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Introduction

Crush injury can be categorised into 3 areas, which are;

  • Crush Injury: Tissue injury as a result of prolonged compressive forces applied to an area of the body, most commonly limbs.
  • Compartment Syndrome: Increased pressure within a muscle, due to the non-elastic nature of the fascia, leading to reduced circulation distal to the injury. If left untreated this can result in tissue ischaemia and necrosis.
  • Crush Syndrome: The systemic manifestation of crush injury, as a result of tissue destruction. This results in the destruction of myocytes release of myoglobin, potassium and uric acid upon reperfusion. This can further deteriorate into rhabdomyolysis leading to hypovolaemia, hyperkalaemia, metabolic acidosis and acute kidney failure, resulting in death.
Clinical Presentation

Mechanism or pattern of injury suggesting crush injury, with prolonged entrapment.

Signs of crush injury include;

  • Hypovolaemia
  • Compartment syndrome

Reperfusion injuries are common;

  • Shock
  • Hyperkalaemia
  • Dysrhythmias

ECG Signs of Hyperkalaemia;

  • Tall tented T-waves
  • Absent p-waves
  • Widened QRS
  • Sine Wave
Exclusion Criteria
Exclusion Criteria
Risk Assessment
  • Remove crushing force as soon as possible.
  • If entrapment is prolonged consider USAR Physician deployment.
  • Patients with diabetes and bleeding disorders are at increased risk of reperfusion injury.
  • Do not delay transport time if patient is no longer trapped.
  • Fluid bolus should be started prior to release of compressive forces or immediately after if unable to do so.
  • Adequate fluid resuscitation in crush syndrome should be performed as a preference over permissive hypotension.
  • Tourniquets on trapped limbs have shown no benefit
Management
Primary Care
Intermediate Care (EMT / Level 2)
  • Administer pain relief
  • Consider applying cardiac monitor if trained and authorised
  • Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
  • Transport Priority 1 if patient time critical, pre-notifying receiving facility
Advanced Care (AP)
Critical & Extended Care (CCP, PSO)
Additional Information
  • Hypovolaemia
  • Hyperkalaemia
  • Metabolic Acidosis
  • Acute Kidney Injury
  • Cardiac Dysrhythmias
  • Clinical deterioration
  • Death
References

Gibney, R. T. N., Sever, M. S. and Vanholder, R. V. (2014). Disaster Nephrology: crush injury and beyond. Kidney International, 85(5), pp. 1049-1057. doi: 10.1038/ki.2013.392

Queensland Ambulance Service (2015). Clinical Practice Guidelines: Trauma/Crush Injury. Retrieved from: https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_Crush%20injury.pdf

Genthon, A. and Wilcox, S. R. (2014). Crush Syndrome: A Case Report and Review of the Literature. The Journal of Emergency Medicine, 46(2), pp 313-319. doi: 10.1016/j.jemermed.2013.08.052

Australian Capital Territory Ambulance Service (2016). Clinical management Guideline: Crush Syndrome. Retrieved from: http://cdn.esa.act.gov.au/wp-content/uploads/CMG-30-CRUSH-SYNDROME-June  -2016.pdf

Walters, T., Powell, D., Penny, A., Stewart, I., Chung, K., Keenan, S. and Shackelford, S. (2016). Management of Crush Syndrome Under Prolonged Field Care. Journal of Special Operations Medicine.

Sever, M. S. and Vanholder, R. (2011). Management of Crush Syndrome Casualties after Disaster. Rambam Maimonides Medical Journal, 2(2). doi: 10.5041RMMJ.10039

Sahjian, M. and Frakes, M. (2007). Crush Injuries: Pathophysiology and Current Treatment. Advanced Emergency Nursing Journal, 29(2), pp. 145-150

Palmer, B. F. and Clegg, D. J. (2017). Diagnosis and Treatment of Hyperkalaemia. Cleveland Clinic Journal of Medicine, 84(12), pp. 934-942. doi: 10.3949/ccjm.84a.17056

Queensland Ambulance Service (2018). Drug Therapy Protocols: Calcium Gluconate 10%. Retrieved from: https://www.ambulance.qld.gov.au/docs/clinical/dtprotocols/DTP_Calcium%20gluconate.pdf

Queensland Ambulance Service (2016). Drug Therapy Protocols: Sodium Bicarbonate 8.4%. Retrieved from: https://www.ambulance.qld.gov.au/docs/clinical/dtprotocols/DTP-Sodium-bicarbonate.pdf

Australian Capital Territory Ambulance Service (2016). Clinical management Guideline: Hyperkalaemia. Retrieved from: http://cdn.esa.act.gov.au/wp-content/uploads/CMG-27-HYPERKALAEMIA-June- 2016-top.pdf

Australian Capital Territory Ambulance Service (2017). Clinical management Guideline: Calcium Chloride. Retrieved from: http://cdn.esa.act.gov.au/wp-content/uploads/CALCIUM-CHLORIDE-Nov-  2017-left-justified.pdf

Sever, M. S. and Vanholder, R. (2012). Management of Crush Victims in Mass Disasters. Clinical Journal of the American Society of Nephrology. doi: 10.2215/CJN.07340712

Kidney Health Australia. (2017). Pre-Budget Submission Federal Budget. Retrieved from: https://kidney.org.au/cms_uploads/docs/kha-pre-budget-submission-2016-2017.pdf

Queensland Ambulance Service (2016). Clinical Practice Guidelines: Medical/Hyperkalaemia. Retrieved from: https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_Hyperkalaemia.pdf

North Carolina EMS. (2012) Treatment Protocol: Crush Syndrome Trauma. Retrieved from: https://www.ncems.org/nccepstandards/protocols/88CrushSyndrome.pdf

Abuelo, J. G. (2018). Treatment of Severe Hyperkalaemia: Confronting 4 Fallacies. Kidney International Reports, 3(1), pp 47-55. doi: 10.1016/j.ekir.2017.10.001

Guthrie, K. (2018, June 29th). Hyperkalaemia. Retrieved from: https://lifeinthefastlane.com/hyperkalemia/

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