If you run a bicarb gtt you can't use that line for meds because anything given with bicarb will precipitate and clog the line. I also would suggest giving one gram of calcium chloride just prior to releasing the weight. Calcium will improve cardiac contractility and help with the resultant hypotension.

This situation is very similar to what we do in the operating room when we do an open AAA repair. The surgeon clamps the aorta above the aneurysm and then releases the clamp after the graft is sewn in place. The reperfusion of both legs can become interesting especially if the SOB doesn't give you advance warning and just releases the clamp. Lots of swearing then.

Obviously you might be restricted by the circumstances such as how much of the patient is pinned and what body parts are available for IV's. The bottom line is lots of fluids and rapid transport. The Israeli's and the Japanese have a lot of experience with this and I have seen literature recommending urine output of 12 liters per day. That requires a lot of fluid! Diuretics are best left for the hospital.

Pennsylvania just added a crush injury protocol to our state protocols. I submitted a very aggressive protocol for consideration but I didn't see the final version. I'll try to share it when it becomes available.

Live long and prosper.

Spock